OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY CALDWELL-LUC (RADICAL ANTROSTOMY), INFERIOR MEATAL ANTROS- TOMY & CANINE FOSSA AND INFERIOR MEATUS PUNCTURES Johan Fagan The Caldwell-Luc operation involves The canine fossa is a depression on the creating an opening into the maxillary anterior surface of the maxilla below the antrum through the canine fossa via a infraorbital foramen and lateral to the ca- sublabial approach. nine eminence and the incisive fossa (Figures 2, 3). It is larger and deeper than Canine fossa (CFP) & inferior meatal the incisive fossa, and is separated from it puncture are used to obtain samples of pus by the canine eminence, a vertical mound from the antrum, to irrigate the antrum overlying the socket of the canine tooth. (“antral washout”), or as an adjunct to en- The caninus muscle arises from the canine doscopic ethmoidectomy. fossa. Surgical anatomy Orbital rim The Caldwell-Luc operation involves en- Infraorbital foramen tering the maxillary sinus via an opening in the thin bone of the canine fossa (Figures Inferior turbinate 1-3). Canine fossa Caninus muscle Incisive fossa Nasalis muscle Depressor alae nasi Canine eminence Canine tooth Incisors Figure 2: Right canine fossa (yellow), incisive fossa and canine eminence The infraorbital foramen transmits the in- Figure 1: Thin bone of canine fossa (yel- fraorbital nerve, artery, and vein. The in- low arrow); nasolacrimal duct (red arrow) fraorbital neurovascular bundle traverses a groove in the orbital floor/roof of the sinus A series of eminences overlie the roots of which can be dehiscent. It exits through the the teeth on the inferior part of the face of infraorbital foramen, located approximate- the maxilla (Figures 2, 3). Just above the ly 5mm below the midportion of the infe- eminences of the incisor teeth is a depres- rior orbital rim to enter the soft tissues of sion called the incisive fossa; it gives ori- the cheek. Branches of the nerve supply gin to the depressor alae nasi. The nasalis the lower eyelid, nose, cheek and upper lip muscle arises just lateral to it (Figure 2). (Figures 3, 4). Care must be taken when elevating the periosteum from the anterior wall of the sinus to avoid injury to the The maxillary sinus is lined by ciliated co- infraorbital nerve where it exits the canal. lumnar epithelium. The cilia move secre- Branches of the anterior and posterior su- tions toward the natural sinus ostium; this perior alveolar nerves travel through bone explains the limited efficacy of an inferior to supply the upper teeth and gums (Fig- meatal antrostomy. The adult maxillary si- ures 3, 4). These nerves may be injured nus is 25-35mm wide, 36-45mm high, and when extending the antrostomy too low 38-45mm long, and has an average volume and cause loss of sensation to the teeth and of 15ml. The superior wall is formed by gums. the orbital floor which is thin and often de- hiscent. The infraorbital nerve is in the roof of the sinus. Medially and posteriorly the roof is composed of the floor of the ethmoid sinuses (Figure 10). The anterior Palpebral branches wall contains the nerves and vessels that Infraorbital nerve supply the upper teeth. It is thinner ante- Nasal branches riorly and thickens posterolaterally where Labial branches it joins the zygomatic process (Figure 1). Septae are present in about a third of cases, Ant superior mainly anteriorly (Figure 1). The medial alveolar nerve wall of the maxillary sinus separates it Septal branch from the nasal cavity (Figures 5, 6). Branches of post sup alveolar nerve Frontal sinus Branches to teeth Post ethmoidal foramen Branches to gums Orbital process pal bone Anterior ethmoidal Sphenopalatine for foramen Foramen rotundum Figure 3: Infraorbital nerve and branches Lacrimal fossa of the anterior superior alveolar and pos- Uncinate Max sinus ostium terior superior alveolar nerves; antros- Inferior turbinate Pterygoid canal tomy in canine fossa (red circle); stippled Palatine bone lines indicate nerves within the bone Lateral pterygoid plate Pyramidal process palatine of bone Figure 5: Lateral view with windows cut in lateral and medial walls of maxillary sinus The inferior turbinate is attached along the nasal wall below the level of the maxillary sinus ostium (Figure 6). The nasolacrimal duct traverses the thicker bone at the junction of the medial and anterior walls before opening into the nose below the in- ferior turbinate (Figures 1, 12). The sinus Figure 4: Branches of V2 (An Atlas of communicates with the nasal cavity via the Anatomy, by regions; 1962: Grant) maxillary sinus ostium in the hiatus semi- 2 Frontal sinus Anterior cranial fossa floor Crista galli Frontonasal duct Sella turcica Lacrimal sac in lacrimal fossa Anterior end of maxillary sinus Inferior turbinate Uncinate Maxillary sinus ostium Medial pterygoid plate Pterygoid hamulus Figure 7: Coronal CT slice through lacri- mal fossa Figure 6: Bony anatomy of the lateral wall of the nose Floor anterior cranial fossa lunaris of the middle meatus (Figures 8, Lamina papyracea 9). The posterior wall is the infratemporal Middle turbinate surface of the maxilla and separates the Uncinate process sinus from the pterygomaxillary fissure and the pterygopalatine fossa which con- Infraorbital nerve tains the internal maxillary artery and its Maxillary sinus branches and the pterygopalatine ganglion Inferior turbinate and its branches (Figure 4). The radiological anatomy of the maxillary sinus is assessed on plain X-rays or by co- Figure 8: Coronal plane through anterior ronal and axial CT scans and is essential to ethmoids midway along the maxillary sinus do prior to a Caldwell-Luc procedure (Fi- gures 1, 7-13). Figures 7-10 demonstrate Fovea ethmoidalis the coronal anatomy at the anterior, mid- and posterior maxillary sinus. Figure 11) is Anterior ethmoidal foramen a slice immediately behind the maxillary Lamina papyracea sinus in which the internal maxillary arte- Uncinate process ry and its branches as well as the spheno- palatine ganglion and its branches are Infraorbital nerve encountered within the pterygopalatine fossa. The pterygopalatine fossa communi- cates laterally with the infratemporal fossa via the pterygomaxillary fissure and me- dially with the nasal cavity via the spheno- palatine foramen. Figure 9: Anatomy at uncinate process 3 Posterior ethmoidal foramen Optic nerve Infraorbital foramen Lamina papyracea Inferior turbinate Ground lamella Zygoma Inferior orbital fissure Pterygomaxillary fissure Pterygoid plates Figure 10: Coronal slice through posterior Figure 13: Axial cut at level of infraorbital maxillary sinus; note its relationship to the foramen and pterygoid plates ethmoids Orbital apex Sphenopalatine foramen Pterygopalatine fossa Pterygomaxillary fissure Pterygoid plates Figure 11: Coronal cut immediately be- hind the maxillary sinus Figures 12 & 13 show axial views demon- Figure 14: Hypoplastic maxillary sinus strating the pterygopalatine fossa, pterygo- maxillary fissure and pterygoid plates. The dimensions of the maxillary sinus Imaging may also reveal important anato- change with age, and may affect surgery. mical variations that can affect the surgical Expansion at 2-3 mm/year of the maxillary approach e.g. congenital hypoplasia sinuses continue until adulthood. At birth (Figure 14). they are small and the floors of the sinuses are approximately 4mm above the nasal floor; at 8-9 years of age the floors of the sinuses and nasal cavity are at about the same levels and the sinus dimensions are 2 Infraorbital nerve x 2 x 3cms. In adults the sinus floor is 0.5- Nasolacrimal duct 1 cm below that of the nasal cavity (Figure Zygoma 15). The maxillary alveolus atrophies in edentulous patients so that the floor may Pterygomaxillary fissure be even lower. Pterygopalatine fossa Figure 12: Axial cut at level of infraorbital nerve and orbital floor 4 Figure 15: Floor of sinus lower than nasal floor in adults Figure 17: Branches of internal maxillary No significant vessels are encountered dur- nd ing Caldwell-Luc antrostomy other than artery; blue shaded area is the 2 part of the small infraorbital vessels that exit the artery before it enters the pterygopalatine infraorbital foramen to supply the over- fossa lying soft tissues of the face (Figure 16). Angular vein Angular artery Infraorbital artery Figure 18: Branches of internal maxillary Figure 16: Vasculature around the orbit artery Only if one breaks through the posterior wall of the sinus does one encounter the Caldwell-Luc / Radical antrostomy internal maxillary artery, a branch of the external carotid artery, which, passes The Caldwell-Luc operation involves through the pterygomaxillary fissure to making an opening in the thin bone of the enter the pterygopalatine fossa (Figures canine fossa and entering the maxillary 17, 18). sinus. It was first employed to remove in- fection and to strip diseased mucosa from the maxillary sinus; counter-drainage into the nose was established via an inferior meatal antrostomy. However with an im- proved understanding of sinus pathophy- siology, and introduction of endoscopic, mucosa-sparing functional sinus surgical 5 techniques, the Caldwell-Luc procedure is Imaging now infrequently used to treat sinusitis. This is routinely done to assess the size of Indications the sinus and the height of its floor relative to the nasal floor, to exclude hypoplasia Biopsy or resection of tumours of the and unerupted dentition, and to evaluate nose and paranasal sinuses underlying pathology. Even though centres Transantral access for tumours in the may only have access to sinus X-rays, CT pterygopalatine fossa scan is a far superior investigation. Both Transantral ligation of internal maxil- axial and coronal CT should be requested. lary artery and its branches for epi- Coronal views provide information about staxis the orbit, orbital floor, sinus floor and al- Transantral access for fractures of the veolus, and lateral wall of the nose and si- midface and orbital floor nus ostia. Axial views provide information Orbital decompression about the anterior wall of the sinus, the As part of medial maxillectomy pro- pterygopalatine fossa and infratemporal cedure e.g.