THE CALDWELL-LUC RADICAL OPERATION
Indications. This is the favourite operation in well-marked chronic empyema of the antrum.
The mouth, teeth, and gums are purified as thoroughly as possible. The face, with any moustache or beard, should also be well cleansed. The nose on the affected side is prepared with cocaine and adrenalin (see [p. 572)].
On the Continent this operation is sometimes carried out under local anæsthesia, but chloroform is generally employed. When the patient is unconscious, a sponge is packed in the post-nasal space (see [p. 575]), the tongue is drawn forward with a tongue clip ([Fig. 314]), and the chloroform administered from a Junker’s apparatus.
Operation. The surgeon, armed as usual with a forehead electric search-light or Clar’s mirror ([Figs. 282], [283]), stands on the affected side. In addition to the post-nasal sponge, another is inserted far back between the molars on the side to be operated. This cheek sponge prevents any blood from running down into the pharynx and requires changing frequently.
The cheek being well retracted by an assistant, an incision is made half a centimetre below the gingivo-labial fold, extending from the first molar to the canine tooth (Fig. 327). It is carried down to the bone, so that the muco-periosteum can quickly be separated upwards, exposing the canine fossa. With hammer and chisel a circular piece of the wall is then cut through, measuring about half an inch across, and the opening is enlarged with bone-forceps or burr sufficiently to admit the surgeon’s little finger.
| Fig. 327. The Incision in the Caldwell-Luc Operation upon the Maxillary Sinus. | Fig. 328. The Caldwell-Luc Operation upon the Maxillary Sinus. Breaking through the antro-nasal wall below the level of attachment of the inferior turbinal. The opening has been purposely represented coming too far forward in order to include the view of the antro-nasal wall. |
The first opening of the sinus is frequently accompanied by free bleeding. This soon ceases, particularly if the cavity is packed for a little while with a strip of 2-inch ribbon gauze. During the operation, pieces of this gauze, 1 to 1½ yards long, prove very useful in checking any oozing and allowing a clear inspection of the walls of the sinus. They may be dipped in adrenalin, or, if the bleeding is sharp, in a 10% solution of peroxide of hydrogen, and left in place for a few minutes, while iced water is freely applied to the face and neck. As soon as the bony wall has been removed, the diseased mucous membrane presents in the opening in irregular, polypoid, bluish-greyish masses, bathed in pus which may be highly fœtid. The diseased mucous membrane should be carefully plucked out of the cavity with a pair of Grünwald’s forceps, supplemented by the use of a small ring curette, and guided by the eye and the touch of the operator’s little finger. Some surgeons recommend that the whole mucous lining of the sinus be carefully and completely removed, and the walls scraped down until they are white and bare. Unless the whole mucosa is diseased, this hardly seems necessary, particularly if a free opening be made into the nose. Polypoid masses and degenerate mucous membrane are chiefly met with on the floor of the antrum (in the crevices between the cusps of the teeth), on the inner wall in the neighbourhood of the ethmoid, and in the recess in the malar region, and it is to these areas that attention should be directed.
Fig. 329. Opening the Maxillary Sinus from the Nose. This is done with a Krause’s trochar and canula, after removal of the anterior end of the inferior turbinal.