At the conclusion of this presentation, the participants should be aware of the technique and success of in-office transnasal esophageal (TNE)-guided tracheoesophageal puncture (TEP) placement in patients who have failed prior attempts in the operating room or are not healthy enough to undergo general anesthesia.The aim of this study was to demonstrate the technique of TEP, which can be completed safely in an office setting when patients are not able to undergo general anesthesia due to medical comorbities or have previously had an unsuccessful attempt at TEP placement in the operating room due to anatomical reasons.This study is a retrospective chart review from 2007 to 2011.A total of 13 outpatient adults with a history of total laryngectomy presenting to the laryngology clinic for TEP after either failing prior placement in the operating room or not being able to undergo general anesthesia due to medical comorbities were identified. In-office TNE-guided TEP placement was performed on all 13 patients.All subjects underwent successful TNE-guided TEP placement in the office. Complications included 1 possible false passage and 1 case of cellulitis.Patients who could not undergo TEP placement in the operating room due to poor exposure or medical comorbities were able to successfully undergo the procedure in an office setting with good results.