The Office based laryngoscopy is dated back to 19th century: the advent in topical anesthesia sometime around the second half of the 19th century enabled the procedure to become interventional.

Operative channel then made it possible to engage lasers in the form of fibers, to perform vocal cord injection of a variety of materials and to take punch biopsies at the office setting.

The video recording was further ameliorated with the invention of the distal chip and high-resolution imaging. Recent development of visual enhancement by refined algorithm for color filtering enabled differential visualization of different wave lengths (NBI) for more accurate diagnosis of various pathologies [1].

Office based procedures must have a meticulous patient selection process, these patients must tolerate the flexible endoscopy without intense gag reflex. They must sit motionless for a duration of 10–30 min, which is a reasonable duration for most of the interventions. Guiding the patient regarding different throat maneuvers is a helpful tool to improve access to the lesion and for a better exposure of the surgical field. Medications that alter the blood clotting profile, like anticoagulants or antiplatelets should be stopped several days before the procedure, if possible. The patient should be as relaxed as possible, since anxiety might hamper success. The patient is awake and receives no more than local anesthesia, light sedation is optional, yet the patient is in the sitting position and should be able to phonate when asked. The sufficient anesthesia is critical for the completion of the procedure, and it should be provided to the larynx and pharynx [2].

Most of the patients experience only mild pain post-operatively. It is recommended to have the patient waiting for an additional 30–60 min at the end of the procedure, however not all the authors argue for that. Patients are instructed to refrain from eating or drinking for 30–45 min at least to avoid aspiration risk.

The flexible laryngoscope equipped with the operative channel provides three main interventions: Biopsy, Injection, and Laser.

Flexible forceps using through the operating channel is appropriate for punch biopsy or polypectomy for example [3].

The history of vocal cord injections is more than one hundred years old [4]. The vocal cord injection has two different purposes: augmentation, for filling of a defect or medialization of the vocal cord, versus drug delivery, which creates local therapeutic effect due to the absorption of the substance in the tissue. The injection is well established either transoral or trans-nasal, through the operative channel, or via the percutaneous route, sometimes with an optional EMG guidance (for injection of botulinum toxin). Several percutaneous punctures were described, through the cricothyroid ligament, trans thyrohyoid membrane, passing through the thyroid cartilage. The augmentation can remain temporarily within the fold, as it is when using hyaluronic acid, or longer effect can be achieved by using substances like calcium hydroxyl apatite. The office-based flexible endoscopic injection is highly effective, nevertheless, sometimes a challenging procedure, especially with anxious patients, robust vasovagal reaction, excessive gag reflex, intolerance, and anatomical variations.

Office based laser surgery, is conducted via a glass fiber which is transferred through the operative channel. There are several different lasers in favor of this mode of intervention. Each one has a different wavelength, depth of penetration, maximal absorption by different tissue. The net effect is a consequence of power, spot size, time of operation, and the mode of action. The most utilized lasers are the co2 laser, thulium laser, pulsed dye laser, KTP laser, YAG laser and the True-Blue laser [5,6]. The Trublue laser (TruBlue; A.R.C. Laser Company) was introduced to the laryngology field in the last 7–8 years. It has a 445 nm wavelength and is capable of photoangiolytic effect. Hence it is appropriate for a manipulation over the laryngeal sub-epithelial vessels. It reaches the power of 10 watts and perfectly carbonize and coagulate the target lesion. The firing is either in the contact or non-contact mode. It serves both photoangiolytic effect and cutting ability, and fits for diverse pathologies in laryngology [7].

It is estimated that >15 % of the laryngeal operations are carried out in the setting of office-based procedures, and the number is growing due to the bucketful of benefits in terms of short duration, lack of hospitalization, lower cost, no need for general anesthesia, short waiting list, suitability for patients with comorbidities, optimal setting for highly recurrent diseases, better visualization of all laryngeal subsites including ventricles and posterior commissure, real time vocal outcomes with fine tuning of the intervention, overcoming the oral tissues that are prone to trauma during direct laryngoscopy, and a strong patient's preference for this setting [1,2,8].

Herein we represent our experience with office-based flexible endoscopic laryngeal interventions during the years 2020–2021. Our purpose of this study was to analyze the characteristics and tolerance of such procedures.