DOI: 10.

2478/rjr-2020-0017

Romanian Journal of Rhinology, Volume 10, No. 39, July - September 2020

LITERATURE REVIEW
Indications of the Caldwell-Luc procedure in the era of
endoscopic sinus surgery

Andreea Bajan1, Codrut Sarafoleanu1,2,3, Violeta-Gabriela Melinte1,2,3, Roxana Decuseara1,2,3

1
ENT&HNS Department, “Sfanta Maria” Clinical Hospital, Bucharest, Romania
2
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
3
CESITO Centre, “Sfanta Maria” Clinical Hospital, Bucharest, Romania

ABSTRACT

Surgical treatment of chronic rhinosinusitis is indicated after failure of correctly conducted maximal drug therapy or the occurrence
of complications. Radical maxillary sinus surgery has been abandoned nowadays, to the detriment of endoscopic sinus surgery, for
several reasons, such as: increased incidence of complications, decreased healing rate compared to the endoscopic technique. The
literature cites many situations in which the Caldwell-Luc procedure is used as a first-line surgical technique: recurrent chronic rhi-
nosinusitis, malignant tumors of the maxillary sinus extending to the lateral wall of the nasal fossa and the pterygomaxillary space,
the cases where an extensive approach to the pterygopalatine fossa is required – for ligation of the internal maxillary artery or the
approach of the vidian canal in vidian neurectomy.
The authors highlight the use of Caldwell-Luc procedure in endoscopic sinus surgery era, by reviewing the complications rates, in-
dications and long-term effectiveness of the two surgical techniques.
KEYWORDS: Caldwell-Luc surgery, endoscopic sinus surgery, rhinosinusitis, bleeding, sinusoscopy, histopathological score.

INTRODUCTION cal drainage in the inferior meatus, in order to

evacuate the pathological content3. It is an excep-
The Caldwell-Luc procedure was first described tional procedure, through which the endosinusal
in 1893. The American surgeon George Caldwell mucosa is completely removed, the patient’s dis-
associates the surgical approach of the anterior comfort, both immediately and late postopera-
wall of the maxillary sinus through a gingival-labial tively, being superior to endoscopic techniques.
incision with the inferior meatotomy, while Henry Functional endoscopic sinus surgery (FESS) was
Luc, French surgeon, describes the same proce- first described in the 1970s4,5, then having a success
dure, but combined with middle meatotomy 1. It rate (90%) similar to the Caldwell-Luc surgery in
was widely used until 3 decades ago as a standard the treatment of recurrent chronic and acute max-
surgical procedure to solve various rhinosinusal illary rhinosinusitis 6,7. Radical maxillary sinus sur-
pathological cases, today with very limited indica- gery has been abandoned nowadays, to the
tions due to the development of endoscopic surgi- detriment of endoscopic sinus surgery, for several
cal techniques2. reasons, such as: increased incidence of complica-
Surgical treatment of chronic rhinosinusitis is tions (10-40%)8,9, decreased healing rate compared
indicated after failure of correctly conducted max- to the endoscopic technique10.
imal drug therapy or the occurrence of complica- Pentilla et al. support the effectiveness of endo-
tions. The Caldwell-Luc surgery involves opening scopic surgery in terms of ameliorating symptoms
the maxillary sinus at the level of its anterior wall in chronic rhinosinusitis, compared to the
through a gingival-labial incision, ensuring surgi- Caldwell-Luc procedure 9. Thus, endoscopic antros-

Corresponding author: Prof. Dr. Codrut Sarafoleanu, ENT&HNS Department, “Sfanta Maria” Hospital, 37-39 Ion Mihalache Blv., District 1,
Bucharest, Romania
e-mail: [email protected]
Received for publication: May 25, 2020 / Accepted: June 17, 2020
79 Romanian Journal of Rhinology, Volume 10, No. 39, July - September 2020

tomy is recommended as the first surgical proce- In the Caldwell-Luc surgery, the damage of the den-
dure used in the treatment of chronic maxillary tal root or of the superior alveolar nerve may occur.
rhinosinusitis. On the other hand, the hospitaliza- The most common postoperative complications
tion of the patient who underwent a Caldwell-Luc in the Caldwell-Luc approach are represented by
type of intervention is much longer, 5-7 days post- facial swelling or numbness, facial and cheek dis-
operatively, compared to one day postoperatively comfort, facial asymmetry, facial paresthesia in the
in the case of endoscopic intervention11. suborbital region, hemorrhage, persistent subor-
bital neuralgias, oro-antral fistulas, gingival-labial
fistulas, dental devitalization, dacryocystitis, or re-
COMPLICATIONS OF CALDWELL-LUC currence of rhinosinusitis.
SURGERY VERSUS FESS Referring to immediate postoperative complica-
tions, the most commonly described are facial
In the literature, there are numerous studies swelling reported in 62-90% of cases and the dis-
highlighting the complications associated with comfort in the cheek area in up to 33% of
the Caldwell-Luc procedure, which limits the use cases10,15,16. Facial and cheek swellings can occur as
of this procedure as a technique for surgical treat- a result of anaesthetic infiltration, of the tampon-
ment of rhinosinusal pathology. A number of ade of the sinus cavity or of the violent traction
complications can also occur in the case of endo- exerted by the retractors during the surgery. Re-
scopic approach of the maxillary sinus. These can garding late complications, the most common are
be both immediate (intraoperative and postoper- recurrent rhinosinusitis, facial paresthesias (by in-
ative) and late. juring the infraorbital nerve) and chronic dacryo-
If we refer to the intraoperative incidents and ac- cystitis (stenosis of the lacrimal ducts by injury of
cidents in the two types of surgical interventions, the nasolacrimal duct) 16. Very rare complications
bleeding is the main event described. Injury to the are periostitis of the orbital arch, phlegmon of the
suborbital neuro-vascular bundle, by not identifying cheek, osteomyelitis of the upper jaw17.
or not protecting it at the time of the incision in the In a study conducted on a group of 271 patients,
labiogingival groove during the Caldwell-Luc ap- Yaringston reported complications in 3% of cases,
proach, can cause intraoperative hemorrhage with these being represented by hyperaesthesia of the
postoperative suborbital neuralgias. In the case of suborbital region (by including the nerve or its
classical surgery, the injury of the internal maxillary emergences in the resulting scar tissue), postop-
artery by breaking through the posterior wall of the erative ethmoiditis (by incomplete curettage of os-
sinus surgery can trigger significant bleeding. Spe- teitis lesions or pathological mucosa), dental
cialist studies report an incidence of bleeding com- devitalization (atrophy and degeneration of dental
plications of about 3%10. Comparatively, functional nerve fibres) and, less often, blindness (by acciden-
endoscopic sinus surgery reports bleeding as part of tally perforating the orbital floor). Late complica-
minor (about 5%) and major (0.5 -1 %) complica- tions such as neuralgias or cheek paresthesias have
tions. Diffuse bleeding from the nasal mucosa dur- been reported in a small number of patients16,18.
ing endoscopic sinus surgery is more common, DeFreitas and Lucente highlight that other com-
compared to severe bleeding from the sphenopala- plications such as facial asymmetry (due to retrac-
tine or anterior ethmoidal artery injury (the inci- tion of the cheek on the side of the operated
dence reported by some authors is between 0.1 maxillary sinus), oro-antral fistula (due to alveolar
– 0.8%)12,13. A study conducted in 1996 evaluated ridge osteitis, persistence of suppurations) or den-
intraoperative bleeding in classically operated pa- tal devitalization, persisted for 1 year postopera-
tients (Caldwell-Luc) compared to endoscopic sinus tively; in some cases, treatment is necessary, up to
surgery, demonstrating a lower value in FESS minor surgeries10. Increased frequency of facial tu-
(53.0±71.8ml, respectively 297.5±339.5ml; p<0.01)8. mefactions (61.9%), facial (46%) and dental or
At the orbital level, in both types of interven- gingival (30%) pain and paresthesias was also re-
tions, trauma to the extrinsic ocular muscles may ported by Low. In most cases, these complications
occur, with the subsequent onset of diplopia, intra- received treatment, their persistence being re-
orbital hemorrhage, periorbital emphysema, eye- ported in 15-20% of cases. In Low’s study, rare
ball trauma that can lead to blindness, tear duct complications such as epistaxis (0.4%), oro-antral
injury. These accidents are rare in both types of fistula (0.4%) and epiphora (0.44%) represented
interventions and can be avoided by intraoperative a small percentage 16.
eyeball examination and by performing a correct Moreover, it has been demonstrated that by
and complete imaging evaluation preoperatively making a triangular incision at the gingival-labial
(CT and / or MRI)13-15. level, patients no longer had late postoperative
Bajan et al Indications of the Caldwell-Luc procedure in the era of endoscopic sinus surgery 80

complications such as paresthesias in the infraor- doscopic control who had a percentage of 76%.
bital region 18. Also, a lower percentage of patients who under-
Murray et al. reports postoperative complica- went a Caldwell-Luc type of surgery required a revi-
tions in a study on a group of patients with malig- sion surgery at 7-9 years postoperatively (18%
nant pathologies in the maxillary sinus and the compared to 20% of patients operated by endo-
pterygopalatine fossa including recurrent rhinosi- scopic procedure). The authors conclude that the
nusitis, infraorbital paresthesias, intranasal syn- Caldwell-Luc surgical technique may be superior
echiae, persistent facial/cheek swelling and dental to the endoscopic technique, taking into consider-
complications19. ation the long-term postoperative results25.
Comparing the side effects of endoscopic sinus Regarding relapse, a high rate (40-80%) of local
surgery with those of the Caldwell-Luc procedure, relapses of inverted papillomas treated by conser-
a randomized controlled study in Finland showed vative surgical procedures was noted26.
that they may be significantly more numerous and Närkiö-Mäkelä compared the effectiveness of
longer lasting in classical surgery20. surgical treatment by external approach
In the case of endoscopic rhinosinusal surgery, (Caldwell-Luc) with that by endoscopic approach,
complications are reported between 2 and 17% with significantly lower results of the need for re-
and are primarily related to the surgeon’s experi- vision surgery in the group of patients treated by
ence 21. Postoperative complications are hemor- external approach 27.
rhages, crusts, synechiae, stenosis, epiphora,
anosmia or CSF leaks, periorbital emphysema8,21,22.
CURRENT INDICATIONS FOR THE
CALDWELL-LUC PROCEDURE
LONG-TERM EFFECTIVENESS OF THE
CALDWELL-LUC PROCEDURE VERSUS As we can see, the above-mentioned complica-
ENDOSCOPIC SINUS SURGERY tions can be significant and long-lasting. For this
reason, the endoscopic surgical technique has pri-
In the literature, there are numerous studies ority and should be considered as the first method
comparing the long-term results of the two types of of surgical treatment.
surgery. The evidence attests a superiority of endo- On the other hand, the literature cites many
scopic techniques in terms of efficacy and long- situations in which the Caldwell-Luc procedure is
term evolution of local and general symptoms. used as a first-line surgical technique: recurrent
In a randomized controlled study, Jakob et al. chronic rhinosinusitis (despite endoscopic surgi-
compared the postoperative results of 40 patients cal treatment associated with maximal drug treat-
diagnosed with chronic rhinosinusitis and treated ment); malignant tumors of the maxillary sinus
with the Caldwell-Luc radical therapy with those extending to the lateral wall of the nasal fossa and
of 40 patients treated with endoscopic sinus sur- the pterygomaxillary space 28; the cases where an
gery. It should be noted that 77.5% of the patients extensive approach to the pterygopalatine fossa is
also associated nasal polyposis 23. 1 year postopera- required – for ligation of the internal maxillary
tively, 44% of the patients treated with radical sur- artery (in the case of a massive epistaxis) 3 or the
gery and 89% of those treated endoscopically approach of the vidian canal in vidian neurec-
showed significant improvement in symptoms, tomy. Some authors consider this procedure
which demonstrates the superiority of the efficacy much more effective in the surgical treatment of
of the endoscopic technique in the treatment of facial trauma, in the fracture of the maxillary
chronic rhinosinusitis 24. bone or the orbital floor 29.
In 1997, Pentilla et al. revealed in a group of 128 The choice of surgical technique must take into
patients with chronic maxillary sinusitis a different account several parameters, the most important
evolution of postoperative symptoms in the two being the diagnosed pathology, the local endo-
types of surgery 25. The patients were followed up scopic and imaging aspects.
for a period of 5 to 9 years postoperatively. There- Clinically, Cannady et al. 30 recommended a clas-
fore, 51% of patients treated by the Caldwell-Luc sification of types of inverted papilloma according
procedure, respectively 77% of those who received to its location and extent, information that can
endoscopic sinus surgery showed a favourable evo- help assess the risk of recurrence and then choose
lution of symptoms one year postoperatively, while the surgical technique:
at 5-9 years, 82% of patients treated with radical • T ype A – tumor limited to the nasal fossa,
surgery experienced the complete disappearance ethmoidal sinus or medial wall of the maxil-
of symptoms, compared to those treated under en- lary sinus.
81 Romanian Journal of Rhinology, Volume 10, No. 39, July - September 2020

•T  ype B – tumor with extension to the walls of characterized by structural and functional com-
the maxillary sinus (except for the medial promise of the sinus mucosa, classic Caldwell-Luc
one), sphenoid sinus or frontal sinus. surgery is indicated.
• T ype C – tumor with extension outside the pa- Because the evaluation of the endoscopic as-
ranasal sinuses. pect can be subjective, in the ENT&HNS Depart-
According to this staging, Cannady et al. demon- ment, “Sfanta Maria” Hospital, a correlation was
strated that the use of endoscopic surgery in the made between the endoscopic score and a histo-
case of inverted papillomas can lead to a recur- pathological score, which objectively assesses the
rence rate of 3% in type A, 19.8% for type B and structural changes in the mucosa taking into ac-
35.3% for type C. Therefore, inverted papillomas count the following parameters: density and dis-
included in type B require treatment with radical tribution of the inflammatory infiltrate, the
surgery of the Caldwell-Luc type 30. presence of eosinophils, the presence of edema
Clinico-pathological aspects of the maxillary in the nasal mucosa, the presence of neoforma-
sinus were first described in the literature by the tion vessels (formed by neoangiogenesis) and
British surgeon Nathaniel Highmore in 1651, the presence of fibrosis. After the histopatholog-
hence the name “Highmore’s antrum” associated ical examination of mucosal fragments collected
with it31. In addition to research into surgical tech- during sinusoscopy, a score is awarded for each
niques discovered over time, huge leaps have been of the above-mentioned parameters, thus obtain-
made in the study of rhinosinusal pathophysiology ing the histopathological score 34 (Table 1). The
and histological structure. Discovery of the micro- score obtained was used in the decision of thera-
scope in 1830 allows the detailed study of the struc- peutic approach. A score of 0-3, grade 0 fibrosis,
ture of the rhinosinusal mucosa; thus, the benefit from conservative treatment with endo-
pathologist Friedrich Henle was the first to de- scopic monitoring. In case of a 3-7 score, corre-
scribe the different types of mucosa, as well as the sponding to a grade 1 fibrosis, endoscopic sinus
function of the ciliated epithelium in the upper surgery is indicated. Extensive rhinosinusal en-
respiratory tract32. doscopic surgery is the intervention of choice in
According to the experience of the ENT&HNS cases with grade 2 fibrosis, histopathological
Department, “Sfanta Maria” Hospital, sinusoscopic score between 7 and 10. Grade 3 fibrosis, a score
aspects of the endosinusal mucosa may have pre- equal to 11, requires classic surgery – radical
dictive value in the treatment of chronic rhinosi- Caldwell-Luc procedure 35.
nusitis 33. Therefore, 5 types of aspects of the Becker et al., in a comparative study performed
maxillary sinus mucosa are recognized: in 2011, demonstrated that the sinus mucosa re-
• T ype 0 – normal mucosa, without secretions, moved after the Caldwell-Luc procedure shows ne-
with vascular pattern within normal limits; crotic bone debris, compared to the mucosa
• Type 1 – mucosa with accentuated vascular pat- removed by endoscopic antrostomy, which is rela-
tern, with serous secretions; tively normal 36,37. Moreover, postoperatively regen-
•T  ype 2 – thickened mucosa, with consistent se- erated mucosa of the maxillary sinus after the
cretions, accentuated vascular pattern, cystic Caldwell-Luc procedure has been shown to have a
dilatations of the submucosal glands and degree of ciliary dysfunction.
changes in the chorion;
• T ype 3 – important changes in the mucosa,
polyps, mucopurulent secretions; PERSONAL EXPERIENCE
•T  ype 4 – mucosal hyperplasia and metaplasia,
polyps, fungosities and caseum – they denote To exemplify the usefulness of the classical
structural and functional impairment of the Caldwell-Luc type of intervention in the rhinosi-
endosinusal mucosa. nusal pathology in the era of endoscopic sinus sur-
Based on these findings, we adapted the treat- gery, we present the case of a 19-year-old patient,
ment method according to the appearance of the who presented to the ENT&HNS Department,
mucosa revealed by the sinusoscopy. Thus, in type “Sfanta Maria” Hospital, in April 2019 accusing
1, a drug treatment with a role in restoring muco- frontal headache, pressure sensation at the projec-
ciliary and ostial functions is indicated. Type 2 tion of the left maxillary sinus, bilateral antero-
responds to drug treatment or endoscopic surgery posterior mucopurulent rhinorrhea, chronic
for the repermeabilization of the ostium transi- bilateral nasal obstruction. Symptoms had started
tion zones. Type 3 requires endoscopic surgical 6 weeks before and had not yielded to the correctly
treatment to restore rhinosinusal ventilation, fol- recommended and followed drug treatment.
lowed by adjuvant drug treatments. In type 4, The ENT clinical examination and nasal endo-
Bajan et al Indications of the Caldwell-Luc procedure in the era of endoscopic sinus surgery 82

Table 1. Rhinosinusal histopathological score34

Histopathological parameter Score

- 1 point – rare lymphatic elements, diffusely distributed
1. Density and distribution of the
- 2 points – frequent lymphatic elements, diffusely distributed
inflammatory infiltrate
- 3 points – frequent lymphatic elements, subepithelial +/- perivascular densifications or the presence of lymphocyte aggregates
- 0 points – absent
2. Presence of eosinophils - 1 point – rare
- 2 points – frequent
- 0 points – without oedema
- 1 point – minimum subepithelial oedema
3. Intramucosal oedema presence
- 2 points – moderate oedema
- 3 points – severe oedema
- 1 point – a minimum of neoformed vessels
4. The presence of neoformation
- 2 points – frequent neoformed vessels
vessels
- 3 points – frequent neoformed vessels with thickened walls due to fibrosis (in the walls and perivascularly)
- 0 points – absent fibrosis

5. Fibrosis – independent - 1 point – minimal fibrosis, periglandular +/- intramucosal

parameter - 2 points – moderate, with cystic glandular dilatations
- 3 points – marked, with irreversible mucosal hyperplasia

scopic examination showed hypertrophied inferior The native cranio-facial CT examination re-
nasal turbinates, heavily congested nasal mucosa, vealed a heterodense tissue mass that completely
and quantitatively important mucopurulent secre- occupied the left maxillary sinus, extending into
tions in the left middle nasal meatus (Figure 1). the nasal fossa, the ethmoid cells and frontal sinus

Figure 1. Nasal endoscopic examination – mucopurulent secretions in the left middle nasal meatus.
83 Romanian Journal of Rhinology, Volume 10, No. 39, July - September 2020

erative evolution, without the relapse of symptoms.

This case supports the indication and efficiency
of the Caldwell-Luc type radical surgery in the treat-
ment of recurrent maxillary rhinosinusitis despite
previously correctly established and performed en-
doscopic drug and / or surgical treatment.

CONCLUSIONS

Although the endoscopic technique is the stand-

ard approach for the maxillary sinus pathology,
certain areas of the sinus (anterior wall and floor)
are more difficult to approach.
The Caldwell-Luc procedure must mandatorily
remain in the surgical repertoire of an otorhi-
nolaryngologist, for exceptional cases38.

Conflict of interest: The authors declare that

Figure 2. Cranio-facial CT scan, coronal section – heterodense tissue
mass completely occupying the left maxillary sinus, areas of osteolysis
there is no conflict of interest.
in the medial wall of the left maxillary sinus. Contribution of authors: All authors have
equally contributed to this work.

on the same side, areas of osteolysis in the medial

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