My Doctor Said I Am Too High Risk for Surgery — Can I Still Have Sinus Treatment?

Dr. Franklyn Gergits, ENT

Short answer: Yes — in many cases. When a patient is considered high risk for surgery under general anesthesia, in-office sinus procedures performed under local anesthesia represent a genuinely different risk category. There is no general anesthesia, no intubation, no operating room, and no hospital facility involvement. For patients with cardiac disease, pulmonary conditions, obesity, obstructive sleep apnea, or other comorbidities that elevate surgical risk, in-office procedures at SAWC have allowed us to provide meaningful sinus treatment that would otherwise have been considered too dangerous to pursue. We coordinate with your cardiologist, pulmonologist, or primary care physician when appropriate — because your overall health picture matters as much to us as your sinus symptoms.

What “High Surgical Risk” Actually Means

When a physician tells a patient they are too high risk for surgery, what they almost always mean is that the risks associated with general anesthesia — and the physiologic stress of a hospital-based operative procedure — outweigh the likely benefit. This is a careful and responsible assessment. General anesthesia places significant demands on the cardiovascular and respiratory systems. For patients with heart disease, pulmonary disease, uncontrolled hypertension, significant obesity, or a history of adverse anesthetic events, those demands can carry meaningful risk.

What that assessment does not always account for is whether the sinus procedure can be done without general anesthesia at all. In-office sinus procedures under local anesthesia are a fundamentally different clinical situation — and for many patients who have been told surgery is not an option, they represent the path forward that nobody mentioned.

Who We Commonly See as High-Risk Candidates

At the Sinus and Allergy Wellness Center of North Scottsdale, we regularly evaluate and treat patients who have been told they are not surgical candidates due to:

Cardiac disease — including coronary artery disease, heart failure, significant valvular disease, arrhythmias, and patients on anticoagulation therapy. We have treated patients whose cardiologists were specifically relieved that the procedure could be performed in our office under local anesthesia rather than requiring a hospital setting. While sinus surgery under general anesthesia is classified as low-risk noncardiac surgery, the absolute cardiovascular risk is still meaningfully higher than a local anesthesia procedure — and for patients with significant cardiac disease, even a low-risk general anesthetic carries elevated concern. The absence of general anesthesia eliminates the cardiovascular stress response associated with intubation and systemic anesthetic agents, and for patients with controlled cardiac disease, this is a clinically meaningful distinction — not a minor convenience.

Pulmonary disease — including COPD, asthma, and significant obstructive sleep apnea. Patients with reactive airway disease face elevated risk of bronchospasm and respiratory complications under general anesthesia. In-office procedures with local anesthesia allow these patients to breathe independently throughout the entire procedure with no airway manipulation.

Obesity — which increases the risk of difficult intubation, aspiration, and post-operative respiratory complications under general anesthesia. In-office procedures under local anesthesia eliminate the cardiovascular, respiratory, and neurological risks specific to general anesthesia for appropriate candidates. Local anesthesia carries its own low-risk profile — including the possibility of vasovagal reactions — but these are rare, manageable in the office setting, and represent a fraction of the systemic risk associated with general anesthesia in this population.

Advanced age — older patients face elevated risk of post-operative cognitive dysfunction — temporary confusion, memory lapses, and difficulty concentrating — with early POCD incidence approximately 26 percent in elderly patients compared to 19 percent in middle-aged patients. Though usually self-limiting and resolving within weeks to months in most patients, these effects can meaningfully disrupt daily life and independence. The local anesthesia protocol used in our office carries none of these systemic neurological risks.

Anticoagulation — patients on blood thinners for cardiac or vascular indications are often considered poor surgical candidates because of bleeding risk in an operative setting. A prospective study of 35 patients who underwent in-office balloon sinuplasty while on concurrent antiplatelet and anticoagulant therapy found no systemic complications and no significant postoperative bleeding events — with SNOT-22 symptom scores improving well beyond the minimal clinically important difference. In-office sinus procedures, which involve no tissue excision and minimal bleeding, can often be performed safely in anticoagulated patients in coordination with their managing physician.

What Our In-Office Protocol Looks Like for Higher-Risk Patients

For patients with significant medical comorbidities, our pre-procedure evaluation is thorough. We review your complete medical history, current medications, recent laboratory and cardiac studies, and any specialist evaluations. When appropriate — and it frequently is — we contact your cardiologist, pulmonologist, or primary care physician directly before scheduling a procedure. We want to know that your managing team is aware of and comfortable with the plan.

On the day of the procedure, vital signs are monitored throughout. The local anesthesia we use is carefully dosed and chosen with your medical history in mind — including consideration of cardiac effects for patients on relevant medications. We take our time. We do not rush. And for patients who need it, we have the flexibility to modify, pause, or reschedule any step of the procedure based on how you are feeling in the moment.

This is what it means to treat the patient, not just the sinus.

What We Cannot Do — and When We Refer

In-office procedures under local anesthesia are not appropriate for every patient. Patients with extensive nasal polyp disease requiring complete surgical clearance, those with severe anatomical complexity, or those whose comorbidities require active anesthetic management during the procedure may still need a hospital-based approach — ideally with an anesthesiologist who specializes in high-risk patients and at a center equipped to manage any intraoperative event.

When that is the right recommendation, we make it clearly and help coordinate the referral. But in our experience, many patients who have been told surgery is not an option have not had someone sit down with them and explain that there is more than one way to address sinus disease — and that the in-office option may be exactly right for where they are in their health picture.

If you or someone you care for has been told they are too high risk for sinus surgery, we would be glad to evaluate whether in-office treatment is a viable option. The evaluation alone — nasal endoscopy and CT imaging — carries no anesthetic risk whatsoever and gives us the information we need to have an honest conversation about what is possible.

Want to Understand More?

This post is part of the Why Sinus Treatments Fail — And What Starts Before Them series on the Airway & Sinus Wellness Review.

→ Does Balloon Sinuplasty Actually Work?

→ Is Balloon Sinuplasty Painful?

→ Is the Combination Procedure Too Much?

→ Will Balloon Sinuplasty Help Me Breathe Better?

→ Airway & Sinus Wellness Review — Full Publication

This post is part of the Why Sinus Treatments Fail — And What Starts Before Them section of the Airway & Sinus Wellness Review.

References

1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Journal of the American College of Cardiology. 2014. acc.org

2. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022. asahq.org

3. Levy JM, Marino MJ, McCoul ED. In-office balloon dilation of paranasal sinuses: A systematic review and meta-analysis. International Forum of Allergy & Rhinology. 2020.

4. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008. Post-operative cognitive dysfunction in older patients.

5. Piccirillo JF, Payne SC, Rosenfeld RM, et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngology–Head and Neck Surgery. 2025. entnet.org

6. American Society of Anesthesiologists. Risks and side effects of anesthesia. asahq.org

7. Nardelli P, et al. Awake office-based sinus procedures: systematic review of 1,283 patients — tolerability 82–95%, high patient satisfaction, low complication rates, rapid recovery. International Forum of Allergy & Rhinology. 2026.

8. Higgins TS, et al. In-office balloon sinuplasty with concurrent antiplatelet and anticoagulant therapy: prospective cohort of 35 patients — no systemic complications, no significant postoperative bleeding, SNOT-22 improvement exceeding MCID. International Forum of Allergy & Rhinology. 2020.

9. Fleisher LA, Fleischmann KE, et al. 2024 AHA/ACC Guideline on Perioperative Cardiovascular Management of Patients Undergoing Noncardiac Surgery. Journal of the American College of Cardiology. 2024. acc.org

About the Author

Dr. Franklyn R. Gergits, MBA, DO, FAOCO is a Board-Certified Otolaryngologist and Fellowship-Trained Otolaryngic Allergist with a Clinical Focus in Rhinology and Airway Disorders and over 30 years of clinical experience. He is the founder of the Sinus & Allergy Wellness Center of North Scottsdale, where he performs in-office balloon sinuplasty, turbinate reduction, NEUROMARK® posterior nasal nerve ablation, and Eustachian tube dilation under local anesthesia. He performed the first balloon sinuplasty in Pennsylvania and holds dual Entellus Centers of Excellence certifications. Dr. Gergits is the originator of the Posterior Sinonasal Syndrome (PSS) hypothesis — a clinical framework identifying pepsin-mediated posterior nasal mucosal injury as an upstream driver of chronic rhinosinusitis. Preprint available at Preprints.org (DOI: 10.20944/preprints202603.0858.v1). ORCID: 0009-0000-4893-6332.

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This content is for educational purposes only and does not constitute medical advice. If you have been told you are too high risk for surgery, consult with a qualified otolaryngologist to determine whether in-office sinus procedures under local anesthesia are appropriate for your specific medical situation.