The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2003 The American Laryngological,
Rhinological and Otological Society, Inc.
Results of Caldwell-Luc After Failed
Endoscopic Middle Meatus Antrostomy in
Patients With Chronic Sinusitis
Jeffrey L. Cutler, MD; James A. Duncavage, MD; Keith Matheny; Jenny L. Cross, MD;
Murat C. Miman, MD; Charles K. Oh, MD
Objectives/Hypothesis: The Caldwell-Luc opera-
tion for treatment of medically refractory chronic
maxillary sinusitis has largely been replaced by func-
tional endoscopic sinus surgery. Despite this change,
the Caldwell-Luc procedure still has well documented
indications including treatment of both failed endo-
scopic middle meatus antrostomy and irreversible
mucosal changes. The purpose of the study was to
review the authors’ experience and results of
Caldwell-Luc procedure after failed endoscopic mid-
dle meatus antrostomy in patients clinically deemed
to have irreversible mucosal changes. Study Design:
Retrospective review of preoperative and postopera-
tive results of patients who underwent Caldwell-Luc
procedure for refractory chronic maxillary sinusitis
after failed endoscopic middle meatus antrostomy.
Methods: The preoperative and postoperative clinical
course of patients treated with Caldwell-Luc proce-
dure performed by a single surgeon between 1996 and
2001 were reviewed. Only patients with a history of
chronic sinusitis after failed maximal medical ther-
apy, no prior Caldwell-Luc procedure, prior endo-
scopic middle meatus antrostomy, and at least 6
months of follow-up were included. Outcome mea-
surements including documented endoscopic exami-
nations and the need for repeat surgery, and postop-
erative computed tomography scan results were
evaluated to assess treatment success. Results: The
study involved 11 men and 26 women who underwent
50 Caldwell-Luc procedures. Caldwell-Luc procedure
was performed bilaterally in 13 patients. The average
number of prior endoscopic middle meatus antrosto-
mies before Caldwell-Luc procedure was 2. Of all pa-
tients, 92% responded to surgical treatment as dem-
onstrated by an endoscopic examination or computed
From the Departments of Otolaryngology—Head and Neck Surgery,
Vanderbilt University Medical Center (J.L.C., J.A.D., K.M., C.H.O.), Nashville,
Tennessee, and West Virginia University Health Sciences Center (J.L.C.),
Morgantown, West Virginia, U.S.A.; and the Department of Otolaryngol-
ogy (M.C.M.), Inonu University School of Medicine, Malatya, Turkey.
This Manuscript was accepted for publication July 7, 2003.
Send Correspondence to Jeffrey L. Cutler, MD, Department of Oto-
laryngology—Head and Neck Surgery, Vanderbilt University Medical Cen-
ter, 1301 22nd Avenue South, Suite 2900, Nashville, TN 37232-5555,
U.S.A. E-mail: Jeff.cutler@vanderbilt.edu
Laryngoscope 113: December 2003
2148
tomography scan revealing a disease-free maxillary
sinus. Repeat Caldwell-Luc procedure was required
in 8.0% (n ⴝ 3) because of continued sinusitis. Two of
the three cases with repeat Caldwell-Luc procedures
demonstrated clinical improvement during follow-up.
Average follow-up was 23.5 months. Conclusion:
Caldwell-Luc procedure seems to be highly effective
in the management of medically refractory chronic
sinusitis after failed endoscopic middle meatus antr-
ostomy. Caldwell-Luc procedure should remain in the
otolaryngologist’s surgical repertoire for these se-
lected cases. Key Words: Caldwell-Luc, chronic sinus-
itis, middle meatus antrostomya.
Laryngoscope, 113:2148 –2150, 2003
INTRODUCTION
The Caldwell-Luc (CL) procedure was first described
in the late 19th century. Both George Caldwell of the
United States and Henri Luc of France described a proce-
dure to remove the contents and mucosal lining of the
maxillary sinus through an anterior maxillary antrostomy
while creating a drainage port through an inferior meatus
antrostomy.1 This procedure was a mainstay in the treat-
ment of chronic maxillary sinusitis until the development
of the sinus endoscope. Endoscopic middle meatus antro-
stomy (EMMA) has largely replaced the CL procedure
because it has been proven safe and effective in the treat-
ment of chronic sinus disease.2
Despite advances in endoscopic equipment and tech-
nique, many indications for the CL procedure remain.
These include removal of foreign bodies, removal of benign
tumors, management of maxillary osteomyelitis of osteo-
radionecrosis, exposure for orbital decompression for
Grave’s ophthalmopathy, access to the pterygomaxillary
space, repair of oroantral fistulae, management of some
types of facial trauma, irreversible scarring and metapla-
sia with failure of the mucociliary apparatus, and endo-
scopic surgical failures.3
The purpose of the present study was to analyze the
results of CL procedure in patients with chronic sinusitis
after failed EMMA. These patients are clinically deemed
to have irreversible mucosal changes as demonstrated by
Cutler et al.: Caldwell-Luc Procedure
persistent sinus disease despite maximal medical therapy
and an adequate middle meatus antrostomy. The CL pro-
cedure allows the removal of the infected contents, as well
as the nonfunctional condemned mucosa. The goal after
effective surgical treatment with CL procedure is the im-
proved ability to medically treat recurrent sinus symp-
tomatology without further surgical intervention.
PATIENTS AND METHODS
A retrospective review of all CL procedures performed by
the senior author (J.A.D.) from 1996 to 2001 was performed. Only
patients with a history of failed EMMA ipsilateral to the site of
the future CL procedure were included in the review. Patients
with a previous CL procedure before EMMA were excluded. The
presence of allergy, asthma, aspirin triad, immunodeficiency, and
eosinophilia and the number of previous endoscopic middle me-
atus antrostomies was documented.
The CL procedure was performed in the following fashion. A
gingivolabial incision was made through the mucosa and perios-
teum of the canine fossa. Careful periosteal elevation was per-
formed over the anterior maxilla up to the infraorbital nerve. The
maxillary sinus was carefully entered with a sinus trocar. A
Kerrison punch was used to widen the opening created by the
trocar. The maxillary sinus contents were removed, and a speci-
men was sent for Gram stain and culture. A Coakley curette was
used to remove the diseased sinus mucosa. Next, an inferior
meatus antrostomy was gently performed using a curved hemo-
stat. The sinus was then copiously irrigated, and the incision site
closed in layers with absorbable sutures.
The postoperative course was evaluated with careful atten-
tion to resolution of symptoms as documented in the patient
chart. Results were evaluated through computed tomography
(CT) scan and endoscopic examination of the maxillary sinus.
Patients with a CT scan revealing a normal maxillary sinus or
contracted sinus with thickened bone were considered responders
to treatment. All patients with a contracted sinus on CT scan
were also evaluated endoscopically to be certain that the sinus
was infection free. Individuals with a maxillary sinus endoscopic
examination demonstrating a normal or contracted cavity with
the absence of infection were also considered responders to treat-
ment. The duration of follow-up and repeat surgical intervention
were determined.
RESULTS
In all, 133 CL procedures were performed by the
senior author for a variety of indications from 1996 to
2001. Of these, 50 CL procedures were performed in 11
men and 26 women with chronic sinusitis after having
failed prior EMMA. The CL procedure was performed
bilaterally in 13 of these patients. All patients had failed
maximal medical therapy and were deemed to have irre-
versible mucosal changes. The average patient age was 48
years. The patients had, on average, two prior endoscopic
middle meatus antrostomies before CL surgery. Allergic
rhinitis was present in 78%, asthma was previously diag-
nosed in 53%, aspirin triad was present in 17%, immuno-
deficiency had been found in 5%, and eosinophilia was
documented in 35% of patients.
Ninety-two percent of all patients responded to sur-
gical treatment as demonstrated by an endoscopic exam-
ination or CT scan revealing an absence of infection in a
normal or contracted maxillary sinus cavity. These pa-
tients were able to be medically controlled without further
surgical intervention after treatment with the CL proce-
Laryngoscope 113: December 2003
dure. Repeat CL procedure was performed in 8% (n ⫽ 3) of
patients because of continued sinusitis demonstrated by
residual symptoms and documented purulence at the
maxillary ostium on endoscopic examination. Of these
three initial failures, two patients demonstrated clinical
improvement during follow-up after a second CL proce-
dure. The presence of asthma, allergy, immunodeficiency,
eosinophilia, or aspirin triad was not statistically signifi-
cant in those who failed CL treatment. Mild postoperative
pain was identified in 37% of patients within the first few
postoperative months. Facial numbness and/or deformity
was noted in only 2% of patients. The average follow-up
period was 23.5 months (range, 6 – 61 mo). All patients
were followed for at least 6 months after having the CL
procedure performed.
DISCUSSION
Functional endoscopic sinus surgery has been an im-
portant advance in the treatment of chronic sinusitis and
has largely replaced the CL procedure in the treatment of
chronic sinusitis. Despite the widely accepted use and
success of EMMA to treat chronic maxillary sinusitis,
failures do exist and are varied. Richtsmeier4 evaluated
the records of 85 patients who presented with continued
maxillary sinusitis after EMMA over a 5-year period. He
identified 10 causes for failure. The most common reason
for failure was an obstructed ostium, followed closely by
chronic ethmoid and/or frontal disease. Interestingly, pri-
mary mucosal disease was the fifth cause in EMMA fail-
ures. Diseased mucosa with malfunction of the mucocili-
ary transport apparatus allows stasis and continued
infection despite an aerated sinus. It was suggested that
the CL procedure might be necessary to treat the under-
lying mucosal disease in this select patient population.
The effects of CL procedure on the maxillary sinus
mucosal lining have been analyzed by many authors. In
1930, Gorham and Bacher5 analyzed human maxillary
sinus mucosa both microscopically and macroscopically.
They concluded that after CL procedure, virtually normal
mucosa with proper ciliary orientation regenerates. Ben-
ninger et al.6 performed CL procedure on 10 New Zealand
white rabbits. Postmortem analysis performed 6 to 8
weeks postoperatively revealed seven animals exhibiting
new growth of respiratory tract epithelium; however,
granulation, fibrosis, and both acute and chronic inflam-
mation were also noted. Kennedy and Shaalan7 evaluated
the effects of nasal antral window, middle meatal antros-
tomy, and CL procedure on mucociliary clearance in 30
rabbits. The animals were re-explored 6 to 8 weeks after
the initial procedure. In the CL procedure group, 46% of
animals demonstrated mucociliary clearance. In all cases
in which mucociliary clearance was present, it was toward
the natural ostium.
In 1993, Forsgren et al.8 examined the entire sinus
complex to include the underlying bone. A CL procedure
was performed to completely remove the sinus mucosa,
taking care to avoid injury to the natural ostium in 17
rabbits. The animals were killed at 1 and 2 weeks and at
1, 2, 3, 4, 6, and 9 months postoperatively. The mucosa
re-epithelialized within 2 weeks, but the lamina propria
was incomplete at 9 months. Bone remodeling, fibroblast
Cutler et al.: Caldwell-Luc Procedure
2149
proliferation, and formation of polyps and “atypical
glands” were characteristic of regenerating mucosa.8
Further study by Forsgren et al.9 sought to ascertain
postoperative histopathological changes and symptom
scores comparing CL procedure with EMMA. A prospec-
tive study with 150 patients randomly divided between CL
procedure and EMMA was performed. One-year postoper-
ative biopsy results revealed the CL procedure group to
have reduced inflammatory cells and overall normaliza-
tion of the mucosa compared with the EMMA cohort.
Fibrosis was increased in both groups. There was no cor-
relation of symptoms (nasal obstruction, facial pain, and
severity of rhinorrhea) to the histological parameters. The
authors concluded that a CL procedure should be consid-
ered for asthmatic patients, especially those with severe
sinonasal polyposis. These data suggest that in conditions
in which the mucosa has reached a pathophysiological
point of irreversible mucosal change, CL procedure with
the removal of diseased mucosa and subsequent regener-
ation can be effective in improving histological mucosal
appearance and function.
Patients who fail traditional approaches of EMMA
despite maximal medical therapy fall outside the norm
and represent patients with severe sinonasal disease. The
current study does not suggest that CL procedure should
replace EMMA for the treatment of routine chronic max-
illary sinusitis. It is suggested that these select patients
seem to benefit from radical removal of diseased and con-
demned mucosa through CL procedure. Through this pro-
cedure, patients may be better managed medically as mu-
cosal regeneration occurs.
CONCLUSION
The CL procedure appears to be effective in treating
the vast majority of patients with chronic sinusitis who
have failed prior EMMA. In 92% of patients treated with
Laryngoscope 113: December 2003
2150
CL procedure by the senior author, a demonstrated nor-
mal finding on endoscopic examination or a normal CT
scan after at least 6 months of follow-up has been identi-
fied. These data support current indications for CL proce-
dure, including treatment of EMMA failures and the
treatment of irreversible mucosal changes within the
maxillary sinus. The CL procedure should remain in the
surgical repertoire for the well-rounded sinus surgeon,
especially in cases in which an adequate EMMA does not
allow resolution of chronic sinusitis because of poor func-
tion of the mucociliary transport mechanism caused by
irreversible mucosal changes.
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Cutler et al.: Caldwell-Luc Procedure