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| CASE REPORT |
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| Year : 2022 | Volume
: 16
| Issue : 2 | Page : 171-173 |
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Caldwell Luc in the era of endoscopic approach for maxillary sinus
Rajashekhar D Gadad1, Vivek Saxena2, H Rangarajan2
1 Dental Centre, Malad, Military Dental Centre, Mumbai, Maharashtra, India
2 Army Dental Centre (R and R), New Delhi, India
| Date of Submission | 10-Jun-2021 |
| Date of Decision | 13-Feb-2022 |
| Date of Acceptance | 14-Jul-2022 |
| Date of Web Publication | 21-Dec-2022 |
Correspondence Address:
Rajashekhar D Gadad
Military Dental Centre, Malad, Mumbai - 400 097, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jodd.jodd_16_21
Caldwell Luc is a historical procedure for the maxillary sinus, which is more than 100-year-old and is still a useful procedure of choice among surgeons in certain maxillary sinus pathologies. In the era of endoscopic sinus surgeries, the usefulness of Caldwell Luc is often questioned. We report two cases of chronic maxillary sinus disease one with an iatrogenic tooth root in the sinus for 2 years and the other with a mucosal polyp both of which were managed endoscopically earlier but with recurrence of symptoms. Both the cases were managed using a modified Caldwell-Luc approach. The patients were asymptomatic postoperatively with no recurrence.
Keywords: Caldwell Luc, endoscopic sinus surgery, inferior meatal antrostomy, maxillary sinus
How to cite this article:
Gadad RD, Saxena V, Rangarajan H. Caldwell Luc in the era of endoscopic approach for maxillary sinus. J Dent Def Sect. 2022;16:171-3 |
| Introduction | |  |
In this era of endoscopic surgeries, an open and direct approach to the maxillary sinus the Caldwell Luc raises eyebrows among surgeons. A historical procedure for the maxillary sinus, which is more than a 100-year-old and is still the procedure of choice among surgeons for various maxillary sinus pathologies. George Caldwell and Henri Luc found the easiest way to reach the maxillary sinus with adequate exposure, which is relevant till today.[1],[2]
In the present-day scenario with the use of advanced endoscopes available Caldwell Luc is used as a last resort of surgical treatment for maxillary sinus pathologies. Chronic maxillary sinus infections are one of the most difficult to treat despite antrostomy and good endoscopic techniques. Caldwell Luc as a first-line surgical technique is used in recurrent chronic maxillary sinus infections that have iatrogenic causes such as over instrumentation or displacement of a maxillary tooth root into the sinus, dental cysts, recurrent antrochoanal polyps which have recurred and have failed to be removed through endoscopic techniques, malignant tumors where an extensive approach to pterygopalatine fossa is required, approach to vidian canal, and ligation of the internal maxillary artery. Caldwell Luc becomes the preferred choice after functional endoscopic sinus surgery (FESS) in such cases.[3] We report two cases where the Caldwell-Luc technique was used after endoscopic approaches to the maxillary sinus.
| Case Reports | | |
Case-1
A 38-year-old female visited our center with a primary complaint of pain in her left upper teeth and maxillary sinus (L) region for 2 years. On eliciting the history, she had a chronic sinus infection for the past 4 years, which was accompanied sometimes with pus discharge and was not responding to treatment. The individual gave a history of undergoing a traumatic tooth extraction a few years back after which she developed pain and some watery discharge from the nose for a few days. She took symptomatic treatment for the same with relief in symptoms, but there was a recurrence in the symptoms after a few weeks. She had undergone repeated consultations and had undergone endoscopic surgery for the same without any relief. A digital orthopantomogram was done, and a radiopaque mass in the maxillary sinus (L) was confirmed as the tooth root of the extracted maxillary first molar [Figure 1]. The case was discussed with the ear, nose, and throat (ENT) specialist, and a Caldwell-Luc approach instead of an endoscopic approach was planned for surgery. The Caldwell-Luc approach was used to remove the tooth root [Figure 2] and the entire maxillary sinus lining was removed along with thorough irrigation as it was infected, and a yellowish white fluid was present in the entire sinus which was sent for culture and sensitivity testing. Antibiotic (Augmentin 625 mg every 8 hourly) was prescribed for 10 days till the symptoms subsided. The case was followed up with no recurrence in symptoms. | Figure 1: Preoperative OPG showing tooth root in the maxillary sinus (l). OPG: Orthopantomogram
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 | Figure 2: Intraoperative maxillary sinus (l) opening with tooth root in sinus
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Case-2
A 34-year-old male reported to our center with a history of recurrent swelling in the nasolabial region (L) that subsides on its own after some fluid drains out of the swelling through the nose. On eliciting the history, the individual gave a history of chronic recurrent sinusitis for which he had undergone treatment but was not responding to treatments. The patient's history revealed that the individual had already undergone conservative endoscopic procedures and repeated conservative antibiotic therapies previously with relief in his symptoms for a few weeks, followed by recurrence of symptoms and had come for a consultation now. The computed tomography and radiographs revealed a large polyp in the maxillary sinus (L) and multiple polyps in the ethmoidal sinus [Figure 3]. The case was discussed with the ENT specialist and a Caldwell-Luc approach instead of an endoscopic approach was planned for surgery with removal of the maxillary polyp, followed by antibiotics and steroid treatment for the remaining ethmoid and frontal sinus polyps. Caldwell-Luc approach was used and the entire polyp with its intact lining and its contents was removed [Figure 4], and thorough irrigation and closure were done. A 10-day course of antibiotic (Augmentin 625 mg 8 hourly) along with systemic corticosteroid (Dexamethasone 8 mg) in tapering dose was prescribed, and the case was followed up with no recurrence in symptoms. | Figure 3: (a) 3 (b) CT scan depicting mucosal cyst in the maxillary sinus (L). CT: Computed tomography
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 | Figure 4: Entire cyst with its contents removed from a maxillary sinus (l)
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| Discussion | | |
Despite the success of the endoscopic technique, there are still several well-documented indications for the Caldwell-Luc operation because the procedure provides good access to the sinus, perisinus, and pterygomaxillary fossa. One of the main limitations of the endoscopic approach is that the lateral wall of the maxillary sinus is difficult to visualize which might require multiple entry points. Current indications include intrasinus cysts and tumors, intrasinus foreign bodies, oroantral fistulae, maxillary osteonecrosis, epistaxis control, sinusitis with irreversible mucosal change, mycotic fungal balls, and facial trauma.[4],[5]
In the standard Caldwell-Luc operation, inferior meatal antrostomy is usually performed to promote postoperative drainage of bloody discharge or sloughs through gravity.[6] There is controversy about the need for inferior meatal antrostomy for the Caldwell-Luc operation. The Caldwell-Luc operation does not preserve the integrity of the natural mucociliary pathway, and the regenerated sinus mucosa often lacks an adequate mucociliary function and there is a high incidence of stenosis or complete closure of the small inferior meatal antrostomies.[7],[8] These factors pose a disadvantage because the creation of an inferior meatal nasoantral window may not provide a physiologic drainage pathway. The modified Caldwell-Luc procedure provides easier postoperative care and fewer complications and can be the treatment of choice in odontogenic sinus disease.[9]
A few of the reported complications of standard Caldwell-Luc operation include facial swelling (90%), cheek discomfort (33%), fever (12%), hemorrhage, facial asymmetry, facial paresthesia, oroantral fistula, dacryocystitis, devitalized teeth, recurrent polyps, and recurrent sinusitis.[10] With the increasing use of endoscopic techniques, many authors have compared the effectiveness of the endoscopic approach (FESS) with the Caldwell-Luc operation, but the issue still needs a thorough review.
| Conclusion | | |
Caldwell-Luc procedure is a safe and effective procedure and can be used to manipulate the sinus wall completely, the modification of this procedure without an inferior meatal antrostomy was used in our cases with no complications and good postoperative results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Caldwell GW. Diseases of the accessory sinuses of the nose and an improved method of treatment of suppuration of the maxillary antrum. New J Med J 1893;58:526-8.  |
| 2. | Terrell JE. Primary sinus surgery. In: Cummings CW, editor. Otolaryngology Head and Neck Surgery. 3 rd ed., Vol. 2. St. Louis: Mosby; 1993. p. 1171. |
| 3. | Cutler JL, Duncavage JA, Matheny K, Cross JL, Miman MC, Oh CK. Results of Caldwell-Luc after failed endoscopic middle meatus antrostomy in patients with chronic sinusitis. Laryngoscope 2003;113:2148-50. |
| 4. | Barzilai G, Greenberg E, Uri N. Indications for the Caldwell-Luc approach in the endoscopic era. Otolaryngol Head Neck Surg 2005;132:219-20. |
| 5. | Matheny KE, Duncavage JA. Contemporary indications for the Caldwell-Luc procedure. Curr Opin Otolaryngol Head Neck Surg 2003;11:23-6. |
| 6. | Saito H, Takanami N, Saito T, Wakui S, Fujieda S. Studies on the Caldwell-Luc operation with or without counteropening at the inferior meatus. ORL J Otorhinolaryngol Relat Spec 1990;52:249-53. |
| 7. | Lund VJ. Inferior meatal antrostomy. Fundamental considerations of design and function. J Laryngol Otol Suppl 1988;15:1-18. |
| 8. | Forsgren K, Fukami M, Penttilä M, Kumlien J, Stierna P. Endoscopic and Caldwell-Luc approaches in chronic maxillary sinusitis: A comparative histopathologic study on preoperative and postoperative mucosal morphology. Ann Otol Rhinol Laryngol 1995;104:350-7. |
| 9. | Huang YC, Chen WH. Caldwell-Luc operation without inferior meatal antrostomy: A retrospective study of 50 cases. J Oral Maxillofac Surg 2012;70:2080-4. |
| 10. | Penttilä MA, Rautiainen ME, Pukander JS, Karma PH. Endoscopic versus Caldwell-Luc approach in chronic maxillary sinusitis: Comparison of symptoms at one-year follow-up. Rhinology 1994;32:161-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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