Sinonasal imaging after Caldwell–Luc surgery: MDCT findings of an abandoned procedure in times of functional endoscopic sinus surgery

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Abstract

Background and purpose

Today, functional endoscopic sinus surgery (FESS) is performed in most of the patients with sinonasal inflammatory disease. The postoperative imaging findings of FESS in multidetector computed tomography (MDCT) considerably differ from those of historic Caldwell–Luc (CL) maxillary sinus surgery which is an uncommon procedure today. Thus, the postoperative CL imaging findings may lead to diagnostic confusion and misinterpretation. Therefore, this study explicitly presents the MDCT findings of post-CL patients which have not been described previously.

Methods

Twenty-eight patients with clinically suspected sinusitis and documented history of CL-procedure underwent 16 row MDCT (MDCT Mx8000 IDT Philips) with multiplanar reconstructions of the paranasal sinuses in the axial plane. The following parameters were used: 140 kV, 50 mAs; 16 mm × 0.75 mm detector collimation; 1 mm reconstructed slice thickness; 0.5 mm increment. The studies were reconstructed with a bone algorithm (W3000/L600; 1 mm slice thickness) in axial plane and coronal plane (3 mm slice thickness). The images were retrospectively evaluated for the presence of normal surgery-related and pathological findings.

Results

Surgery-related imaging characteristics presented as follows: an anterior and a medial bony wall defect and sclerosis and sinus wall thickening were observed in all 28/28 cases (100%). Collaps of the sinus cavity was seen in 26/28 cases (92.9%). Furthermore, inflammatory disease of the operated sinus(es) was found in 23/28 cases (82.1%): 14/28 patients (50%) had inflammatory mucosal thickening of the operated sinus(es) as well as of other sinonasal cavities and 9/28 patients (32.1%) had inflammatory mucosal thickening limited to the operated sinus(es). A postoperative mucocele was depicted in 3/28 cases (10.7%). 2/28 patients (7.1%) showed neither maxillary nor other mucosal swelling.

Conclusion

MDCT with multiplanar reconstructions is a precise method to evaluate post-CL patients and helps to differentiate normal surgery-related findings, which may mimic pathology, from real pathological findings.

Introduction

Over 100 years ago in the late 19th century, in the pre-antibiotic era, George Caldwell and Guy Luc designed an operation to remove diseased mucosa from the maxillary sinus and to provide drainage and ventilation of the sinonasal system [1], [2], [3], [4], [5], [6]: the maxillary sinus is entered via the canine fossa and the mucosa is radically dissected. In most cases, also an inferior antrostomy is performed, in which the lateral nasal wall of the inferior meatus is partially resected to create a nasoantral window for better drainage. Nowadays however, in times of minimal invasive surgery, functional endoscopic sinus surgery (FESS) has become the standard procedure for most surgical cases of chronic sinusitis. The use of the Caldwell–Luc (CL) surgical approach is uncommon today and only rational in cases of fungal disease and inverted papilloma or in patients with severe recurrent inflammatory disease [1], [2], [3], [4], [5], [6].

From the imaging point of view, MDCT in bone window level setting is the modality of choice in the diagnosis of inflammatory sinonasal disease and in the pre- and postoperative evaluation [7], [8], [9], [10], [11], [12].

CT findings in patients after CL surgery considerably differ from those in post-FESS patients [4], [5], [6], [12], [13]. Due to the somewhat historical value of CL surgery, since it was replaced by FESS in the 1980s, associated imaging findings in patients with suspected sinonasal disease may lead to diagnostic confusion today. Thus, this study wants to explicitly present the imaging findings in the evaluation of post-CL patients in MDCT with multiplanar reconstructions.

Section snippets

Methods

In this retrospective case series, 28 patients (13 women and 15 men with a mean age of 58.5 years, range of age 39–84 years) were included after chart review if following criteria were fulfilled: (a) clinically suspected sinusitis with sinonasal complaints (nasal congestion, rhinitis, facial pain, general malaise, elevated inflammatory blood parameters and fever), (b) documented history of CL-procedure and (c) no medical history of tumor. Six patients underwent CL surgery of the left maxillary

Results

According to the surgical history of CL-procedure normal surgery-related imaging findings due to radical mucosal removal presented as follows: an anterior and a medial osseus wall defect were observed in 28/28 cases (100%) (Fig. 1). Sclerosis and sinus wall thickening were shown in 28/28 cases (100%) (Fig. 2a). Collaps of the sinus cavity was seen in 26/28 cases (92.9%) (Fig. 2b).

Overall, clinically suspected sinonasal complaints were confirmed in 26/28 (92.9%) patients by imaging. Pathological

Discussion

Numerous studies have underlined the role of thin slice axial MDCT with multiplanar reconstructions in the pre- and postoperative evaluation of inflammatory sinonasal disease. The axial plane provides optimal visualization of the sinus walls, coronal studies depict the ostiomeatal complex and closely correlate with the surgical orientation [5], [7], [8]. MDCT scanners allow excellent coronal images to be reconstructed from axial images, which are virtually indistinguishable from images directly

Conclusion

MDCT in bone window level setting with multiplanar reconstructions is a precise method to evaluate the postoperative maxillary sinus and provides a high potential to differentiate normal post-CL findings from real pathology. The combination of osseus wall defects, sclerosis, sinus wall thickening and sinus collaps seems to be characteristic for the normal post-CL sinus. If mucosal thickening is present active inflammation should be discussed.

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