Caldwell Luc Procedure: Indications, Technique, and Care

The Caldwell-Luc procedure is a surgical approach used to access the maxillary sinus, often for chronic infections or removal of pathological tissue. Though less common today due to advances in endoscopic techniques, it remains relevant when other interventions are insufficient.

Anatomical Relevance

This procedure is rooted in the anatomy of the maxillary sinus and its surrounding structures. The maxillary sinus, the largest of the paranasal sinuses, is a pyramidal cavity within the maxilla, bordered by the orbit superiorly, the nasal cavity medially, and the pterygopalatine fossa posteriorly. It drains through the ostiomeatal complex into the middle meatus of the nasal cavity, a pathway that can become obstructed due to chronic inflammation, polyps, or tumors. The Caldwell-Luc procedure provides direct access to this sinus through the anterior maxillary wall, bypassing the natural ostium when endoscopic approaches are inadequate.

The anterior wall, or canine fossa, is a thin bony structure located above the maxillary premolars and first molar, making it an ideal entry point. Dental infections frequently extend into the sinus, necessitating surgical drainage. The infraorbital nerve, which exits the infraorbital foramen just above the canine fossa, must be carefully avoided to prevent sensory disturbances in the midface. The posterior sinus wall is adjacent to the pterygopalatine fossa, which houses the maxillary artery and its branches, posing a risk of vascular injury if dissection extends too far posteriorly.

The sinus’s relationship with the orbit is another critical factor in surgical planning. The thin orbital floor, which also serves as the sinus roof, can be compromised by infections or tumors, leading to complications like orbital cellulitis or proptosis. The Caldwell-Luc approach allows for direct visualization and removal of pathological tissue in cases where endoscopic access is insufficient. Additionally, the medial wall, which separates the sinus from the nasal cavity, contains the nasolacrimal duct, which must be preserved to prevent postoperative epiphora.

Indications

The Caldwell-Luc procedure is indicated for maxillary sinus conditions that do not respond to conservative or endoscopic treatments. Chronic maxillary sinusitis persisting despite medical therapy remains a common reason for this surgery. Patients with recurrent infections, particularly those with ostial obstruction, may experience persistent facial pain, nasal congestion, and purulent drainage. When functional endoscopic sinus surgery (FESS) fails due to anatomical variations, scarring, or extensive mucosal disease, the Caldwell-Luc procedure provides an alternative means of drainage and ventilation.

Beyond infection, this procedure is used in managing maxillary sinus neoplasms. Benign tumors like inverted papillomas, which have a high recurrence rate, may require this approach for complete removal. Malignant lesions, including squamous cell carcinoma or adenoid cystic carcinoma, may also necessitate this technique when an open approach is required for biopsy or resection. In cases where tumors extend into adjacent structures, the procedure facilitates broader surgical access for complete excision.

Odontogenic infections and cysts are another major indication. Dental pathology, including periapical abscesses, dentigerous cysts, and odontogenic keratocysts, can extend into the sinus, leading to persistent infection and bone erosion. When conservative dental treatments are insufficient, surgical debridement of the sinus is necessary. Oroantral fistulas—abnormal connections between the oral cavity and maxillary sinus, often resulting from dental extractions or trauma—can also be effectively repaired using this approach when conservative methods fail.

Maxillary sinus trauma, particularly cases involving displaced fractures or retained foreign bodies, can be managed with this procedure. Orbital floor fractures with significant sinus involvement may also benefit when endoscopic visualization is limited. Chronic fungal sinusitis, especially in immunocompromised patients, may require extensive surgical debridement beyond what endoscopic methods can achieve.

Technique Outline

The procedure is performed under general anesthesia. A local anesthetic with epinephrine is injected into the gingivobuccal sulcus above the maxillary premolars to provide hemostasis and postoperative analgesia. A mucoperiosteal incision is made in the sulcus, extending from the canine to the first molar, allowing elevation of soft tissue and exposure of the anterior maxillary wall.

A small bony window is created in the canine fossa using a drill or osteotome, carefully avoiding the infraorbital nerve. Once the bony defect is made, the underlying sinus mucosa is incised and elevated, granting direct access to the cavity. Any pathological contents, including inflamed mucosa, polyps, or neoplastic tissue, are debrided using curettes and suction. The sinus walls are inspected for additional pathology, and further resection is performed if necessary.

To improve long-term drainage, the maxillary sinus ostium is often enlarged into the inferior meatus, a step known as inferior meatal antrostomy. This enhances postoperative aeration and reduces the risk of recurrent obstruction. In cases of chronic infection, irrigation with sterile saline or antibiotics may be performed. When addressing odontogenic infections or oroantral fistulas, reconstructive measures such as soft tissue grafting or buccal advancement flaps may be used to promote healing.

Postoperative Care

Recovery requires a structured approach to minimize complications and support healing. Pain management typically involves acetaminophen or NSAIDs, though opioids may be prescribed for severe discomfort. Swelling and bruising around the midface are common due to soft tissue and bone manipulation, peaking within 48 hours before gradually subsiding. Cold compresses can reduce edema, and patients are advised to sleep with their head elevated to limit fluid accumulation.

Nasal congestion and mild epistaxis are expected due to mucosal disruption. Saline nasal irrigation helps keep passages clear and prevents crusting, which can contribute to secondary infection or delayed healing. Antibiotics may be prescribed if extensive infection was present, though routine prophylaxis is debated. Patients should avoid forceful nose blowing, sneezing with their mouth closed, or activities that increase sinus pressure, as these can disrupt surgical repair.

Follow-up visits assess wound healing and ensure adequate sinus ventilation. The oral surgical site is monitored for infection, dehiscence, or persistent fistula formation, which may require further intervention. If an inferior meatal antrostomy was performed, endoscopic examination confirms patency and assesses for residual obstruction. Over time, mucosal regeneration restores normal sinus function, though patients with chronic rhinosinusitis may require ongoing management to prevent recurrence.