Caldwell-Luc Procedure

What Is Caldwell Luc Procedure?

When the maxillary sinus lining or the mucosa of the sinus gets diseased or infected, or scarred by infection, this 120-year-old procedure remains the most adopted technique to access the sinus mucosa and remove it successfully.

Surgical procedures akin or similar to the Caldwell-Luc procedure are the recently in place endoscopic sinus surgery (ESS), antrostomy surgery, and conservative approaches to the sinus mucosa like FESS, Mini-FESS, and balloon sinuplasty. However, in cases where the maximum exposure of the maxillary sinus, the floor of the orbit, and the pterygopalatine fossa are required- the Caldwell-Luc procedure is only used even today for easier access, surgical instrumentation, and hence scope for preventing recurrence of sinus tumors, fistulas, and infections.

It is mandatory for the oral and maxillofacial surgeon to see the risks and benefits of this surgery before adopting this line of surgical access, as it would be appropriate in certain low-risk cases to be more conservative. The Caldwell-Luc procedure is prone to complications as well, given that it needs a large opening for surgical access. The regeneration of the sinus mucosa after removal of the diseased mucosa either through ESS, conservative antrostomy, or Caldwell-Luc depends to a great extent on the systemic or bodily health status of the patient directly linked to his or her regenerative potential or capacity. This decision hence should be better advised by the physician or surgeon before operating on the patient.

What Are the Causes And Symptoms of Sinus Disease?

Sinus infections, cysts, polyps, tumors, or any lesions or foreign bodies that are the cause of sinus disease pose multiple problems to the patient.

The symptoms may resemble maxillary sinusitis like facial pain, blocked nose with discharge, tenderness of orofacial musculature, etc., with the more serious lesions causing mucous discharge tinged or permeated by blood and severe or unbearable pain and pressure along with facial inflammation.

What Are the Objectives and Need of ESS or Caldwell Luc Procedure?

The aim hence be it of the current trending endoscopic sinus surgeries or of the historic and adopted Caldwell-Luc procedure, is the same as to achieve the following objectives after treating the patient:

• Removal of the large foreign bodies or tumor or lesion (cyst or polyp or fistula) in the sinus region.

• Reduction in the frequency or recurrence rate of sinus infections.

• Improvement in patients' sense of smell as well as the breathing (airflow improvement).

• Reduction in the severity of symptoms in the patients suffering from sinus disease.

• Improvement in orofacial and nasal symptoms that would be cumbersome in the long term to the patient.

What Are the Indications For the Surgery?

The indications for this surgery include the following conditions or diseases:

For obtaining access to orbital decompression procedures or orbital floor repair.

• For obtaining access to the exploration of pterygopalatine fossa.

• Excision of tumors involving the antrum like papilloma.

• Oroantral fistulas.

• In maxillary sinusitis.

• Removal of maxillary antrum foreign bodies.

• Multiseptate maxillary sinus mucocele.

• Recurrent polyp.

• Revision procedures.

• Mucociliary damage.

• Kartagener’s syndrome.

• Young’s syndrome.

• In drainage of infected tissue from the maxillary sinus.

How Is the Caldwell Luc Procedure Done?

The two important anatomic landmarks for this surgery are:

1) Canine Fossa:

The thinnest portion that forms the anterior wall of the maxillary sinus. This portion is bound by the canine eminence of the upper or maxillary canine medially and is the easiest to breach for this surgery.

2) The Infraorbital Foramen:

This foramen situated approximately over the roof of the maxillary sinus transmits the neurovascular bundle that supplies the lower eyelid, nose, cheeks, and lip apart from the important vital infraorbital artery and vein.

Care should be taken during the elevation of the anterior wall of the maxillary sinus by the operator to avoid nerve injury. As this surgery or operation is mainly aimed at improving mucosal function and histologic appearance of the maxillary sinus, the advantage is that the access is both safe and easier for the maxillofacial surgeon as compared to the endoscopic sinus surgeries followed by a few practitioners this days. No special instrumentation other than the surgical equipment available in the oral and maxillofacial surgery operation room is needed.

Anesthesia: The surgery is planned under local anesthesia –(1 ml of 2% xylocaine mixed with 1 in 2,00,000 adrenaline) infiltrated over the canine fossa. (Xylocaine is mixed because the process of infiltration would be painless). The inferior orbital nerve and the anterior superior alveolar nerve are blocked by this anesthesia. A cotton pellet soaked in a 4% xylocaine adrenaline mixture can also be placed over the sublabial area to anesthetize the canine fossa mucosa. If general anesthesia is given, then the patient needs to be intubated primarily before positioning for the surgery.

Procedure: The surgeon gives a 3 to 4 cm incision on the buccogingival sulcus at the canine eminence area. The Langenbach's retractor is used to retract the soft tissue and a periosteal elevator to retract the anterior wall of the sinus till the infraorbital bundle is visible. (Care should be taken by the surgeon here to not to damage the bundle). Antrostomy opening round 1.5 to 2 cm diameter by a round cutting bur is done and the instrumentation done through this opening. The diseased mucosa can then be curetted out in direct vision by the operator. Some operators visualize the antrostomy via the inferior meatus (meatus nasi inferior or the air passage of the lateral nasal cavity), opening a nasoantral window.

What Are the Postoperative Complications?

There is no major complication of Caldwell-Luc other than self-limiting edema or swelling over the cheek that reduces within a week usually. However, infraorbital nerve damage, devitalization of tooth roots, or injury to the nasolacrimal duct (inferior meatus visualization as mentioned earlier) may be possible, but these complications differ only and mostly due to the operator’s limitations and skill. After surgery, precautions should be taken to prevent emphysema or edema of the cheek and for reduction of discomfort.

What Precautions Have To Be Followed After the Surgery?

• Ice packs can be given externally to reduce swelling over the affected area.

• Nasal or antral packing that is done by the operator can be removed within 48 hours post-surgery.

• Dentures or other dental appliances should not be worn to facilitate proper wound healing at the surgical site.

• Nose blowing should be avoided.

Conclusion:

Caldwell-Luc surgery thus remains the most effective and applicable management strategy for surgical resolution and elimination of maxillary sinus issues. Proper coordination and interaction between the operator and the patient pre and post-surgery will be useful in managing post-surgical complications, if any.