Clinical Indicators
Caldwell-Luc

Procedure CPT FUD
Caldwell-Luc
Sinusotomy, maxillary (antrostomy); 31030 90
  • radical (Caldwell-Luc) without removal or antochoanal polyps
  • radical (Caldwell-Luc) with antrochoanal polyp removal
 31032 90
Indications

1. History... one or more required

a) Maxillary sinusitis unresponsive to office management or medical treatment.
b) Recurrent or persistent pain in maxillary area.
c) Imaging report of disease in the maxillary sinus. 

2. Physical Examination

a) Description of nasal examination noting any obstruction or discharge.. required.
b) Description of facial examination noting the presence of any swelling, pain, or distorted trigeminal sensation... required.
c) Transillumination of maxillary area -- (optional). 

3. Test... required

a) Sinus imaging demonstrating abnormal contents of antrum. 

Postoperative Observations

1. Bleeding--notify surgeon.
2. Packing--if not in desired location, notify surgeon.

Outcome Review

1. One Week

a) Healing--Did patient require treatment for bleeding or infection?
b) Pathology--Does pathology report indicate need for further treatment and if so, how managed? 
2.Beyond One Month
a) Presenting problem--Is it (see history) improved?
b) Airway--Is there obstruction due to crusting?
c) Healing--Is there facial or dental paresthesia?
d) Healing--Is there oroantral fistula? 

Associated ICD-9 Diagnostic Codes

212.0 Benign neoplasm of nasal cavities, middle ear, and accessory sinuses
461.9 Acute sinusitis, unspecified
470.  Deviated nasal septum
473.0 Chronic maxillary sinusitis
473.2 Chronic ethmoidal sinusitis
473.8 Other chronic sinusitis
478.1 Other diseases of nasal cavity and sinuse

Additional Information
Assistant Surgeon -- N
Supply Charges -- N
Prior Approval -- N

Anesthesia Code(s)
00162

Patient Information

A Caldwell-Luc operation is advised in order to evaluate, remove, and perform microscopic examination of disease located in the maxillary sinus. Since it was first performed at the end of the 19th century, a vast amount of knowledge has developed not only about its proven value as a method to treat maxillary sinus disease but also about potential risks, which fortunately are infrequent. They include: injury to the infra-orbital nerve (facial numbness-not weakness), injury to the eye, failure of the incision above the upper teeth to heal, post operative bleeding or infection, numbness of upper teeth, and recurrence of sinus disease.

Important Notice

The Clinical Indicators for Otolaryngology--Head and Neck Surgery are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The American Academy of Otolaryngology-Head and Neck Surgery, Inc. emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.

© 1999 American Academy of Otolaryngology-Head and Neck Surgery. One Prince Street, Alexandria, VA 22314.