The Caldwell-luc procedure Radical antrostomy. Definition- Entering the maxillary sinus through mouth through an incision in buccal mucosa in canine region of maxilla with removal of all diseased mucosa and formation of antrostomy in inferior meatus.
History Christopher Heath Of University College in London- 1889:trephination of canine fossa. 1893: George Caldwell( ) –American surgeon-New York medical journal-antrostomy Henri Luc( ) –French laryngologist of Paris. Luc - Europe Caldwell – America.
Indications: Chronic maxillary sinusitis: Intractable sinus infection: irreversibly diseased epithelial lining of maxillary antrum- 1. failure from conservative treatment: 2. Incessant purulent discharge even with patent transnasal antromeatal window. Repeated sinus infection: conservative treatment+ to prevent chronicity, involvement of adjoining sinuses or complications. Endoscopic surgery: Failure unapprochable sites
revision of transnasal antromeatal window: Failiure of transnasal operation to maintain antromeatal fenestra. Better visualization with wider fenestra-increased patency. Maxillary sinusitis +bronchiectasis: Presistent purulent drainage from antrum calls for radical eradication.
antrochoanal polyp- evulsion– recurrance-polyp excised at its wall of maxillary antrum. oroantral fistula: Biopsy : maxillary antrum. Antrostomy prior to radiotherapy
Mucocele: Open approach: ESS: accessible through middle meatus antrostomy Away from natural ostium: post CL procedure. Post traumatic extension of mucocele outside sinus through anterior and lateral wall Mucous retention cyst: Signs of growth Bone erosion Obstructing drainage. Subtotal or total removal via ESS Recur /large to cause bony errosion then CL.
Facial trauma Foreign body: displaced dental root, missile: Blow out fracture of orbit: Fresh fractures-periorbital tissues reduced —antrum packed/balloon placed. Delayed fracture-bone graft Tripod fracture of the zygoma: malar fracture-reduction +packing. Fractures of maxillary tuberosity:
The American Academy Of Otolaryngology Head And Neck Surgeryclinical indication for Caldwell-Luc :
Contemporary indications: Non physiological: Distorted ciliary physiology: Ciliary dyskinesia Cystic fibrosis Fungal mycetoma Antro choanal polyps Tumor: inverted papilloma Orbital decompression Intractible posterior epistaxis Endoscope inaccessibility. Mini Caldwell-Luc:
Principle of operation: Antrum is opened—irreversibly damaged mucosa removed—fresh opening into inferior meatus.
Technique: Incision 5 mm above GBS- 3-5 cm long.Close to midline ----end of alveolar ridge laterally inferior orbital nerve.
Exposure: Superiorly infraorbital nerve: mid pupillary line about 1cm below infraorbital rim. antrostomy: 5mm square marked by 4mm osteotome- Mucocele,extensive mucosal disease,polyp,transantral ethmoidectomy,tumor surgery, orbital decompression-entire anterior wall removed,nerve encased by peninsula of bone.
Removal of pathologic material: Preservation of normal mucosa. Extensive disease- intramucosal debridement: periosteum preserved: oseitis and bone thickening minimised. Recesses,loculi & septas,groove between anterior and medial wall.
Antrostomy inferior vs middle meatus Sublabial approach. few mm above the floor midway between anterior and posterior Intranasally also. Injury to ascending palatine artery. nasolacrimal duct
Middle meatus antrostomy: Begins at natural ostium. Incise and remove posterior fontanelle along the floor of orbit along the top of inferior turbinate. Fontanelle pedicled on posterior wall of sinus-cut. Uncinectomy edges smoothened. Anterior part of trubinate removed:
Closure: Layered in anterior-to-posterior from medial to lateral. Hemostasis good -filled with antibiotic ointment only.
Modifications & alternate procedures: Osteoplastic flap: Anterior wall preserved and elevated as flap attached to overlying periosteum. Minimizes trauma to infraorbital nerve Preserve sinus post surgery:prevents collapse of ant wall+ingrowth of fibrous tissue due to large anterior wall defect. contracture obliteration
Submucosal flap eleveted Periosteal incision medially along pyriform aperture laterally along maxillary buttress with central area left attached. Osteotomy –anterior surface of maxilla through inferior, medial & lateral incision Superiorly fracture just below level of infraorbital nerve
Osteoplastic antrostomy-Feldmann et al. Anterior wall lid removed temporarily with fine keyhole saw. Lid replaced with sutures through small burr holes. Limitations: radical antrostomy-trauma, after Denker’s operation, malignant tumor.
Denker’s operation Extended radical antrostomy anterior bony supporting pillar as far as pyriform aperture removed. Access through antrum to nasopharynx. posterior part of nasal cavity Localized resection of tumor.
Landmarks and danger points Infraorbital nerve-point of exit and course in the floor of orbit.lack bony covering lying free within the antrum. Root of canine and 1st molar, tooth buds of 2nd dentition in children. Sphenopalatine artery and its end branches. Ostium of nasolacrimal duct. Erroded Posterior wall of antrum-damage to maxillary artery Penetration through thin orbital roof –diplopia, damage to orbital contents.
Typical mistakes Incision too downwards on alveolar crest-wound closure difficult. Denture-as superiorly as possible. Preservation of Frenulum of upper lip- b/l operation. Excessive retraction of soft tissue-crushing of infraorbital nerve in its foramen or hematoma of cheek. First blow of chisel for opening anterior wall of antrum parallel to inferior edge of orbit below edges of infraorbital nerve to prevent fracture or entry to bony canal of nerve. Excessive curettage around infraorbital canal- neuralgia/injury. Inferior meatus opened accidently if wall of nose bulges laterally.
Complications Bleeding,Hematoma,absecess Infraorbital nerve injury-9-46% Parasesthesia / hyposthesia Neuralgia—chronic pain syndrome. Superior alveolar nerve. Massive secondary haemorrhage Subcutaneous emphysema. Globe injury/ orbital floor injury/extraoccular muscle injury. Orbital hematoma/proptosis/blindness. Foetid suppuration—FB Osteomyelitis of maxilla. Nasolacrimation duct injury Injury to roots of teeth. Vesibuar fistula. Oroantral fistula
Frontal sinus trephine: Kuemmel-Beck frontal trephine Principle: Burr hole in anterior wall of frontal sinus Blunt cannula introduced into lumen of sinus. Indications Acute frontal sinusitis Diagnosis and function of ostium. Not responding within 48hrs of medical treatment. symptoms worsens/ complications. Early intracranial complications
Chronic sinusitis: Inspissated secretions unable to locate internal ostium Mucocele: Removal/Drain into sinus lumen or nasal cavity Inaccessible mucocele: Recess, lateral or superiorly. Loculation of frontal sinus Intrafrontal sinus cell
Contemporary indications Classical indication-acute sinusitis –quick,small well camouflaged incision,preservation of normal sinus function Control acute infection before fat obliteration osteoplastic flap Acute frontal sinusitis: trephination vs. Endoscopic: Operative time Surgical skills Image guidance Risk of permanent scaring the frontal recess--revision Difficult endoscopic approach : Identify sinus-revision cases. Instillation of saline or catheter—sinus drainage tract.
Technique : Incision: Radiological confirmation of sinus. short curved inferomedial aspect of eyebrow
Supraorbital foramen:inferior aspect of superior orbital rim 1-2 cm lateral to nasion
Drilling & Closure: Underside at jun of medial and superior orbital rims cm opening.
Modifications & alternative procedures: Frontal sinoscopy - rigid telescope Ogston’s frontal sinus operation: Unsuccessful Kuemmel-Beck’s in U/L sinusitis. Contralateral drainage :excision of interfrontal septum. Office procedure: Turkel bone biopsy needle.
Hints,Rules & mistakes: Radiographs in 2 planes prior to trephination. Exclusion of loculation. Lateral extension avoided Cosmetic eyebrow incision. Burr must be guarded Ostium & frontonasal duct-contrast. Osteomyelitis
External ethmoidectomy Ferris Smith in 1933 originally described. “External ethmoidectomy”- distinguish transorbital approach to ethmoid labirynth from transnasal appproach.
Acute sinusitis: Intranasal approach difficult due to severe mucosal reaction. Chronic sinusitis: Extensive : supraorbital ethmoid Recurrent: Anatomical distortion Damaged orbital content Require Extensive resection Orbital infection: Pyogenic infection of ethmiod labyrinth:Exclude intraorbital abcess. Subperiosteal abcess, orbital abcess: orbital decompression procedures. Mucormycosis :orbital exploration + exenteration. Mucocele with orbital extension. Complications of acute ethmnoid or frontal sinusitis: repair of CSF leak in cribriform,fovea ethmoidalis, ethmoidal, sphenoidal region
Control of epistaxis Combined procedures: Sphenoidectomy Lynch frontal sinus operation Caldwell-Luc procedure Transethmoid hypophysectomy Dacrocystorhinostomy Access to to frontal,ethmoidal,sphenoidal sinus tumors Craniofacial resection Medial maxillectomies
Contemporary indications : Anterior ethmoidal artery ligation: Intractable epistaxis. Inaccessible to interventional radiologist. Endoscopic approach:medial orbitalwall removal—orbital collpase into ethmoid. Reduction of nasoethmoid complex fractures. Subperiosteal abcess & orbital abcess: Drainage of infected site into ethmoid cavity. Exenteration of acutely infected ethmoid cells. identification of abcess pocket in inflamed field. Cranial base tumor surgery: Bicornal flaps, facial translocation,external ethmoidectomy.
The American Academy Of Otolarygology And Head And Neck Surgery For Ethmoidectomy:
Preoperative consideration: Ophthalmological examination: Basic: VA, EOM, pupillary response. Orbital involvement: complete examination
Technique: Incision: Standard Lynch incision. sup :below supraorbital foramen,inf: inferior edge of lacrimal fossa. Angular artery branches in Submuscular layer
Exposure: Orbital side periosteum elevated Superiorly :above nasofrontal suture. Inferiorly: anterior lacrimal crest. Elevation of Orbital content,lacrimal sac Anterior ethmoid artery: Posterior ethmoid artery:
Ethmoidectomy: middle turbinate-preservation. Careful removal on medial ethmoid to preserve nasal mucosa. Posteriorly based mucosal flap created to enter nasal cavity. Inferior portion of medial turbinate resected,superior attachment-cribriform plate preserved. Orbital wall anterior to ant ethmiod artery preserved:
Lynch Procedure: External Frontoethmoidectomy Ethmoidectomy + middle turbinectomy + resection of entire floor of frontal sinus.
Chronic sinusitis: Failiure to medical therapy.+ lesser procedure: septoplasty, intranasal ethmoidectomy. Polyps, hyperplastic sinusitis or anatomical obstruction of frontal sinus drainage. Goal –normal mucociliary clearance. Failure of endoscopic frontal sinusotomy. Cant tolerate osteoplastic operation. Others: Mucocele. Orbital complications : Frontocutaneous and ethmoidcutaneous fistula. Recurrent sinusitis or polyposis after failure of endoscopic approach.
Benign neoplasm of superior nasal cavity,ethmoid,frontal sinuses and anterior skull base. Malignant tumors. Closure of CSF leak. Contemporary indications: Endoscopic, drills not available Surgeon not comfortable with endoscopic approach. Chronic rhinosinusitis in large well areated frontal sinuses with extensive pneumatization-complete obliteration difficult. Severely scarred frontal recess with osteitic bone after multiple endoscopic approaches.
Techniques : Incision: Nasofrontal connection created: With intact bridge of bone:lateral wall of frontal recess+ Complete frontoethmoidectomy: collapse of frontal recess-stenosis.
Reconstruction: Intact bridge: Stenosis. Stent : Silastic or rubber : Tube ( multiple side holes) Rolled sheet. Sewell-Boyden flap 90% patency 1-2 cm wide, 2-3 cm long Rotating distal end on itself laterally & superiorly into frontal sinus through external incision. It will line medial and posterior wall of frontal recess with mucosa facing lumen of frontal sinus. Stent.
Postoperative care: Stent removal: 5-7th POD vs. 6 wks or longer Flap: 1-2 wks. irrigation: FU- 1st 3 mths post op. Areated sinus= annually X 5yrs Opacified = revision surgery. Complications: Poor cosmetic result Recurrance: mucocele 90% patency 30% revision surgery-
Osteoplastic frontal sinus surgery Principle: Inferiorly hinged ‘trap door’ of bone fashioned from anterior wall of frontal sinus, sinus cleared, wide drainage duct created to nose, closure of sinus with bone flap. Late 19th century. Popularized in US Montgomery and colleagues. Goal: Remove /obliterate the sinus- air space-non physiological.
Indications : Acute sinusitis: Intraorbital or intracranial complications: Definitive surgical management. Recurrent acute frontal sinusitis: Failed Endoscopic approach. Chronic sinusitis: Failiure of endoscopic and frontoethmoidectomy : recurrent infection. Anatomical limitations of endoscope Inherent mucosal disease requiring functional restoration of sinus: cystic fibrosis, ciliary dyskinesia, sarcoidosis.
Allergic fungal sinusitis: Recurrance to avoid chronic steroid use+ complications. Mucocele: Endoscopic drainage not possible: Loculated mucocele: not connected to frontal recess. Anatomical limitations. Others: Extensive sinus requiring supplemantary removal of anterior wall Extensive fractures with dislocation-dura tear, frontal lobe injury
Contemporary indications: Chronic rhinosinusitis or polyposis: Refractory to endoscopic approach : mucocele. Scared /+ osteitic frontal recess Unfavorable anatomic conditions: Narrow frontal recess Type IV frontal recess cells Symptomatic osteomas. Lateral symptomatic disease non responding to endoscope. Altered physiology: Ciliary dyskinesia, cystic fibrosis Frontal sinus fractures Tumors: inverted papilloma.
Contraindications: Hypoplastic sinus Comminuted fractures Advantages: Direct approach: No facial deformity. Less morbidity. Both sinuses simultaneously. Preoperative preparation: Radiological assessment of frontal sinus margin.
Incision: Brow incision: Cosmetically hidden. Sacrifises sensation. Mid forehead incision: Anterior or frontal baldness with deep forehead crease. preserves some sensation Bicoronal incision: Forehead sensation preserved. Hidden by hair.
2-3cm behind the hairline. Laterally to level of preauricular crease. subgaleal plane, laterally superficial to temporalis fascia. Superficial temporal artery Hemostasis achieved in each layer.
Flap elevation: Subgaleal flap: Knife,scissors,electrocautery. Coagulation mode, along the dissection plane Continuous tight traction on flap till supraorbital rims Periosteal flap: Periostium incised from one temporal fossa to another, Periosteal flap elevated with Freer elevator till nasal dorsum in midline and orboial rims laterally: supraorbital foramen and nerve.
Osteoplastic flap: Template of the sinus Intersinus septum cut 1cm curved osteotome. Flap elevated at three points simultaneously
Mucosal resection Sinus Content-C/S Elevation of mucosa complete removal by drill with diamond and cutting burr: interior of anterior wall, intersinus septum: antinf- nasal septum,post-crista galli,bony overhange. orbital and cranial surface of sinus, frontal recess, ethmoid sinus
Obliteration: Muscle: Temporalis muscle-resolves Ethmoid sinus at level of anterior ethmoidal artery. Bone: Osseous and fibrous plug preventing mucosal growth from below. 1.5X5cm Calvarial graft + bone dust. Outer cortex from calvarium of parietal bone Graft broken into 2-3 mm pieces packed in frontal recess+ bone dust. Temporalis fascia graft : over frontal recess Fat graft: adequately filling the sinus.
Closure: Osteoplastic flap repositioned :26 gauge wires - 2 & 10 o’clock. Periosteal flap sutured. Drains: Over eyebrow Across the top of skull behind incision. Hemostais achieved. Skin closure. U/L procedure:
Complications: Wound problem: Hematoma,seroma infection, Flap necrosis. Blood transfusion Orbital injury Recurrent Mucocele Chronic headache: Frontal numbness/parasthesia Cosmetic alterations: absorption of bone flap/bone thickening due to excessive periosteal reaction.
Summary Endoscopic approach vs. External approach: Advancements in endoscopic sinus surgery: Surgical skills Easy availability of instrumentaions in operating theaters