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Oronasalfistulaincleftpalatesurgery

IndianJPlastSurg.2009Oct42(Suppl):S123S128.

PMCID:PMC2825081

doi:10.4103/09700358.57203

Oronasalfistulaincleftpalatesurgery
ParthaSadhu
GlobalHospital&ResearchCentre,MountAbu,India
AddressforCorrsepondence:Dr.ParthaSadhu,GlobalHospital&ResearchCentre,MountAbu,India.Email:drparthasadhu@yahoo.com
CopyrightIndianJournalofPlasticSurgery
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Oronasalfistula(ONF)isthecommonestcomplicationassociatedwithcleftpalatesurgery.Themain
symptomsassociatedwithONFarenasalregurgitationoffoodmatterandhypernasalityofvoice.Repairof
cleftpalateundertensionisconsideredtobethemainreasonofONFthoughvascularaccidentsand
infectioncanalsobethecause.MostoftheONFsaresituatedinthehardpalateoratthejunctionofhard
andsoftpalate.RepairofONFdependsonitssite,sizeandmodeofpresentation.Awholespectrumof
surgicalproceduresstartingfromsmalllocalflapstomicrovasculartissuetransfershavebeenemployedfor
closureofONF.RecurrencerateofONFis25%onanaverageafterthefirstattemptofrepair.
Keywords:Cleftpalate,Oronasalfistula,Palatalfistula

INTRODUCTION
Oronasalfistula(ONF)isprobablythecommonestcomplicationassociatedwithcleftpalatesurgery.Therate
ofONFvariesfrom435%[1]orevenmoreincaseofprimarypalatoplasty.Thetwomainsymptoms
associatedwithONFarenasalregurgitationandspeechproblems,mainlyhypernasality.Thesiteandsizeof
thefistulaarevariableandsoarethecauses.ONFdevelopsprimarilybecauseofrepairundertensionandin
somecases,especiallyinadults,asaresultofpostoperativeinfection.
Asalreadymentioned,theincidenceishighlyvariable.MusgraveandBremmer[2]presentedhealing
problemsinabout10%oftheircaseswhereapproximately7%developedfistulas.Theyfound,theincidence
tobemoreinbilateral(12.5%)thaninunilateralcases(7.7%).Kilner[3]reportedonlyararefailureofunion
andhealmostalwaysthoughtitwasduetoinfection,whereasHoldsworth[4]feltthatwoundinfectionis
surprisinglyrare.Inrecentdays,PhuaanddeChalain[5]inastudyof211patientscollectivelyoperatedby
fivedifferentsurgeonsfoundanoverallfistularateof12.8%overameanfollowupperiodoffouryears10
months.Fistularateswerehigherforthemoreseveredegreeofcleftingbutwerenotaffectedbygenderor
typeofsurgicalrepair.

AETIOLOGYOFONF
TheprimarycauseofdevelopmentofONFisrepairundertension.However,therearesomepalatalclefts
whicharequitewideandtheavailabletissuetorepairthepalateseemsinadequate.Inthesecases,thechance
ofdevelopmentofONFishigherthoughinexperiencedhandstheycanbeprevented.Theotherreasonis
postoperativeinfectionwhichishardlyseeninsmallchildren.Theprotocolofswabculturefrompharyngeal
wallhasnotbeenadoptedbytheauthor.Vascularaccidentsduringpalatoplastycancauseflaplossandis
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relativelyanuncommonreasonfordevelopmentofONF[Figure1].Besidesthese,inadvertentuseof
diathermy,particularlynearthegreaterpalatinepediclecancompromisethebloodsupplyofthe
mucoperiostealflapandcanresultinanONF.

CLASSIFICATIONOFONF
Basedontheirsize,fistulasmaybeclassifiedassmall(<2mm),medium(35mm)orlarge(>5mm).[6]
Accordingtothelocation,fistulasaredescribedasanteriorfistula,midpalatalfistula,fistulaatthejunctionof
thesoftpalateandhardpalateandsoftpalatefistula.Inastudyof64patients,Diah,Lo,Yunetal.[7]
reportedthehardsoftplaltejunctionasthecommonestsite(53.1%).Localflapsandtwoflappalatoplasty
werethemostcommontechniquesusedtorepairtheseONFs.Theyalsoreportedthat25%ofthesecases
werereoperatedforrecurrenceofthefistula.SimilarsiteandrateofoccurrencewasreportedbyAmartunga.
[8]

SURGICALTREATMENTOFONF
Timingofsurgery:SurgicalclosureofONFshouldbeattemptedatleastsixmonthsaftertheprevious
surgery.
Assessment:OtherthanthesizeandsiteoftheONFtheimportantfactorinassessmentistheamountofscar
tissuepresentaroundthefistula.Acloseinspectionwillrevealthepreviousincisionmarkifusedforlateral
release.Lateraltothismarkisallepithelialisedscartissuewhichifelevatedasflaphasunpredictable
vascularsupply[Figure2].Iftheprevioussurgerywasdonealongtimeago,thistissuemaybehavelikea
normalmucoperiostealflap.Itiswisetoelevatethemucoperiostealflapfromthecrevicularmargintoensure
greaterwidthandlengthoftheflap.Therugosity[Figure2]thatispresentintheanteriormostaspectofthe
mucoperiostealflapshouldbeinspected.Presenceofthislandmarkusuallyexcludesvascularaccidentsin
previoussurgery.Ifthisisfoundtobesituatedalmostinthemidpalatalregion,itindicatestheoralflapshave
goneintosignificantcontracture.IncasewheretheONFisquitebigandavascularaccidentissuspected,a
handheldDopplerprobecanbeusedbeforemakingtheincisiontoassessthegreaterpalatinepedicle.Ifno
signalisregisteredbytheprobe,itisbetternottoelevatethepalatalmucoperiosteumonthatside.
Surgicalprinciple
Preferablythefistulashouldbeclosedintwolayers.Boththelayersshouldhavewellvascularisedtissueand
thesuturingshouldbefreeoftension.TherearealsoreportsinliteraturewhereinclosureofONFwas
effectedinthreelayers.[9]Asanintermediatelayer,cartilage,boneandacellulardermalmatrixhavebeen
used.
Surgicaltechniques
Closurebysmalllocalflaps:SmallONFcanbeclosedbylocalflapsonly.Aturnoverflapisdevelopedfrom
themucoperiosteallayeronthenoncleftside(incaseofunilateralcleft)tomakethenasallining.Another
rotationflapisdevelopedfromtheothermucoperiosteallayertocreatetheorallayer.Therotationflap
requiredisusuallybiggerthanexpected.Singlelayerclosurecanbeachievedinselectedcases.Inthatcasea
biggerturnoverflapisharvestedandistuckedundertheoppositemucoperiosteallayerinadoublebreasting
technique[Figure3].Therecurrencerateinsinglelayerclosureishigher.
Redopalate
ThisisanoptionformidpalatalONFsurroundedbyadequatepalataltissueandisassociatedwith
velopharyngealincompetence.Acompleteredopalatoplastyaddressesboththeproblems[Figure4].
Useofabuccalmucosalflap
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OriginallydescribedasacheekflapbyMukherji[10]whouseditinprimarypalatoplastyforshortpalates,
thisisparticularlyhelpfulwhenthefistulaissituatednearthehardpalatesoftpalatejunctionandthe
originalcleftisalsowide.Buccalmucosalflapisaposteriorlybased,randompatternflapwithitsbase
situatedneartheretromolartrigone[Figure5].Thedistalendoftheflapcanbeharvestedtoapointlittle
shortoftheoralcommissureandtheonlystructuretobetakencareofduringflapharvestisthepapillaofthe
parotidduct.Theaveragewidthoftheflapis15mminchildren.However,awiderflapcanbeharvestedin
youngadults.Theflap,ifnecessary,canbeharvestedfrombothsidesandcanbeusedbothfororalaswell
asthenasallayer.Partofthebuccinatormusclecanbeincorporatedintheflaptootomakeitmorereliable
androbust.Inthatcase,theflapistermedasbuccinatormyomucosalflap.
Mucosal/myomucosalflapfromtheundersurfaceofthelip[Figure6]:
Thisisparticularlyhelpfulforanteriorfistulaswherethereisdeficiencyinoralmucoperiosteallayer.Theflap
canbetransportedintothepalatethroughthealveolarcleftandcanreach34cmintothepalate.Similarflaps
canbetakenbilaterallyincaseofbilateralcleftlipandpalatetocloseanteriorfistulasoneithersideofthe
premaxilla[Figure7].
Tongueflap
Thisisatwostageprocedure.Useoflingualtissueinpalatalfistularepairhasbeenreportedmorethan50
yearsagobySantosandAltamirano.[11]Jackson[12]hasshownthattheflapissafeandwelltoleratedby
childrenwhenexecutedproperly.TheflapisindicatedforbiggerONFwherethereissignificanttissue
deficitintheoralmucoperiosteallayer.Theflapcanbeanteriorly[Figure8a,b]orposteriorlybased
dependingonthesiteofthefistula.Compositionwise,thisisamyomucosalflapandtheaveragethickness
shouldnotbelessthan6mmtoensureitsvascularity.Agoodnasallayerrepairisaprerequisiteforsuccess.
Detachmentisdoneonthe10thto14thpostoperativeday.Childrentoleratetheflapquitewellandusually
thereisnoneedtoputanasogastrictubeforfeeding.Thedonorareaisalmostalwaysclosedprimarilyand
thereisnoresidualdefectofthetongueoranyspeechproblem.
Thetwomaincomplicationsarehaemorrhageandspontaneousdetachmentfromthepalate.Aprefabricated
flapretainercanbeusedtoensurethesuccessoftheflap.[13]
Facialarterymyomucosalflap(FAMM)
TheflapwasdescribedbyPribazetal.[14]in1992.ThisflapisparticularlyusefulforbiggerONFinthe
anteriorpalatewhichisextendingtothemidpalatalregionandisassociatedwithanalveolarcleft.Thefacial
arteryofthecleftsideistracedwithahandheldDoppleratthebeginningofthesurgery.Thebaseoftheflap
isnearthealarbase.Thewidthcanbeupto2.5to3cmandismyomucosalincomposition.Thefacialartery
isdividedasitcrossesthelowerborderofthemandibleandisincorporatedintheflapasitscentralaxis.
Preferably,thenasalliningshouldbecreatedwithlocaltissueontopofwhichtheflapisinset.Thealveolar
cleftisthegatewayforthisflaptoenterfromthecheektothepalate.
Freetissuetransfer
Freeradialforearmflap,[15]andfreescapularflaphavebeendocumentedtobeusedtoclosebigONF
wherelocaltissueisnotavailable.Thecompositionoftheflapcanbeadipocutaneous,fasciocutaneousor
adipofascialdependingonthechoiceofthesurgeon.
Besidesthese,theuseoftheturbinateflaphasbeenreportedbyPennaetal.[16]Temporoparietalgalealflap
hasbeenalsosuccessfullyusedforclosureofONF.[17]Loseeetal.[18]publishedtheuseofacellular
dermalmatrixin39.4%casesofprimarypalatoplastytopreventONF.
Nonsurgicalclosure
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TheONFcanbeclosedbyaplatedesignedbyanorthodontistcolleague.Thisisindicatedwherethepatient
hasgonethroughseveralunsuccessfulsurgicalattemptsandisnolongerwillingtoundergoanother
procedure.Thisplatecanhaveanalveolarcomponentwhichbridgesthealveolarcleftandcanhaveartificial
teethincorporatedinit[Figure9].
Author'sexperience
Theauthorperformsprimarypalatoplastybythreedifferenttechniques.Theyarea)Bardach'stwoflap
palatoplasty,b)Furlow'stechniqueandc)twostagepalatoplastywherethehardpalateisclosedbysingle
layervomerflapduringliprepairandsoftpalateisclosedatalaterdate.Consideringallthreeprocedures,
wehaveaverylowfistularateofaround1%.Weneverperformapreoperativethroatswabcultureandthe
smallpercentageoffistulasthatwehave,wefoundtheculturenegativeinthepostoperativeperiod.We
firmlybelievethatONFisalmostalwaysrelatedtothesurgicaltechnique.
Wedescribethefistulasinthefollowingway:
IsolatedsmalltomediumsizedONF
ONFwithvelopharyngealincompetence(VPI)
ONFwitharepairedlipnosethatneedsrevisionsurgery
ONFinthealveolarregionpresentingatmixeddentitionperiod
HugeONF
SimpleONFisrepairedmostofthetimebylocalflapsorbyredoofthehardpalate.Singlelayerrepairis
notadvocatedbecauseofthehighrateofrecurrence.ForONFwithVPIacompleteredopalatoplastyis
donewhichaddressesboththeproblemsinthesamesitting.Sometimes,abuccalmucosalflapis
incorporatedinthenasallayerofthesoftpalatewhichhelpsinlengtheningandcreatesatensionfreerepair.
Incaseswherethelipneedsarevisionsurgery,itisalwaysadvisabletoopenthelipanddoarevisionalong
withtheONFrepair.Theaccesstothefistulabecomesmoredirectandthenasalfloorrepairbecomeseasier
andbetter.Forpatientswithananteriorfistula,whopresentduringmixeddentitionperiod,wepreferto
preparethechildorthodonticallyandtoperformanalveolarbonegraftinthesamesitting.ItisinhugeONF
usuallycausedbyvascularaccidentsthatatongueflapincombinationwithotherflapsneedstobeused.
However,everycaseofONFhastobeindividualisedandaccordinglythetreatmentplanhastobemade.We
prefertowaitfor1012monthsaftertheprevioussurgery,unlessthereisstrongrecommendationfromthe
speechpathologistforearlyclosure.Theauthorhasverylimitedexperiencewithtongueflapsandhasnever
performedfreetissuetransferforpalatalfistulaclosure.Wehavesuccessfullyclosedpalataldefectsby
temporalismusclebutnotinacleftpatient.Inonecaseofrecurrentfistulawherehalfthehardpalatewas
destroyed,wecloseditwithacombinationofintraoralflaps.Afterrepairingthenasallayerbymobilization
ofavailablelocaltissue,aFAMMflapfromonecheekandabuccalmucosalflapfromtheothercheekwere
usedtoclosethisbigONF[Figure10,b].

RESULTS
Withasinglelayerclosure,therecurrencerateoffistulaswasabout40%henceasinglelayerclosureshould
beavoided.TherateofrecurrenceforhardpalateONFaftercompleteredoofhardpalateislessthan5%.
RecurrenceofONFatthejunctionofhardandsoftpalateisnil.Thiscouldbeattributedtofrequentuseof
buccalmucosalflaptorepairthesefistulas.

CONCLUSION
Oronasalfistulaisthecommonestcomplicationofcleftpalatesurgery.Theincidenceishighlyvariable
thoughalmostalwaystheprimarycauseremainsthesamei.e.closureundertension.SymptomaticONFis
associatedwithnasalregurgitationandhypernasalityofspeech.PrincipleofrepairofONFisappositionof
wellvascularisedtissuewithouttension.Differenttechniques,startingfromlocalflapstofreetissuetransfer
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havebeenemployedtorepairONFdependingonitssite,sizeandtissueavailable.Ingeneraltherecurrence
rateofONFisaround25%.Withbettertechniqueandskill,theincidenceandrecurrencerateofONFcan
bothbeminimized.

Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

REFERENCES
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18.LoseeJE,SmithDM,AfifiAM,JiangS,FordM,VecchioneL,etal.Asuccessfulalgorithmforlimiting
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FiguresandTables
Figure1

Bilateraldamagetogreaterpalatinearteries.Flapsnecrosed

Figure2

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Previousincisionmarkandanteriorrugosity

Figure3

Anteriorfistulawithintactalveolus.Singlelayerclosurebyturnoverflap(notrecommended

Figure4

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Anteriorfistula.Redoofthehardpalate

Figure5

Buccalmucosalflapmarkingandinset

Figure6

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Myomucosalflapfromtheundersurfaceofthelip

Figure7

Bilateralanteriorfistulas.Useofbilateralflapsfromtheundersurfaceoftheliparoundthepremaxilla

Figure8a

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Anteriorlybasedtongueflapandclosureofthedonorsite

Figure8b

Repairedfistulabytongueflap

Figure9

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ProstheticmanagementofONF

Figure10

HugeONFrepairedwithcombinationofintraoralflaps
ArticlesfromIndianJournalofPlasticSurgery:OfficialPublicationoftheAssociationofPlasticSurgeonsof
IndiaareprovidedherecourtesyofMedknowPublications

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