The Caldwell-Luc operation

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY

CALDWELL-LUC (RADICAL ANTROSTOMY) , INFERIOR MEATAL ANTROS -
TOMY & CANINE FOSSA AND INFERIOR MEATUS PUNCTURES
Johan Fagan

The Caldwell-Luc operation involves
creating an opening into the maxillary
antrum through the canine fossa via a
sublabial approach.

Canine fossa (CFP) & inferior meatal
puncture are used to obtain samples of pus
from the antrum, to irrigate the antrum
(“antral washout”), or as an adjunct to en-
doscopic ethmoidectomy.


Surgical anatomy

The Caldwell-Luc operation involves en-
tering the maxillary sinus via an opening in
the thin bone of the canine fossa (Figures
1-3).


Figure 1: Thin bone of canine fossa (yel-
low arrow); nasolacrimal duct (red arrow)

A series of eminences overlie the roots of
the teeth on the inferior part of the face of
the maxilla (Figures 2, 3). Just above the
eminences of the incisor teeth is a depres-
sion called the incisive fossa; it gives ori-
gin to the depressor alae nasi. The nasalis
muscle arises just lateral to it (Figure 2).


The canine fossa is a depression on the
anterior surface of the maxilla below the
infraorbital foramen and lateral to the ca-
nine eminence and the incisive fossa
(Figures 2, 3). It is larger and deeper than
the incisive fossa, and is separated from it
by the canine eminence, a vertical mound
overlying the socket of the canine tooth.
The caninus muscle arises from the canine
fossa.


Figure 2: Right canine fossa (yellow),
incisive fossa and canine eminence

The infraorbital foramen transmits the in-
fraorbital nerve, artery, and vein. The in-
fraorbital neurovascular bundle traverses a
groove in the orbital floor/roof of the sinus
which can be dehiscent. It exits through the
infraorbital foramen, located approximate-
ly 5mm below the midportion of the infe-
rior orbital rim to enter the soft tissues of
the cheek. Branches of the nerve supply
the lower eyelid, nose, cheek and upper lip
(Figures 3, 4). Care must be taken when
elevating the periosteum from the anterior
Orbital rim

Infraorbital foramen

Inferior turbinate

Canine fossa
Caninus muscle
Incisive fossa
Nasalis muscle
Depressor alae nasi
Canine eminence
Canine tooth

Incisors

2
wall of the sinus to avoid injury to the
infraorbital nerve where it exits the canal.
Branches of the anterior and posterior su-
perior alveolar nerves travel through bone
to supply the upper teeth and gums (Fig-
ures 3, 4). These nerves may be injured
when extending the antrostomy too low
and cause loss of sensation to the teeth and
gums.


Figure 3: Infraorbital nerve and branches
of the anterior superior alveolar and pos-
terior superior alveolar nerves; antros-
tomy in canine fossa (red circle); stippled
lines indicate nerves within the bone


Figure 4: Branches of V2 (An Atlas of
Anatomy, by regions; 1962: Grant)

The maxillary sinus is lined by ciliated co-
lumnar epithelium. The cilia move secre-
tions toward the natural sinus ostium; this
explains the limited efficacy of an inferior
meatal antrostomy. The adult maxillary si-
nus is 25-35mm wide, 36-45mm high, and
38-45mm long, and has an average volume
of 15ml. The superior wall is formed by
the orbital floor which is thin and often de-
hiscent. The infraorbital nerve is in the
roof of the sinus. Medially and posteriorly
the roof is composed of the floor of the
ethmoid sinuses (Figure 10). The anterior
wall contains the nerves and vessels that
supply the upper teeth. It is thinner ante-
riorly and thickens posterolaterally where
it joins the zygomatic process (Figure 1).
Septae are present in about a third of cases,
mainly anteriorly (Figure 1). The medial
wall of the maxillary sinus separates it
from the nasal cavity (Figures 5, 6).


Figure 5: Lateral view with windows cut in
lateral and medial walls of maxillary sinus

The inferior turbinate is attached along the
nasal wall below the level of the maxillary
sinus ostium (Figure 6). The nasolacrimal
duct traverses the thicker bone at the
junction of the medial and anterior walls
before opening into the nose below the in-
ferior turbinate (Figures 1, 12). The sinus
communicates with the nasal cavity via the
maxillary sinus ostium in the hiatus semi-
Orbital process pal bone
Pyramidal process palatine of
bone
Lateral pterygoid
plate
Pterygoid canal
Foramen rotundum
Palpebral branches
Infraorbital nerve
Nasal branches
Labial branches

Ant superior
alveolar nerve
Septal branch

Branches of post
sup alveolar nerve
Branches to teeth
Branches to gums
Frontal sinus
Post ethmoidal foramen
Sphenopalatine for
Anterior ethmoidal
foramen
Lacrimal fossa
Uncinate
Max sinus ostium
Inferior turbinate
Palatine bone

3

Figure 6: Bony anatomy of the lateral wall
of the nose

lunaris of the middle meatus (Figures 8,
9). The posterior wall is the infratemporal
surface of the maxilla and separates the
sinus from the pterygomaxillary fissure
and the pterygopalatine fossa which con-
tains the internal maxillary artery and its
branches and the pterygopalatine ganglion
and its branches (Figure 4).

The radiological anatomy of the maxillary
sinus is assessed on plain X-rays or by co-
ronal and axial CT scans and is essential to
do prior to a Caldwell-Luc procedure (Fi-
gures 1, 7-13). Figures 7-10 demonstrate
the coronal anatomy at the anterior, mid-
and posterior maxillary sinus. Figure 11) is
a slice immediately behind the maxillary
sinus in which the internal maxillary arte-
ry and its branches as well as the spheno-
palatine ganglion and its branches are
encountered within the pterygopalatine
fossa. The pterygopalatine fossa communi-
cates laterally with the infratemporal fossa
via the pterygomaxillary fissure and me-
dially with the nasal cavity via the spheno-
palatine foramen.




Figure 7: Coronal CT slice through lacri-
mal fossa


Figure 8: Coronal plane through anterior
ethmoids midway along the maxillary sinus


Figure 9: Anatomy at uncinate process

Frontal sinus
Crista galli
Sella turcica
Uncinate
Pterygoid hamulus
Maxillary
sinus ostium
Medial pterygoid plate
Anterior cranial fossa floor

Frontonasal duct

Lacrimal sac in lacrimal fossa

Anterior end of maxillary sinus

Inferior turbinate
Floor anterior cranial fossa

Lamina papyracea

Middle turbinate

Uncinate process

Infraorbital nerve

Maxillary sinus

Inferior turbinate
Fovea ethmoidalis

Anterior ethmoidal foramen

Lamina papyracea

Uncinate process

Infraorbital nerve

4

Figure 10: Coronal slice through posterior
maxillary sinus; note its relationship to the
ethmoids


Figure 11: Coronal cut immediately be-
hind the maxillary sinus

Figures 12 & 13 show axial views demon-
strating the pterygopalatine fossa, pterygo-
maxillary fissure and pterygoid plates.
Imaging may also reveal important anato-
mical variations that can affect the surgical
approach e.g. congenital hypoplasia
(Figure 14).


Figure 12: Axial cut at level of infraorbital
nerve and orbital floor


Figure 13: Axial cut at level of infraorbital
foramen and pterygoid plates


Figure 14: Hypoplastic maxillary sinus

The dimensions of the maxillary sinus
change with age, and may affect surgery.
Expansion at 2-3 mm/year of the maxillary
sinuses continue until adulthood. At birth
they are small and the floors of the sinuses
are approximately 4mm above the nasal
floor; at 8-9 years of age the floors of the
sinuses and nasal cavity are at about the
same levels and the sinus dimensions are 2
x 2 x 3cms. In adults the sinus floor is 0.5-
1 cm below that of the nasal cavity (Figure
15). The maxillary alveolus atrophies in
edentulous patients so that the floor may
be even lower.

Infraorbital foramen

Inferior turbinate

Zygoma

Pterygomaxillary fissure

Pterygoid plates
Infraorbital nerve

Nasolacrimal duct

Zygoma

Pterygomaxillary
fissure

Pterygopalatine fossa


Posterior ethmoidal foramen

Optic nerve

Lamina papyracea

Ground lamella

Inferior orbital fissure
Orbital apex

Sphenopalatine foramen

Pterygopalatine fossa

Pterygomaxillary fissure

Pterygoid plates

5

Figure 15: Floor of sinus lower than nasal
floor in adults

No significant vessels are encountered dur-
ing Caldwell-Luc antrostomy other than
the small infraorbital vessels that exit the
infraorbital foramen to supply the over-
lying soft tissues of the face (Figure 16).


Figure 16: Vasculature around the orbit

Only if one breaks through the posterior
wall of the sinus does one encounter the
internal maxillary artery, a branch of the
external carotid artery, which, passes
through the pterygomaxillary fissure to
enter the pterygopalatine fossa (Figures
17, 18).


Figure 17: Branches of internal maxillary
artery; blue shaded area is the 2
nd
part of
artery before it enters the pterygopalatine
fossa


Figure 18: Branches of internal maxillary
artery


Caldwell-Luc / Radical antrostomy

The Caldwell-Luc operation involves
making an opening in the thin bone of the
canine fossa and entering the maxillary
sinus. It was first employed to remove in-
fection and to strip diseased mucosa from
the maxillary sinus; counter-drainage into
the nose was established via an inferior
meatal antrostomy. However with an im-
proved understanding of sinus pathophy-
siology, and introduction of endoscopic,
mucosa-sparing functional sinus surgical
Angular vein
Angular artery
Infraorbital
artery

6
techniques, the Caldwell-Luc procedure is
now infrequently used to treat sinusitis.

Indications

• Biopsy or resection of tumours of the
nose and paranasal sinuses
• Transantral access for tumours in the
pterygopalatine fossa
• Transantral ligation of internal maxil-
lary artery and its branches for epi-
staxis
• Transantral access for fractures of the
midface and orbital floor
• Orbital decompression
• As part of medial maxillectomy pro-
cedure e.g. to resect juvenile naso-
pharyngeal angiofibromas
• Removal of foreign bodies e.g. bullets
or dental roots, from the antrum
• Removing base of antrochoanal polyp
• Transantral ethmoidectomy approach
to ethmoids and sphenoid e.g. for pitui-
tary resection
• Repairing oroantral fistulae
• Dental cysts
• Vidian neurectomy
• Chronic sinusitis in the absence of en-
doscopic sinus surgery facilities

Age considerations

Caldwell-Luc is generally contraindicated
if <7yrs of age
• Expansion of maxillary sinus continues
until adulthood at 2-3 mm/year
• At birth, the floor of sinus approx.
4mm above nasal floor
• At 8-9 years: Floors of sinus and nasal
cavity about at same level, and sinus
dimensions 2 x 2 x 3cms
• Adult: Sinus floor usually 5-10 mm
lower than nasal cavity




Imaging

This is routinely done to assess the size of
the sinus and the height of its floor relative
to the nasal floor, to exclude hypoplasia
and unerupted dentition, and to evaluate
underlying pathology. Even though centres
may only have access to sinus X-rays, CT
scan is a far superior investigation. Both
axial and coronal CT should be requested.
Coronal views provide information about
the orbit, orbital floor, sinus floor and al-
veolus, and lateral wall of the nose and si-
nus ostia. Axial views provide information
about the anterior wall of the sinus, the
pterygopalatine fossa and infratemporal
fossa (Figures 1, 12, 13). MRI may be use-
ful to assess pathology as it distinguishes
between soft tissue and mucus.

Consent

• Sublabial incision
• Possibility of sensory loss of cheek,
lower eyelid, side of nose, upper gum
and teeth
• Change in facial contour: initial swell-
ing of cheek, and if large antrostomy,
hollowing of cheek
• Risk of oroantral fistula

Anaesthesia

• General or local anaesthesia block