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COMPARATIVE ANALYSIS OF EFFECTIVENESS AND ADVERS
EFFECTS OF FESS AND CALDWELL-LUC PROCEDURE IN
MAXILLARY CYST CASES: ARETROSPECTIVE STUDY
Das Sharodiya
1
,
Norjigitov Firdavs Nordirjonovich
2
Student , International Students’ Faculty Of Medicine ,
Tashkent Medical Academy
1
Assistant Teacher of the Department of Otolaryngology,
Tashkent Medical Academy
2
Abstract
Functional endoscopic sinus surgery (FESS) and Caldwell-Luc operation are
both maxillary sinus cyst surgical procedures, and comparison between them
regarding effectiveness and status of morbidity is still poorly documented. The
retrospective cohort of 75 adults (60 patients underwent FESS and Caldwell-Luc
operation was done in 15 patients) operated between 2017 and 2023 due to isolated
maxillary sinus mucous retention cysts compared postoperative outcomes such as
infraorbital nerve impairment (paresthesia or numbness) and pain (on Visual Analog
Scale, VAS) facial edema, operation time, and hospitalization duration. Statistically
(compared continuous variables by independent t-test and categorical variables by χ²
or Fisher’s exact) analysis at an alpha level of p<0.05 was carried out.
FESS patients fared much better compared to patients who underwent Caldwell-
Luc surgery. Specifically, infraorbital nerve impairment occurred in only 3 of 60
(5.0%) of the FESS patients versus 4 of 15 (26.7%) of those in the Caldwell-Luc
group (p=0.010). Postoperative pain VAS scores were decreased in the FESS group
(3.2 ± 1.1) versus those of the Caldwell-Luc group (5.8 ± 1.3; p<0.001). Hospital stays
of the FESS group were less (mean 1.8 ± 0.5 days) than those of the Caldwell-Luc
group (3.1 ± 0.9 days; p<0.001). Swelling of the face was less with FESS, and surgical
time was less in the FESS group (both p<0.05).
In conclusion, FESS was revealed to be related to improved perioperative
outcomes and less morbidity in comparison to the conventional Caldwell-Luc
procedure in managing maxillary sinus cysts. The findings provide justification to
apply FESS preferentially to well-chosen patients since it can minimize complications
and improve patient recovery in clinical practice.
Key words:
Maxillary sinus cyst; Functional Endoscopic Sinus Surgery (FESS);
Caldwell-Luc procedure; endoscopic sinus surgery; postoperative results
Introduction
Maxillary sinus mucous retention cysts (so-called pseudocysts) are encountered
commonly as incidental findings on imaging studies, but few of them cause enough
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symptoms to result in nasal blockage, facial pain, or chronic sinusitis [1,2]. Should
and when they do so, they require decompression, re-establishment of normal sinus
drainage, and prevention of infection or cyst growth [3]. Historically, the Caldwell-
Luc operation – an incision in the canine fossa and fenestration of the anterior
maxillary wall – was the standard operation to access and treat maxillary sinus
pathology [4]. The open technique offers great exposure at the expense of hazards of
infraorbital nerve injury, significant facial edema, and protracted recovery [4,5].
The development of endoscopic sinus procedures brought about a revolution in
sinus surgery. Functional Endoscopic Sinus Surgery (FESS) applies nasal endoscopes
to form a minimal access antrostomy by means of which cystic lesions may be
observed directly and removed with minimal damage to normal tissue [6,7]. This has
proved to be associated with less intraoperative trauma, postoperative pain and facial
edema, and recovery periods than in the case of open surgery [6,7]. The Caldwell-Luc
procedure continues to be useful in certain cases of extensive sinus disease, anatomic
disposition, or where endoscopic entrance is unachievable [8, 23,24].
Where there is extensive literature regarding endoscopic versus open sinus
surgeries of chronic sinusitis as well as mucoceles, head-to-head comparison between
outcomes of Caldwell-Luc and FESS is less common in the context of isolated
maxillary sinus retention cysts. Prior studies have suggested endoscopic surgery to be
useful in heterogeneous indications. In response to this lack, we compared
retrospectively between two series of surgeries to compare complication rates and
recovery in the context of benign maxillary sinus cysts. Our goal was to establish in
this group of patients whether minimally invasive FESS results in demonstrably
superior postoperative outcomes when compared to traditional Caldwell-Luc.
Materials and Methods
A retrospective cohort study at Tashkent Medical Academy in the Department
of Otorhinolaryngology was conducted following approval by the institution's review
panel. We retrospectively assessed patient records of patients aged between 18 and
50 years old who were treated surgically for isolated maxillary sinus mucous retention
cysts between 2017 and 2023. The inclusion factors were: (1) computed tomography-
verified diagnosis of benign maxillary sinus cyst; and (2) treatment either by
Caldwell-Luc procedure or by FESS. Excluded were patients with previous history of
sinonasal malignancy or tumor, sinonasal surgery, chronic rhinosinusitis with nasal
polyposis, or sinus pathology following trauma as these would presumably alter
postoperative outcomes.
The surgical procedure was decided by the treating otolaryngologist according
to clinical judgment, nature of cyst, and personal preference. The series consisted of
60 patients operated with FESS and 15 by Caldwell-Luc procedure. The surgeries
were performed by seasoned sinus surgeons with general anesthesia. The technique
of FESS involved routine uncinectomy and antrostomy of middle meatus and total
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removal of the cyst by angled endoscopes. The Caldwell-Luc procedure was done by
performing sublabial incision of fossa canina, removal of mucous of the maxillary
sinus anterior wall by osteotomy, and enucleation of the cyst. Endoscopic control
(FESS) or direct cauterization (Caldwell-Luc) controlled bleeding during surgery.
Postoperative treatment was identical in both groups and consisted of systemically
given antibiotics and saline irrigation of nostrils.
Patient information was abstracted from electronic health records. Demographic
variables (age and sex) and postoperative outcome variables (infraorbital nerve
function as patient complaint of numbness or paresthesia of the cheek or upper lip,
pain level as rated by a 10-point Visual Analog Scale [VAS] on postoperative day 1,
facial edema degree as clinically rated none/mild, moderate, or severe as of
postoperative day 1, operative time as in minutes from incision initiation to closure
and hospital length of stay as days of in-hospital time post-surgery) were obtained
and recorded. Dysfunction of infraorbital nerve and facial edema were assessed at
discharge day. All information was entered in an encrypted database for analysis.
Statistical analysis was done using SPSS software, version 26.0. The results of
the continuous variables (age, VAS pain scores, operative time, and hospital stay) are
given as mean ± standard deviation. The categorical variables (sex, occurrence of
nerve dysfunction, edema category) are given as numbers and percentages.
Comparison of group differences of continuous variables was carried out by the
independent Student's t-test following establishment of normal distribution;
categorical variables by Chi-square or Fisher’s exact test where appropriate. Two-
tailed p-value of less than 0.05 was considered to be statistically significant.
Results
1.Patient Characteristics
The population included 75 patients (mean age, 34.5 ± 8.2 years; males and
females, 42 and 33, respectively). Demographic admission parameters were
comparable in between patients treated by Caldwell-Luc and those treated by FESS.
The mean was 34.1 ± 7.9 years in group FESS and 35.8 ± 8.9 years in group Caldwell-
Luc (p>0.05). The population of males was comparable (70% males in group FESS
and 67% in group Caldwell-Luc, p>0.05). The involved side of maxillary sinus (right
or left) and size of the cyst (on computed tomography) were comparable in between
groups and ensured that both populations were well matched.
2.Post-surgical outcomes
The comparative outcomes have been presented in Table 1. Postoperative results
in all of those parameters that were investigated improved significantly following
FESS.
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Parameter
FESS(n=60)
Caldwell-Luc (n=15)
P value
Infraorbital
Nerve
Dysfunction (%)
5.0
26.7
0.01
Mean
VAS
Pain
score(0-10)
3.2±1.1
5.8±1.3
<0.001
Moderate / Severe
facial Edema (%)
10.0
46.7
<0.001
Mean operation time
(minutes)
45.3±9.8
71.4±12.1
<0.001
Mean Hospital Stay
1.8±0.5
3.1±0.9
<0.001
Infraorbital nerve dysfunction: Postoperative infraorbital numbness or
paresthesia was present in only 3 of 60 (5.0%) patients operated with FESS versus 4
of 15 (26.7%) patients operated with Caldwell-Luc. This difference was significant
(p=0.010, Chi-square) and reflected much less risk of nerve damage by endoscopic
technique.
Postoperative pain: The VAS score of pain at postoperative day 1 was lower in
FESS cases (3.2 ± 1.1) than in those operated by Caldwell-Luc (5.8 ± 1.3) as
determined by an independent t-test (p<0.001). More patients in the group operated
by FESS reported mild pain (VAS ≤4) than in the Caldwell-Luc group (83% versus
27%).
Facial Edema: Facial edema was clinically much less evident in the FESS group.
Mild (or no) edema was the prevailing finding in the majority of the FESS patients,
whereas facial edema of moderate to marked extent was the norm following Caldwell-
Luc operation. This prevalence of facial edema distribution was statistically
significant (p<0.01).
Operative time: The surgical time of the FESS group (mean of 42 ± 10 minutes)
was less than that of the Caldwell-Luc group (mean of 58 ± 12 minutes) and was
significantly different (p<0.05). This shows that, despite there apparently being a
technical disadvantage to endoscopic surgery, it is now possible to do FESS with
existing technique in less time.
Hospital Stay: The hospital stay was less in the case of the FESS patients, with
their mean hospitalization time of 1.8 ± 0.5 days compared to 3.1 ± 0.9 days in
Caldwell-Luc patients (mean difference of 1.3 days; p<0.001). This reflects the
expeditious recovery and lesser immediate morbidity of endoscopic surgery.
Overall, patients operated upon by means of FESS had lower infraorbital nerve
injury rates, less facial edema, lower pain scores, shorter surgical time, and hospital
stays compared to patients operated by means of the Caldwell-Luc procedure.
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Discussion
This retrospective analysis demonstrates Functional Endoscopic Sinus Surgery
to have definite advantages over the classic Caldwell-Luc operation for treatment of
benign maxillary sinus cysts. Specifically, it was found that FESS was linked to much
less morbidity and superior initial postop outcomes. This confirms the paradigm shift
in endoscopic treatment of maxillary sinus disease [6,7].
Infraorbital Nerve Dysfunction: The most striking difference was less
infraorbital nerve dysfunction in the group treated with FESS. Caldwell-Luc
procedure sometimes requires manipulation close to maxillary frontal wall and often
necessitates blunt dissection and bone removal injuring infraorbital canal [4]. In this
series, over a quarter of Caldwell-Luc patients have cheeks and upper lip sensory
disturbances, whereas such disturbances occurred in only 5% of those operated on by
FESS. This observation concurs with studies done previously [9,10] that documented
neuroprotective advantage of endoscopic technique. Weber et al. [9], as an example,
reported significantly lower incidence of cheek paresthesia following endoscopic
compared to Caldwell-Luc surgery in comparable population. Improved visualization
with endoscopes most likely allows surgeon to save infraorbital foramen and to
manipulate tissue carefully, and therefore to prevent nerve injury.
Postoperative Pain and Edema: We observed comparatively low postoperative
pain scores following FESS. The VAS score of patients treated with FESS averaged
nearly half that of patients treated by Caldwell-Luc, and this difference was highly
significant. This is because there is less mucous and muscular trauma and resultant
nociception with FESS; as Lanza and Kennedy [11] noted, endoscopic sinus surgery
is associated with less facial tissue disturbance and therefore less nociception. The
resulting decreased tissue handling was also observed as significantly less facial
edema. Caldwell-Luc procedure necessarily involves periosteal elevation and
formation of a bony window, with attendant inflammatory edema [4]. FESS, by
contrast, is performed entirely via the nasal airway, with no facial tissue disturbance.
Other studies have reported that patients treated by endoscopic sinus surgery
experience less facial edema and bruising than those treated by external procedures
[12,13,14]. Such advantages in pain and cosmetic result have clinical significance, in
that they result in earlier ambulation, increased patient satisfaction, and less need for
analgesia.
Operative time: Although FESS requires special tools and training, in this study
it correlated with lower mean operative times. This may be reflective of both newer
endoscopic equipment capability and operating team experience. This is consistent
with findings by Dessi et al. [20] and Lund [21], both of whom recorded decreased
operating time with experience endoscopic surgeons. Decreased procedure time
reduces exposure to anesthesia and cost of operation, again to the endoscopic
technique's advantage.
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Hospital Stay Duration: The combination of less pain, decreased swelling, and
less aggressive surgeries resulted in greatly diminished hospitalization in patients of
FESS (mean of 1.8 days) compared to Caldwell-Luc (mean of 3.1 days). This takes
significant consideration when looking at resource utilization and patient well-being.
Decreased stays lower cost of care and allow patients to resume activity faster. Our
findings align with prior experience [15,16,17,18,19] of quicker recovery following
endoscopic sinus surgery. Implications to Clinical Practice: As such, these results
confirm that endoscopic access, and hence FESS, is the treatment of choice in solitary
maxillary sinus cysts. The significantly lower morbility with FESS justifies
contemporary clinical practice recommendations favoring endoscopic treatment of
maxillary sinus disease [22–24]. The Caldwell-Luc would be reserved for rare
indications, like in extremely large lesions that cannot be reached by the endoscope
or when extensive antral pathology needs to be cleared beyond middle meatus reach
[8,22]. Even in these cases, improved results with FESS will encourage endoscopic
approaches to be used wherever feasible. Limitations: Our study has following
limitations due to its retrospective nature. The potential selection bias exists since
patients were not randomized and there was potentially selective application of
technique by surgeon based on individual patient anatomy or nature of cyst. The small
population of patients in the Caldwell-Luc group (n=15) decreases statistical power
and comparability as well. We had access to only immediate postop results; long-term
follow-up information (such as recurrence rate or late complications such as
development of mucocele) was not available in this database. As an institutional
study, results can be representative of individual surgeon technique and institutional
practice and would be non-transferable elsewhere. Pain and edema were assessed
using standardized scales; subjective variables as these outcomes measure and can be
confounded by individual patient variables or reporting bias. Conclusion In this
retrospective analysis, endoscopic sinus surgery (FESS) produced far superior
immediate results compared to Caldwell-Luc surgery in patients with benign
maxillary sinus cysts. The endoscopic procedure had less risk of infraorbital nerve
damage, less postop facial edema and pain, less hospital and operation time, and less
hospitalization. The advantages reflect clinical benefits of endoscopic minimal
invasion. Thus, where anatomy and cyst morphology allow, FESS would be the
preferred procedure to treat maxillary sinus cysts. By providing improved recovery
and less risk of morbidity, the study contributes to evidence to inform practice in
otolaryngology.
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