International Journal of Pediatric Otorhinolaryngology 79 (2015) 161–164

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Oronasal fistula repair using the alveolar ridge approach

Haidong Li, Ningbei Yin *, Tao Song
Plastic Surgery Hospital of the Chinese Academy of Medical Science and Peking Union Medical College, Ba-Da-Chu Road, Shi-Jing-Shan District,
Beijing 100144, People’s Republic of China

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Use the alveolar ridge approach operation to repair anterior palate oronasal fistulae.
Received 22 October 2014 Methods: In this study, oronasal communication defects were covered with in situ mucosal flaps,
Received in revised form 20 November 2014 resulting in reduced palatal leakage bilaterally. This treatment approach not only provides good esthetic
Accepted 22 November 2014
appearance results, but also prevents food and liquid leakage into nose.
Available online 4 December 2014
Results: 25 patients were considered in this study. The alveolar ridge approach for the complication of
anterior palate oronasal fistula was a good alternative for these patients; no incision scars were created,
Keywords:
and the physiological state after surgery is optimized, with the resulting outcome most closely
Palatal fistula
approximating true anatomic repair. Mucosal and gingival lateral palatal mucosa post-surgical healing
Alveolar ridge
Labial vestibule results also were good, with return to a natural position.
Anterior palate Conclusion: Oronasal fistula repair with the alveolar ridge approach is an easy and perhaps ideal method,
Oronasal with a high success rate.
The alveolar ridge ß 2014 Elsevier Ireland Ltd. All rights reserved.

Fistulas in the anterior bony palate that communicate with a
cleft through the alveolus still present a great challenging to plastic
surgery. Oronasal fistula is a fairly common complication of cleft
palate repair. Absence of fistula is an important mark of a
successful operation. Oronasal fistula rates after cleft palate repair
are high, and reported from 4 to 35%, or even more in the case of
primary palatoplasty [1–6]. Wound tension [7], infection [8],
hemorrhage [9], flap trauma [10], lack of optimal surgical
technique are all reasons associated with formation of fistulas.
Reported frequent symptoms of fistula occurrence are food
leaking into the nose, halitosis, speech problems [11], velophar-
yngeal insufficiency [12], hearing deficit, and inflammation.
Surgical treatment should be performed with modern, ‘best-
practices’ technique.
Oronasal fistula repair options include turnover flaps [13],
tongue flap, buccal myomucosal flap [14,15], facial artery myomu-
cosal flap [16], free tissue transfers [17], local flap technique [18,19],
osmotic tissue expanders [20], cartilage grafts, skin grafts [21], and
3-layer closure techniques [22–27]. However, none of these
procedures are a perfect fit for the variety of fistula that may form
in the anterior bony palate.
* Corresponding author. Tel.: +86 15910775061; fax: +86 01088771983.
E-mail addresses: lihaidong8@gmail.com (H. Li), zhengxing66@yeah.net
(N. Yin).
Flap techniques (like tongue flaps or buccal mucosa flaps) are
problematic, because the flap pedicle is not long enough, or the
teeth block optimal positioning. The donor site scar may become a
secondary and serious problem.
The alveolar ridge approach to correct anterior palate oronasal
fistula is autogenous, effective, and with no donor area morbidity.
We advocate oronasal fistula repair with alveolar ridge approach
operation because of the need for a minimal incision to obtain the
closure of the palatal fistula.
1. Materials and methods
We carried out a retrospective review 25 patients with repairs
to palatal fistulae in our hospital between 2008 and 2013. 15 were
male, 10 were female. The ages ranged from 8 to 14 years old at
time of surgery. All were unilateral cleft palate. The fistulas on the
left side numbered 15, and on the right side were 10. The length of
the fistulas ranged from 5 to 15 mm (mean of 8 mm) and their
widths varied from 1 to 6 mm (with a mean of 3 mm). Fistulas were
located in the hard palate behind the premaxillary–maxillary
junction. Palatal fistulas occurred after cleft palate repair. The
patients did not have previous alveolar bone graft operation.
Fistulas were observed at primary and labial alveolar sites. All
operations were performed by the same surgeon, with follow up at
one year.

http://dx.doi.org/10.1016/j.ijporl.2014.11.033
0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
162 H. Li et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 161–164

2. Surgical technique Through the gum approach incision, at point A and point C
incision.
Surgery was conducted under general anesthesia, with
additional local anesthetic injections around the fistula and 3. Results
alveolar cleft.
An incision was made along the gingival sulcus and labial Fistula closure was successful in all 25 patients. All fistulas
surface of the alveolus on the labial side, extending into the cleft had been the result of complications from previous cleft palate
fistula edge, separating the nasal mucosa from the gingiva and oral repairs. The anterior fistula repairs were technically difficult in
fistula edge. At the margins of the fistula, the oral mucosal layer all cases.
was dissected free with a scalpel, ensuring adequacy of the mucosa
turnover from the nasal side of the fistula, and to allow suture
closure of the oral side in the midline.
The nasal mucosa was elevated off the lateral wall of the nose
and the piriform aperture, and separated from the oral mucosa.
The procedure utilized the vestibular flaps to close the gingiva
fistula.
Then, the surgery used a mucoperiosteal flap to create a two
sided repair for both the nasal and the oral side of the defect. The
incision was from the alveolar cleft site; then, the nasal side
mucosa was raised to close the fistula on the nasal side.
The oral mucosa was elevated with a periosteal elevator along
the cleft fistula edge away from the palate bone. Palatal flaps were
used to close the oral fistula. A hermetic suture of the aperture
piriformis and two sides of the fistula followed. The oral fistula
closure was performed with oral mucosa around the fistula defect.
Closure of the nasal floor and the alveolar ridge mucosa was
done with interrupted 5-0 suture. The oral mucosa closure was
also done with 5-0 interrupted suture, with reapproximation of
the papilla. The two sides were closed fully, and tested watertight
(Figs. 1 and 2).

Fig. 1. Scheme showing our design, before operation, AB distance plus the distance
between point BDCD is equal to the distance between. Through the gum approach
incision, at point A and point C incision.

Fig. 2. Scheme showing our design after repair operation. Figs. 3–5. Scheme of palatal fistula before operation.
 H. Li et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 161–164
All fistulas healed well. No complications related with around
tissue. No postoperative complications developed.
4. Case study
4.1. Representative case 1
A 9-year-old male patient presented suffering from anterior
palatal fistula. Physical examination revealed the extent and
nature of the fistula (Figs. 3–8). The surgery was performed in
March 2010. A 12-month post surgery follow-up showed a well-
healed anterior palatal fistula repair (Figs. 9 and 10).
Figs. 6–8. Scheme of the incision design in the operation. reflection of the flaps.
163
Figs. 9 and 10. Clinical case showing the aspect of palatal fistula operation after 1
year followup.
5. Discussion
Anterior palatal oronasal fistula after cleft palate repair is a
common and difficult problem. The most difficult area is the
anterior bony palate, because for that region, the oral mucoper-
iosteum is inextensible. Moreover, the mucoperiosteum surround-
ing the fistula lacks adequate blood supply. Any residual fistula
presence may lead to nasal regurgitation of fluids, along with hyper
nasal speech disorders. Anterior palate oronasal surgery is a
difficult kind of plastic surgery. Scarring around the fistula is
difficult to deal with. Blood supply is problematic.
The buccal mucosa and tongue flaps used in repair palate
oronasal fistulae utilize both types of pedicle flaps [28,29]. Use of
buccal musculomucosal flaps to repair anterior hard palate defects
are suboptimal [28], because the pedicle of the buccal musculo-
mucosal flap is blocked by the teeth, and results in motion
restrictions for opening the mouth postoperatively.
The tongue flap technique to close fistulas is anguishing and
uncomfortable for patients; for at least 2 weeks after surgery, they
cannot open their mouths. There also may be severe postoperative
tongue deformity present, along with speech and taste impairments.
Cartilage grafts, skin grafts, acellular dermal matrices, distrac-
tion osteogenesis, and 3-layer closure techniques may be used to
repair fistula; however, they all result in donor site scarring after
surgery. Those tissues from distant sites may also feel ‘‘fat’’ and
clumsy on the palate.
In this study, we used two layers to repair anterior palatal
fistula. Our success rate was 100%.
164 H. Li et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 161–164
The gingival dental alveolus surrounding mucoperiosteum was
used to repair the nasal side fistula. Oral mucoperiosteum and
some nasal mucoperiosteum was elevated and inverted to close
the oral side. The incision was on the medial nasal side, and differs
from other methods. This is the reason for making the incision
though the alveolar ridge.
The surrounding mucoperiosteum and residual scarring
creates repair for the oral side fistula. No distant flap is needed,
so there is no concern regarding flap necrosis or recurrence of the
fistula.
Closure of anterior palatal fistula by the use of alveolar ridge
approach operation is a useful method, with high success
rate and no morbidity. The space between oral and nasal
layers will pack with blood, minimizing likelihood of fistula
recurrence.
The advantages of our method include:
1. A single stage operation does not require additional procedures,
with no wound at the site of the fistula.
2. There is no donor site morbidity, as in contrast to the tongue flap
and buccal flap.
3. Useful in all kind of anterior fistulas.
Disadvantages include:
1. Dissection of the mucoperiosteum from the palate and alveolar
ridge bone is usually difficult due to locate tissue fibrosis.
2. The fistula surround mucoperiosteum may have an inadequate
blood supply, ensuring the integrity and blood supply of the
mucoperiosteum.
3. In the patient with bilateral defects, this operation may result in
the mucoperiosteum between fistulas developing an inadequate
blood supply. It may be better to do the operation unilaterally,
and then to do the other side after half year.
6. Conclusion
Different treatment options for repair of oronasal fistula of the
hard palate that develop after cleft palate repair were discussed.
Oronasal fistula repair with the alveolar ridge approach is an easy
and perhaps ideal method, with a high success rate.
Funding
The authors have no funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgement
The authors thank Dr. Reid E. Thompson for English editing.
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