Caldwell-Luc operation

The Caldwell-Luc operation uses an external approach for surgical treatment of the severely diseased maxillary sinus. It is an alternative to middle meatal antrostomy done via endonasal endoscopic surgery and was the primary approach used for accessing the maxillary sinus before the advent of endoscopic sinus surgery.

The Caldwell-Luc operation is reserved for selected patients with an extensive maxillary disease, particularly those with massive polyposis or fungal disease. Failure to clear the maxillary mucosa completely could result in early postoperative recurrence of disease. The anterior and inferior regions of the maxillary antrum are especially difficult to access endoscopically.

Indications

• complicated acute or chronic rhinosinusitis, usually as an adjunct to endoscopic sinus surgery (ESS)
• pterygomaxillary space surgery
• trauma, e.g. maxillary floor fractures
• foreign body retrieval
• benign tumor removal
• combined with ESS: orbital decompression and inverting papilloma removal

Technique

• under general anesthesia, lidocaine-epinephrine solution is injected into gingivobuccal sulcus, and vasoconstrictor-soaked pledgets are placed in nasal cavity
• incision made in gingivobuccal sulcus above canine fossa
• incision continued through periosteum, which is then elevated superiorly and infraorbital nerve identified
• window cut into maxillary antrum with osteotome
• punch forceps can be used to enlarge window
• curved hemostat passed into sinus under inferior nasal concha to create antrostomy
• maxillary sinus can now be visualized through both windows and debridement (or any other procedure; see "indications" above) commences
• gingival incision is then closed with absorbable sutures

Caveats

• to avoid damage to nasolacrimal duct, antrostomy should be created at least 1 cm posterior to anterior edge of inferior concha
• in children, incision should be made above secondary dentition. Visualization by CT or even plain radiographs can be used to avoid injury

Complications

• recurrent nasal obstruction (most common)
• recurrent sinusitis
• recurrent polyposis
• facial numbness
• facial asymmetry
• wound dehiscence
• oro-antral fistulae
• dacryocystitis
• devitalised teeth

The Caldwell-Luc operation has largely been replaced by the canine fossa puncture (CFP) technique³, whereby debridement is performed through a 4 mm trocar under direct visualization. Being minimally invasive, CFP is associated with a lower complication rate.

History and etymology

The technique was first described by George W Caldwell in 1893 and Henri Luc in 1897.