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Anterior Antrostomy: The Caldwell-Luc Operation


Introduction

The Caldwell-Luc procedure was named after two surgeons, Caldwell and Luc. They both described a similar procedure, with Caldwell advocating an inferior meatal antrostomy and Luc advocating enlargement of the natural ostium in the middle meatus. Caldwell practiced in New York and published a report on anterior antrostomy in the New York Medical Journal in 1896. Luc was French, practiced in Paris, and independently reported his procedure in 1897.

The Caldwell-Luc approach has been used extensively in the past with excellent exposure and classic anatomic landmarks. It was the standard surgical technique for chronic maxillary sinus disease and used gravitational drainage through the inferior meatus ( Fig. 104.1 ). With the development of endoscopic sinus surgery for the treatment of chronic sinusitis as well as facilitating an approach for other conditions, including skull base surgery, most younger surgeons will have had a very limited exposure to this procedure.

Fig. 104.1, Mucociliary flow through the natural ostium. The Caldwell-Luc procedure uses an antrostomy through the inferior meatus, which is essentially drained by gravity.

Open approaches were also used in a number of situations, apart from chronic sinusitis, including a corridor for the transantral ligation of vessels in the pterygopalatine fossa for epistaxis; in Vidian neurectomy, for the repair of fracture of the floor of the orbit, the repair of oroantral fistulas, and the removal of antrochoanal polyps; and as part of the surgical approach in a maxillectomy. While needed less frequently today, it is certainly important to understand and be able to perform the procedure in cases that are not suitable for an endoscopic approach.

Key Operative Learning Points

  • 1.

    The maxillary sinus is entered anteriorly through the thin bone of the canine fossa, which lies lateral to the canine tooth root.

  • 2.

    The contents of the maxillary sinus can be viewed directly and removed with enlargement of the antrostomy.

  • 3.

    The inferior meatal antrostomy (if required) is made below the inferior turbinate 1 to 2 cm behind the anterior tip of the inferior turbinate.

Preoperative Period

History

  • 1.

    History of present illness

    • a.

      Dependent on indications for surgery

    • b.

      Chronic sinusitis with previous surgeries

    • c.

      Immunosuppressed patient with invasive sinusitis, overall medical condition, and underlying coagulopathies

  • 2.

    Past medical treatment

    • a.

      Prior treatment and surgical approaches

    • b.

      Medical illness: specifically a history of bleeding disorders and hypertension. Depending on indications for surgery, the patient may be neutropenic and coagulopathic if surgery is being performed for invasive fungal infection.

  • 3.

    Surgery

    • a.

      Specific details regarding previous sinus surgeries or dental surgery (i.e., odontogenic cysts, maxillary tooth extractions)

  • 4.

    Family history

  • 5.

    Medications

    • a.

      Antiplatelet drugs

    • b.

      Anticoagulation drugs

    • c.

      Herbal products

    • d.

      Alcohol

Physical Examination

  • 1.

    Age and general appearance of patient

  • 2.

    Oral cavity

  • Note whether edentulous or not; the condition of teeth, especially the upper incisors; the site and location of an oroantral fistula, if present. Examine the upper gingivobuccal sulcus.

  • 3.

    Nasal

  • Examine the nasal cavity and perform an endoscopy; check the septum alignment; note the anatomic findings, if previous surgery; check the inferior turbinate location and the relationship to the lateral wall.

  • 4.

    Orbit

  • Document the vision and extraocular movement. If surgery is indicated for a fracture of the orbital floor, document the findings and any muscle entrapment.

  • 5.

    Trigeminal nerve

  • Examine and document the sensation of V2, particularly with regard to the infraorbital nerve.

Imaging

Computed tomography (CT) with contrast (maxillofacial). Images in both the coronal and axial planes define the size and extent of the sinus as well as its relationship to the surrounding structures.

Indications

  • 1.

    Inflammatory disease: chronic maxillary sinusitis, fungal sinusitis, and antrochoanal polyp ( Figs. 104.2 and 104.3 )

    Fig. 104.2, Coronal computed tomography scan in a patient with an antrochoanal polyp. Note the expansion of the natural ostium (arrows) by the polyp.

    Fig. 104.3, Coronal computed tomography scan in a patient with chronic sinusitis and calcified foreign body (“sinolith”).

  • 2.

    Neoplastic disease: biopsy of maxillary sinus tumors, removal of dental tumors, and staging of maxillary carcinoma

  • 3.

    Access to pterygopalatine fossa

  • 4.

    Initial step in medial maxillectomy

  • 5.

    Access to orbital floor for orbital decompression and repair orbital floor fractures

  • 6.

    Closure of oroantral fistula

Contraindications

  • 1.

    Medical complications including uncontrolled hypertension and coagulopathy

  • 2.

    Pediatric patients without secondary dentition

  • 3.

    Initial approach to sinus disease (Functional endoscopic sinus surgery [FESS] should be the initial surgical treatment.)

  • 4.

    Aplastic and hypoplastic maxillary sinus

Preoperative Preparation

  • 1.

    Preoperative medical clearance with optimum stability for elective procedure

  • 2.

    Discontinue antiplatelets and anticoagulants.

  • 3.

    If patient has invasive fungal disease and is immunosuppressed with coagulopathy, a transfusion as needed. Risks of surgery versus disease progression need to be weighed.

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