Cers Cadwell Luc

The Journal of Laryngology & Otology (2010), 124, 663– 665.

Short Communication
# JLO (1984) Limited, 2010
doi:10.1017/S002221510999260X

Endoscopic Caldwell– Luc technique

L MASTERSON, W AL GARGAZ, A P BATH
Abstract
This report describes a combined approach to the maxillary sinus, used to deal with mucosal pathology. The
technique uses a powered microdebrider with angled endoscopes and is minimally invasive. It is cost-effective
and offers the potential for decreased surgical time, reduced post-operative healing time and reduced
post-operative morbidity.
Key words: Maxillary Sinus; Endoscopy; Otorhinolaryngologic Surgical Procedures; Caldwell-Luc
Introduction 308 or 708 telescope into the nose (Figure 2). This allows
Endoscopic nasal surgery has gained wide acceptance as a a view, through the middle meatal antrostomy, of the tip
safe treatment modality for chronic sinus disease.1,2 of the instrument in the maxillary sinus (Figure 3). The
It enables a minimally invasive approach, reducing patient surgeon can now deal with pathology in the maxillary
morbidity. New instruments for endoscopic nasal surgery con- sinus. In order to access more awkward areas, such as the
tinue to be introduced in an attempt to reduce the problems
associated with ‘grabbing’ tools, which essentially tear tissue
and strip mucosa. However, accessing areas that can only be
visualised with 308 and 708 endoscopes remains one of
the most difficult challenges in this field.3 Such access limit-
ations can cause difficulties when dealing with pathology on
the lateral and anterior maxillary sinus walls, such as the
base of an antrochoanal polyp or a transitional cell papilloma.
An endoscopic Caldwell – Luc technique has been uti-
lised by the senior author for many years and is minimally
invasive.4,5 It offers a potential advantage over traditional
approaches, and has not previously been described in the
UK literature.6
Surgical technique
Appropriate pre-operative vasoconstriction of the nose is
performed with the patient under general anaesthetic.
Pathology within the nasal cavity is first addressed. If this
extends into the maxillary sinus, as may occur with an
antrochoanal polyp or transitional cell papilloma, an unci-
nectomy combined with a middle meatal antrostomy is per-
formed to allow visualisation of the sinus.
Local anaesthetic with adrenaline is then infiltrated
beneath the upper lip, over the site of the canine fossa. A
5 mm trocar with sheath is then inserted into the maxillary
sinus via the canine fossa, parallel to the nasal floor, with a
finger extended along its shaft to prevent deep penetration
through the posterior wall (Figure 1). The trocar is
removed, leaving the sheath in place, which is gently
rotated to widen the bony hole. The maxillary sinus can
be inspected using a 4 mm, 08 endoscope introduced
through the sheath. The sheath is then removed and a
microdebrider inserted with its suction tip closed. The FIG. 1
assistant temporarily supports the microdebrider with its Operative photograph showing trocar introduced through
tip in the maxillary sinus whilst the surgeon re-inserts a canine fossa.
From the ENT Department, Norfolk and Norwich University Hospital NHS Trust, UK.
Accepted for publication: 16 October 2009. First published online 6 January 2010.
663
664 L MASTERSON, W AL GARGAZ, A P BATH
FIG. 2
Operative photograph showing combined approach technique,
with the endoscope inserted through the right nostril and the
powered microdebrider inserted through the canine fossa
into the right maxillary sinus.
anterior wall, it is important to ensure that the microdebri- FIG. 3

der is not gripped by the bony hole formed by the trocar. If Diagram showing removal of antral pathology with a 708
it is, the trocar and sheath should be re-introduced so that endoscope, viewed through the middle meatal antrostomy.
the sheath can be rotated to further enlarge the bony hole. O ¼ right orbit; S ¼ septum; M ¼ microdebrider; E ¼
This allows sufficient movement for the suction tip of the endoscope
microdebrider to be rotated and placed directly over the
area of pathology to be removed.
areas of the maxillary sinus when approached from the
One area of potential concern with this technique is
nasal cavity. The 5 mm trocar and sheath are inexpensive
injury to the infra-orbital nerve. Extra care must be taken
and are often included in endoscopic sinus instrument
when using instrumentation on the superior wall of the
sets. The additional cost of extra equipment is therefore
sinus, as the nerve is not always protected within a bony
negligible. The operative time for this procedure would
canal. We would suggest that mucosa in this area is
appear to be no longer, and perhaps shorter, than that
removed with caution, and that the microdebrider should
for an ‘open’ procedure for removing pathology from the
be ‘pulsed’ to prevent suction of the nerve into the lumen.
maxillary sinus.
Over the last two years, this technique has been used suc-
Formal Caldwell–Luc procedures are widely acknowl-
cessfully in 10 patients under the care of the senior author.
edged to be associated with a high incidence of post-operative
Five of these patients underwent surgery for removal of an
complaints (i.e. pain, facial numbness, localised swelling and
antrochoanal polyp, three had transitional cell papilloma,
bleeding).7,8 However, the endoscopic Caldwell–Luc tech-
and the remaining two had dental or unilateral chronic
nique described above offers several benefits to the patient,
sinus pathology. The average time taken to perform the pro-
including surgery as a day case, lower post-operative morbid-
cedure was 38 minutes (range, 19–55 minutes). Seven of the
ity and reduced recurrence of disease.
10 procedures were performed as day cases. No patients
experienced major complications, such as infra-orbital
nerve injury or oro-antral fistula. The post-operative appear- References
ance of the antral wall at six to eight weeks revealed healthy 1 Stammberger H. Endoscopic endonasal surgery –
mucosa in all patients. One patient with transitional cell concepts in treatment of recurring rhinosinusitis. Part II:
papilloma required surgery for recurrence after six months. surgical technique. Otolaryngol Head Neck Surg 1986;94:
147–56
2 Kennedy DW. Functional endoscopic sinus surgery. Arch
Discussion Otolaryngol Head Neck Surg 1985;111:643– 9
3 Orsel S, Sauvage JP, Puyraud S, Bessede JP. An original
This endoscopic Caldwell – Luc technique offers a simple, aspirator spoon for accessing maxillary sinus recesses.
effective means of dealing with pathology in inaccessible ORL J Otorhinolaryngol Relat Spec 2005;86:29 –33
ENDOSCOPIC CALDWELL – LUC TECHNIQUE 665
4 Yanagisawa K, Coelho DH, Yanagisawa E. Endoscopic Address for correspondence:
removal of the antral and choanal portions of an antrochoa- Mr Liam Masterson,
nal polyp. Ear Nose Throat J 2005;84:194– 5 Department of ENT,
5 Endoscopic Mini Caldwell Luc procedure. In: http://www. Norfolk and Norwich University Hospital NHS Trust,
youtube.com/watch?v¼o6XVawv3ZEE [29 May 2009] Colney Lane,
6 Anselmo-Lima W, Demarco R, Asato M, Prado V. FESS Norwich NR4 7UZ, UK.
and Caldwell-Luc as treatment for antrochonal polyps. Oto-
laryngol Head Neck Surg 2006;135(suppl 2):174 Fax: 01603 287211
7 Lund V, Rowe-Jones J. The nose and paranasal sinuses. In: E-mail: [email protected]
Gleeson M, ed. Scott-Brown’s Otolaryngology, Head and
Neck Surgery, 7th edn. London: Edward Arnold, 2008;1493–4
8 Bolger W, Kennedy DW. Surgical complications and post- Mr L Masterson takes responsibility for the integrity
operative care. In: Kennedy DW, ed. Diseases of the of the content of the paper.
Sinuses: Diagnosis and Management, 1st edn. Michigan: Competing interests: None declared
BC Decker, 2001;315– 16

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The Journal of Laryngology & Otology (2010), 124, 663– 665.

Endoscopic Caldwell– Luc technique

Key words: Maxillary Sinus; Endoscopy; Otorhinolaryngologic Surgical Procedures; Caldwell-Luc

anterior wall, it is important to ensure that the microdebri- FIG. 3

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