Background Current shortage of operative space and anaesthetic staff led to 531907 ENT cases waiting to be performed as of June 2022; a trend expected to worsen. Awake surgery can provide a safe and effective alternative reducing the need for anaesthetic cover while utilising alternative operating spaces. Methodology Prospective cohort study of 86 patients undergoing ENT procedures under local anaesthetic with/without operator delivered sedation using midazolam; performed in the ambulatory Procedure Zone of an ENT tertiary centre in the UK by a single sedation trained rhinologist. Results N=54 inferior turbinate reduction (n=19 with radiofrequency ablation, n=25 with co-ablation, n=13 combined with a second procedure). Pre-operative mean SNOT23 score 59, mean NOSE score of 17.89, 3 month post-operative mean SNOT 23 score 36 and mean NOSE score 7.92 (P<0.05). N=18 balloon sinoplasty, n=4 endoscopic sinus procedures; pre-operative mean SNOT23 score 76, 3 month post-operative mean SNOT23 score 25 (P<0.05). N=12 nasal biopsies, n=8 septoplasties, n=6 adhesiolysis, n=1 grommet insertion, n=1 excision of pinna lesion, n=1 canal polypectomy. Visual analogue scale was used to assess patient comfort during the procedure; 4/10 mean score (IQR 2-8) for cases under local anaesthetic ranged, with addition on sedation comfort increased with mean score of 8/10 (IQR 1-10). Due to the low numbers of cases statistical significance was not calculated. Conclusion Awake surgery in ENT is a safe and effective alternative to general anaesthesia. It is a cost effective service, which shortens waiting and treatment times, and coupled with operator delivered sedation leads to high patient satisfaction rates.