CPT® Code 31030

A radical maxillary sinusotomy, also known as an antrostomy or Caldwell-Luc procedure, is a surgical intervention aimed at accessing the maxillary sinus through the mouth. This procedure is indicated for various conditions affecting the maxillary sinus, particularly when there is a need for drainage or specimen collection. The surgery begins with an incision made in the oral cavity, specifically over the canine tooth, which extends to the first premolar. This approach allows the surgeon to reach the maxillary sinus while minimizing external incisions. During the procedure, electrocautery is utilized to dissect through the soft tissue and periosteum, carefully elevating the periosteum from the anterior wall of the maxilla to protect the infraorbital nerve, which is crucial for maintaining sensation in the face. Access to the maxillary sinus is achieved through the canine fossa using a mallet and osteotome, and the opening is subsequently enlarged with rongeurs to facilitate adequate drainage. The procedure is performed without the removal of antrochoanal polyps, which are solitary growths that can obstruct the sinus and nasal passages. The radical maxillary sinusotomy is essential for addressing issues such as chronic sinusitis or other sinus-related complications, allowing for effective drainage and management of the sinus condition.