Sinus Surgical Approaches

1. Caldwell-Luc Procedure (Canine Fossa Approach to the Maxillary Sinus)

History

Principle

Technique

1. General anesthesia; inject gingivobuccal sulcus with 1% lidocaine + 1:100,000 epinephrine
2. Incision in the gingivobuccal sulcus, above the canine fossa (in children, placed above secondary dentition using plain radiographs)
3. Periosteum incised and elevated superiorly until the infraorbital nerve is identified and protected
4. A 4-mm osteotome or drill outlines a window into the maxillary antrum; the anterior wall is thin and entered with gentle tapping
5. Window enlarged with punch forceps or drill
6. Intranasal antrostomy created by passing a curved hemostat under the inferior turbinate into the sinus - placed at least 1 cm posterior to the anterior end of the inferior turbinate (to avoid damage to the nasolacrimal duct and anterior superior alveolar nerve)
7. Partial inferior turbinate removal or stenting prevents closure
8. Gingivobuccal incision closed with absorbable sutures

Fig. (A) Incision in the gingivobuccal sulcus above the canine fossa. (B) Window drilled into the antrum; nasoantral window created at the inferior meatus.

Current Indications (limited)

• Complicated acute or chronic rhinosinusitis not amenable to endoscopy
• Pterygomaxillary space surgery
• Facial trauma
• Foreign bodies
• Benign tumors (e.g., inverting papilloma in inaccessible locations)
• Canine fossa trephination: Samter's triad, allergic fungal sinusitis (removal of debris/polyps), combined with endoscopy for orbital decompression

Complications

• Facial asymmetry
• Facial numbness (infraorbital/anterior superior alveolar nerve neuropraxia)
• Oroantral fistula
• Wound dehiscence
• Dacryocystitis
• Devitalized teeth
• Recurrent sinusitis / polyposis

2. Intranasal Ethmoidectomy

• Classical open approach using a nasal speculum and headlamp (no endoscope)
• Largely replaced by endoscopic approaches
• Complication rates: 1.1-2.8%; few surgeons use it today

3. External Ethmoidectomy (Gull-Wing / Lynch Incision)

Indications

• Orbital complications of acute rhinosinusitis (subperiosteal abscess) where endoscopic visualization is limited by edema
• Access to the anterior ethmoidal artery
• Drainage of periorbital abscesses

Technique

1. Temporary tarsorrhaphy on ipsilateral eye; nasal cavity decongested
2. Gull-wing incision (reduces postoperative medial canthal contracture) made midway between the medial canthus and nasal midline
3. Incision through periosteum; lacrimal sac elevated from its fossa
4. Malleable retractor protects orbital contents
5. Periosteum elevated posteriorly until anterior ethmoidal artery identified (in the frontoethmoid suture line) and ligated
6. Ethmoidal complex entered through lacrimal fossa or dehiscent lamina papyracea
7. Dissection guided by the basal lamella; skull base identified in posterior ethmoids
8. Dissection must not go higher than the frontoethmoid suture line (skull base level)
9. Periosteum formally reattached at the trochlea (non-dissolvable suture) to minimize diplopia
10. Two-layer closure with external drain

Complications

4. External (Lynch-Howarth) Frontoethmoidectomy

• Historical procedure - largely replaced by endoscopic techniques
• ~1/3 of patients develop stenosis postoperatively
• Conceptually flawed: removed the bony support of the frontal recess, resulting in scarring/fibrosis obstructing the outflow tract
• Via a Lynch incision (slightly curved, halfway between nasal dorsum and medial canthus)
• Today, a Lynch incision is still used for: accessing the anterior ethmoidal artery, draining periorbital abscesses, and (if extended superolaterally) trephining the floor of the frontal sinus

5. Frontal Sinus Trephination

Acute setting

• For complicated acute frontal sinusitis not responding to medical management
• Small incision (1-1.5 cm) below medial eyebrow, through periosteum
• Drill makes a window at the junction of the floor and anterior wall of the frontal sinus
• Sinus irrigated and drain placed

Mini-trephine (chronic disease)

• Useful when the frontal sinus outflow tract is difficult to detect endoscopically
• Fluorescein-stained saline irrigation can guide frontal recess dissection
• Always aspirate before irrigating; caution if orbital dehiscence present
• Pre-op CT essential to define depth and extent of pneumatization
• Complications: intracranial penetration, CSF leak, periorbital trauma, incision infection

6. Osteoplastic Flap (With or Without Sinus Obliteration)

Indications

• Extensive osteomyelitis of the frontal sinus
• Endoscopically inaccessible tumors
• Loculated disease/post-traumatic collapse with surrounding bone loss
• Failed Draf III procedure

Technique

1. Coronal flap (zigzag incision disguises scar in male-pattern baldness) or eyebrow / deep wrinkle incision
2. Sterilized template of frontal sinus made from preoperative Caldwell view radiograph or 3D CT model (or guided by image-guided surgery / IGS)
3. Periosteum dissected off frontal bone down to supraorbital margins
4. Initial hole made into sinus in its medial third (not high in the midline - risk of venous sinus bleeding)
5. Blunt-ended hook used to palpate the sinus limits; fissure burr follows the outline
6. Miniplates fixed before full removal of anterior wall (for accurate replacement)
7. All mucosa must be removed (including drilling the posterior wall to clear mucosa following the veins of Breschet); residual mucosa risks mucocele formation
8. Sinus obliterated with fat (e.g., abdominal fat); frontal recess separated from nasal airway with fascia lata or calvarial bone pieces
9. Anterior bony wall replaced and secured with miniplates
10. Tight crepe bandage applied; prophylactic antibiotics given

7. Approaches to the Sphenoid Sinus

• Transseptal and transethmoid approaches
• Can be performed with headlamp or microscope, but now routinely done with endoscopic guidance

8. Endoscopic Sinus Surgery (FESS) - Reference Standard

Summary Table

• Cummings Otolaryngology Head and Neck Surgery, Ch. 44, pp. 897-899
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 1, Ch. 99, pp. 1144-1145

When is Caldwell-Luc Preferred Over FESS?

Core Principle

Specific Situations Where Caldwell-Luc is Preferred (or Used as Adjunct)

1. Massive/Refractory Maxillary Polyposis or Fungal Concretions

• In severe allergic fungal sinusitis, endoscopic antrostomy alone may not allow complete removal of densely packed fungal concretions or mucin, especially from the anterior and inferior recesses
• Samter's triad (aspirin sensitivity + nasal polyposis + asthma): canine fossa trephination helps debulk polyps and debris inaccessible endoscopically
• Radiopaedia notes: "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"

2. Inverting Papilloma with Maxillary Sinus Involvement

• Inverting papillomas require complete removal at the attachment site to prevent recurrence (recurrence rates are high if any residual mucosa is left)
• When the attachment is on the anterior wall, floor, or anterolateral wall, endoscopic access is inadequate
• Caldwell-Luc combined with FESS allows direct visualization and drilling/resection of the bony attachment site

3. Orbital Decompression

• Used as an adjunct to endoscopic surgery when additional access to the orbital floor/medial wall is needed from the anterior direction
• Canine fossa trephination combined with FESS improves access and visualization

4. Pterygomaxillary Space Surgery

• Lesions of the pterygopalatine fossa or pterygomaxillary space (e.g., juvenile nasopharyngeal angiofibroma extension, schwannomas) may require the Caldwell-Luc approach for adequate access to the posterior maxillary wall

5. Trauma

• Maxillary floor (blow-out) fractures: Caldwell-Luc provides direct access to reduce and stabilize the orbital floor from below
• Foreign bodies in the maxillary sinus, particularly those lodged anteriorly or in the floor

6. Benign Tumors

• Tumors within the maxillary antrum that cannot be adequately approached endoscopically (due to size, position, or attachment)

7. Complicated Acute Rhinosinusitis

• Severe acute maxillary sinusitis not responding to antibiotics, where drainage is urgently needed and the natural ostium cannot be safely/adequately accessed

8. Failed FESS / Revision Surgery

• Scarring from prior FESS may distort anatomy, making endoscopic access to anterior recesses impossible
• Caldwell-Luc can be added to clear residual anterior disease

Caldwell-Luc vs FESS: Key Comparison

Bottom Line

1. Anteroinferior/lateral maxillary lesions that an endoscope cannot physically reach
2. Complete mucosal extirpation when bulk of disease (massive fungal, polyp disease) makes endoscopic clearance incomplete
3. Structural/surgical access indications - orbital floor fractures, pterygomaxillary tumors, foreign bodies
4. Inverting papilloma resection at anterior/floor attachments

• Cummings Otolaryngology Head and Neck Surgery, Ch. 44, p. 897
• Radiopaedia: Caldwell-Luc operation
• Medscape: Surgical Treatment of Chronic Maxillary Sinusitis