CONTENTS

1. Introduction

2. Indications of cald well luc operation

3. Instruments required

4. General preparation of patient

5. Operative Procedure

6. Post Operative Treatment

7. Complication

8. Conclusion

9. References
Introduction

Is the technique of creating an opening in the canine fossa with an intra-nasal

antrostomy. This procedure was named after george caldwell & Henri luc.

It was first developed by George cald well in 1893 from Newwork in 1897 Henri Luc

from Paris also reported the same procedure on his own Until the advent of

endoscope, it was the primary approach used for accessing the maxillary sinus. The

creation of an intranasal antrostomy allowed for both dependent drainage of the

maxillary sinus and an opening for irrigations after closure of gingivobuccal sulcus

incision.

The benefits of cald well luc procedure, compared with intranasal antrostomy, are

better visualization of antral disease removal of all disease and creation of window for

permanent drainage.

Today, the cald well luc procedure combined with endoscopic approach also be

helpful for orbital decompression and removal of inverting papillomas.

Indications

1) Removal of tooth or root from the antram that has been accidently pushed up

during course of extraction and removal through the socket could not be

achieved.
2) Removal foreign bodies like antrolithis from the sinus.
3) Chronic maxillary sinusitis where the removal of the lining of the antrum is

desired.
4) For removal of cyst from the antrum.
5) For removal of any benign growths of the maxillary sinus.
6) For control of any active haemorrhages following trauma of maxillary sinus.
7) For lifting floor of the orbit in case of blow out fracture.
8) For removal of an impacted maxillary canine or third molar that is mis directed

and partially erupting in antrum.

9) This operation can be modified for simultaneous closure of the oro antral fistula

by buccal sliding flap operation.

Contra Indication

1) Not performed in patients below 17 years of age as there may be damage

developing tooth bud in that region.

2) Acute infection

3) Systemic diseases
Instruments Required

Instruments required for the surgery :

Retractors
Nasal speculum
Periosteal elevator
Gouge
Nasal trocar
Kerrison or back biting forceps
Rougeurs
Antral rasp
Antral curettes

General Preparation of Patient

The patient with maxillary sinusitis should be hospitalized. Bead rest and nutritious

diet with vitamin reinforcement should be prescribed. A preoperative antibiotic

course may be administered in the weeks prior to surgery if an active infection is

present. A preoperative steroid course may be administrated if significant edema or

polyps are observed on examination.

Anatomy

Cald well luc operation incision is made in the anterior wall of maxilla especially over

the canine lossae. As the maxillary sinus is housed in the body of the maxilla, with

inferior orbital wall as the superior border lateral wall as the medical boundary

alveolar process of the maxilla as inferior border and canine fossa as the anterior

border.

Operative Procedure

Operation is generally performed with the patient under general anaesthesia.

 If an infected tooth is the cause of the sinus infection it should be extracted.

Most surgeons prefer to undertake dental procedures before opening the antrum.
A local anesthetic with adrenalin may be infilterated below the oral mucosa on

the outer surface of the upper jaw to obtain haemostasis.

Incision generally extend from the apex of the canine down to near the gingival

margin and back to the second molar. In identilose cases, it is carried to and

along the alveolar ridge.

The incision should be larger than the window to be cut in the bone.
The mucoperiosteum is then detached and retracted till the intraorbital ridge

taking care to preserve integrity of the intraorbital nerve.

A small gauge is used to perforate centre of canine fossa. This role is inlarged

by mean of rongeur or backbiting forceps until it is large enough to allow

introduction of atleast the index finger. The finger is used to palpate the tining

of the sinus.
Blood and pus contained in the sinus are removed by means of the aspirator.

Bleeding may be arrested by inserting small sponges saturated with adrenaline

the antrum is inspected next. A small light such as nasopharyngoscope, may be

used to illuminate the antral walls. It facilitates inspection of the contents of the

sinus and helps to determine state of the membrane lining it. This method helps

to find out the foreign bodies such as cotton or strips or gauge etc. pushed in

through a tooth socket.

The third molars lost during removal may not be seen inside the antrum dispite

their big size because the usually lie in the post. Wall beneath the antral mucosa,

which however may bulge out they can be removed only after and incision is

made in the mucosa tooth roots may also be difficult to find.

Granulomatous tissue may be found in the floor of the sinus if an abscessed

tooth has been the cause of the infection or if a perforation had bene made while

extracting a tooth.
 If a root has been forced into the sinus, a probe may be inserted into the socket

to help locate it, since often the root is covered by tissue and remains attached

by fibre of the periodontal ligament.

A curette may be useful for removing the inflammatory granulation. The socket

should be allowed to fill with healthy blood clot, and finally, gingival margins

may be approximated by a suture.

Nasal Antrostomy

When nasal antrostomy is planned a gauze piece with adrenaline should be

inserted into the nose at the beginning of the operation to prevent excessive

bleeding.
Nasal antrostomy is performed by introducing a nasal rasp through the nostril

below the inferior turbinate bone. It enters the sinus when force is applied by

moving the rasp back and forth an oblong aperature can be created for drainage

of the cavity.
In a more refined procedure for cutting the window nasoantral bone is removed

with an osteotome, and the nasal mucosa is cut on three sides, leaving it attached

only at the floor of the nose so that it can be folded into the antral cavity.
Any oozing of blood is arrested with adrenaline packs.
A long strip of plain or idoform tape saturated with petrolatum is inserted next.

This generally takes care of minor haemorrhages. End of the tape is pulled

through the nasoantral wall and the nostril since it is to be taken out from the

nose. It should be carefully folded into the antral cavity to facilitate removal.
Finally mucoperiosteal flap is replaced and incision is closed with interrupted

sutures.
Post Operative Treatment

Immediately after the surgery

Complete bed rest

Fluid replacement if there has been considerable blood loss during the operation.
Cold application to the side of the face to prevent swelling.
Sedatives and analogics for pain.
Antibiotic therapy shoulud be continued until all signs of infection subside.

Future Care

On the second postoperative day the patient may be permitted to get up

On second or third post operative day antral dressing should be removed unless

there is a danger of infection.

Large packs completely filling the maxillary sinus may be removed under

nitrous oxide and oxygen or intravenous pentothal anaesthesia in semitive

patients, whereas in other cases morpplune (1/4 gr) may be given 20 minutes

before the removal is contemplated.

Bleeding occuring during the removal of the pack is controlled by placing gauze

strip soacked with adrenaline in the nose.

Complications

Common Complications

Facial swelling
Numbness of the face (infraorbital neurapraxia). This is numbness of check and

not weakness which always occurs temporary but rarely persist.

Numbness (temporary/permanent) of the upper truth and the associated gingiva.

Less Common Complication

Oro-antral communication/fistula
Post-operative nose bleeds (epistaxis)
Overflow of tears (epiphora) due to blockage of the tear duct.
Tooth root injury leading to tooth death & tooth discoloration

Rare Complication

Facial assymmetry due to persistent facial swelling

Prolonged maxillary sinusitis
Post-operative bleeding from the sinus/nose requiring packing of the sinus/nose

or even a blood transfusion.

Infection of naso lacrimal sac
Post Operative hypersensitivity or burning pain over the check gingiva & teeth.
Conclusion

The caldwell-luc operation was first described in the late 19th century as a technique to

remove infection and disease mucosa from the maxilllary sinus via canine fossa,

while creating intranasal counter drainage, through the inferior meatus. The operation

has been performed countless time over the past 20 yrs. This critism is mublifactorial.

Medical management of allergic and infections sinus disease has continued to

improve and endoscopic sinus surgery techniques has proven to be safe and effective

in the vast majority of patients requiring surgical management. Additionally several

retrospetictive studies have shown high complication rales with the operation. Recent

studies have illustrated both the histologic benefit of complete removal of diseased

mucosa as well as better patient outcome with minimal morbidity when a safer

operative technique is used.

Overall, the cald well luc procedure is safe and effective as described and should

remains in the repetoire of surgeons managing the maxillary sinus.