My symptoms of acute and chronic sinusitis became apparent during the
early 1980's, and were treated with two Caldwell Luc operations
performed about four years apart. The biopsies indicated
"squamous/sloughed cells", and large polyps, which were removed. The
symptoms have been with me again for the past five years, or so. A
recent CT scan indicates congestion and blockage in the maxillary sinus,
but endoscpoic surgery is prevented because of the apparent existence of
a vertical piece of bone which runs from under the eye to a point above
the teeth. I am at the end of my tether with pain, fatigue etc., and
have a discernible swelling which runs at an angle below my eye.
(1) Is there anything ominous in what has been referred to (above) ?
(2) Is there any further type of treatment/operation/procedure which you
can suggest ?
(3) What is the prognosis for relief of this condition ?
Thank you for your time, and consideration of the above questions.
> >
Reply: -------------------
Caldwell-Luc procedures are being done less frequently in the US in the last decade since the introduction of endoscopic sinus surgery. A Caldwell-Luc procedure is an operation intended to treat disease located in the maxillary sinus (the largest sinus which is located in the cheek) only and involves removing disease through an opening directly through the front of the sinus through an incision made under the lip above the gum of the upper teeth. An artificial drainage pathway is then created between the sinus and the nasal passage known as an inferior meatal antrostomy.
In contemporary medical thinking there are a couple of problems with this approach. First, considerable research suggests that virtually all chronic sinus disease has its origins in some type of obstructive phenomena involving a common drainage pathway located in the ethmoid sinuses (smaller honey-comb like sinuses located between the eyes). Obstruction in this area is then thought to result in chronic sinus disease which can be limited to one or involve all of the sinuses (frontal, ethmoid, sphenoid, or maxillary). Therefore one problem with Caldwell-Luc surgery is that it doesn't necessarily address the primary origins of sinus disease. Another problem with Caldwell-Luc approach is the inferior meatal antrostomy (also known as a "window"). Research has conclusively shown that the natural drainage course of mucous inside the maxillary sinus is towards the natural ostium which is located near the top of the sinus rather than the bottom. Many studies have demonstrated that even if the inferior meatal window remains open (it frequently scars shut with time), there remains a tendency for the maxillary sinus to drain towards the natural opening and since the original problem causing chronic sinus disease probably involved an obstruction in that location, sinus disease in the maxillary sinus can recur. Other problems with the Caldwell-Luc approach include the morbidity of the operation. Numbness or chronic pain in the cheek can occasionally occur, it is a more invasive type of sinus surgery, and recovery from the operation is longer than with modern endoscopic sinus surgery. Because of all of these issues, endoscopic sinus surgery has largely replaced Caldwell-Luc operations as the initial surgical intervention for chronic sinus disease when medical (non-surgical) therapy has failed. Most otolaryngologists today reserve Caldwell-Luc surgery for certain types of tumors or for chronic maxillary sinus disease that has persisted despite endoscopic sinus surgery in which the natural drainage pathways of the sinuses have been successfully cleared of obstruction.
Your post does not provide a full explanation as to why endoscopic sinus surgery should not be considered. It is possible that if non-surgical treatments have failed to resolve your sinus disease, that repeat Caldwell-Luc surgery may be necessary, but if it is necessary, I believe that endoscopic sinus surgery might also be advisable to clear any potential obstruction in the natural drainage pathways of the sinuses. As to the vertical strip of bone you describe, if this was not present at the time of your original surgeries, then most likely it represents some type of scarring phenomena, and this might explain the recurrence of disease in the maxillary sinus. This is why I believe it might be necessary to consider repeat Caldwell-Luc surgery since this may be the only way to remove that scar, but it should be done in combination with endoscopic sinus surgery in my opinion. Finally, I always strongly emphasize that sinus surgery for chronic sinusitis should be reserved for disease that has persisted despite long-term (one or more months) of sustained medical therapy.
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Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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