And Antrostomy Nasoantral Window

Indications are:

Chronic polypoid maxillary sinusitis unresponsive to conservative intranasal procedures Acute complicated maxillary sinusitis In the treatment of oroantral fistulae As a route to biopsy Infraorbital nerve Maxillary sinus mass As an approach to the orbital floor To treat fracture

For orbital decompression of Grave's ophthal-mopathy

The Caldwell-Luc procedure is a sublabial approach to the maxillary sinus through the anterior wall under the upper lip. Traditionally it was used to treat chronic maxillary sinusitis with irreversible changes of the maxillary sinus respiratory epithelium. During the procedure all the lining mucosa of the maxillary sinus is removed and will be replaced by a rind of scar tissue covered by cuboidal nonciliated epithelium as the sinus heals. Because there is no longer any active transport of mucous within the sinus, drainage must be created inferiorly through the inferior meatus. Since the floor of the maxillary sinus is lower than the floor of the nose, gravity does not serve entirely to drain the sinus. After a Caldwell-Luc procedure, plain films (Caldwell views) of the maxillary sinus will forever be abnormal with some degree of opacification. In recent times, it has been felt that creating aeration of the maxillary sinus via the natural ostium will allow for healing of the damaged mucosa of chronic sinusitis and reestablishment of the natural drainage system. Theoretically, respiratory epithelium within the sinus will regenerate. There may still, however, be a role for this operation in cases in which maximal medical and "functional" surgery of the sinus has failed to restore healthy mucosa to a sinus. Attempts have been made at obliterating the maxillary sinus with fat and other substances, but these have never been successful. After a well-performed Caldwell-Luc operation, the sinus is to some extent "obliterated" by the natural course of healing. Other indications for a Caldwell-Luc approach include the treatment of oroantral fistulae, the treatment of malignant exophthalmos, as an approach to biopsy the infraorbital nerve in cases of suspected perineural invasion by cancer, as an approach to the orbital floor in the treatment of trauma, as an approach to the pterygomaxillary space for ligation of the internal maxillary artery in the treatment of resistant epistaxis, and as part of a larger operation to treat benign and malignant neoplasms of the lateral nasal wall, pterygomaxillary space and nasopharynx.

The operation is performed by retracting the upper lip superiorly, most effectively with a Johnson-type retractor. The soft tissues overlying the canine fossa are infiltrated with local anesthetic and epineph-rine. An incision is made centered on the canine fossa, slightly convex inferiorly and extending from just short of the midline back to the second or third maxillary molar. The incision is kept at least 5 mm above the gingival edge to allow enough tissue for closure. The incision in carried down to bone and then elevated in a subperiosteal plane superiorly to expose the infraorbital foramen and nerve. This elevation is done most expeditiously by beginning with a McKenty or other small periosteal elevator and then pushing on a gauze sponge for further elevation. A 2-mm osteo-tome is used to create a small opening into the maxillary sinus above the level of the maxillary tooth roots and this is then enlarged with a Kerrison-type rongeur. Most of the enlargement occurs superiorly up

Indications are:

Fig. 22.1. Bone incisions used for the Caldwell-Luc and Denker procedures

Fig. 22.1. Bone incisions used for the Caldwell-Luc and Denker procedures to and even around the infraorbital nerve (Fig. 22.1). The offending maxillary sinus mucosa is then completely stripped from the sinus. The roof is saved for last, realizing that the infraorbital nerve is frequently dehiscent within the sinus. Great care is taken to avoid damage to the infraorbital nerve. A variety of small curettes and pituitary-type forceps are used to remove all of the mucosa. Slow, steady traction is better than rapid tearing to remove large portions of the lining mucosa in a single piece.

Since the respiratory mucosa has been removed, the sinus will no longer drain via the natural osti-um. A nasoantral window is therefore created via the inferior meatus. A mosquito-type clamp is inserted approximately 1 cm back into the inferior me-atus to avoid the opening of the nasolacrimal duct. The clamp is directed toward the lateral canthus and bluntly inserted through the lateral wall of the inferior meatus and spread. A rat-tail rasp, Kerrison forceps or large Blakesley forceps are then used to enlarge the new ostium anteriorly and posteriorly to about 1.5-2.0 cm in diameter. If there is no significant bleeding, no packing is necessary. If bleeding persists, the sinus is packed with 0.5-in. gauze impregnated with antibiotic ointment, brought out via the nasoantral window. The gauze can be used as a file, much like dental floss, to smooth the opening of the new antrostomy by sliding it back and forth through the antrostomy. Finally the sublabial incision is closed with interrupted simple absorbable sutures. If packing is used, it is left for 1 or 2 days and then removed through the nose.

The Denker Procedure

Indications are:

■ To gain exposure for removal of lesions of the nasal sidewall or posterior nasal cavity and pterygomaxillary space

■ Inverting papilloma

■ Juvenile nasopharyngeal angiofibroma

The Denker procedure is just a modification of the Caldwell-Luc operation in which the inferior portion of the ascending portion of the maxilla is removed along the lateral aspect of the pyriform aperture, essentially connecting the inferior meatal na-soantral window with the opening via the canine fossa (Fig. 22.1). In recent times such an approach has been termed a partial facial degloving approach and may be useful as an approach to benign tumors such as juvenile nasopharyngeal angiofibromas or inverting papillomas.

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