International Journal of Pediatric Otorhinolaryngology 104 (2018) 43–46

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

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

Closure of fistula of the hard palate with two layers of mucoperiosteum☆ MARK
a,∗ b b c d
Mosaad Abdel-Aziz , Ahmed Kamel , Mohamed Fawaz , Ibrahim Rezk , Mohamed Kamel
a
Department of Otolaryngology, Faculty of Medicine, Cairo University, Egypt
b
Department of Otolaryngology, Faculty of Medicine, Beni Suef University, Egypt
c
Department of Otolaryngology, Faculty of Medicine, Sohag University, Egypt
d
Department of Otolaryngology, Faculty of Medicine, Fayoum University, Egypt

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

Keywords: Objective: Oronasal fistula represents a functional problem, as it may result in nasal regurgitation of food and
Oronasal fistula fluids and it also leads to hypernasal speech. Many methods have been proposed for its closure with a high
Mucoperiosteal flap recurrence rate. The aim of this study was to assess the efficacy of closure of hard palate fistula by two layers of
Nasal regurgitation mucoperiosteal flaps.
Hard palate
Methods: Eighteen patients with fistula of the hard palate were included. The fistula was repaired by two layers
of mucoperiosteal flaps; the first layer was created from the mucoperiosteum surrounding the fistula as bilateral
hinge flaps and the second layer was formed of a rotational flap based on the greater palatine artery. Pre- and
postoperative clinical assessment was performed.
Results: The etiology of fistulas was previous cleft palate repair in 13 patients, previous nasal septal surgery in 3
patients, and untreated sharp accidental trauma to the palate in 2 patients. All patients presented with nasal
regurgitation and hypernasal speech. Complete closure of all fistulas was achieved at first attempt, with no
recurrence through the follow up period.
Conclusions: Closure of oronasal fistula by two layers of mucoperiosteal flaps is an effective method and it has
neither complications nor recurrence.

1. Introduction
Fistula of the hard palate is a common complication after cleft pa-
late repair. However, there are many other causes for this disorder such
as accidental trauma to the palate, surgical trauma as after tumor re-
section or nasal septal surgery, radiation and infectious diseases [1,2].
This fistula communicates the oral and nasal cavities, it can lead to
regurgitation of food and fluid to the nose with subsequent nasal in-
fection and offensive discharge, it can also renders the speech hy-
pernasal with emissions of air through the nose during speech. Al-
though palatal fistula is not a visible lesion for confronting people, it
leads to emotional and psychological troubles either on talking or on
eating [3].
Surgical closure of palatal fistula is mandatory, however, it is a
challenging problem for the surgeons as the recurrence rate is about
25% [3–5]. The principle of surgery is to perform two layers and ten-
sion free closures, to fulfill this objective; several techniques have been
proposed extended from local flap to free tissue transfer [4]. Tongue
flap, orbicularis oris myomucosal flap, buccal flap, or even combination
of flaps may be used [5], bone and cartilage grafts, and also acellular
dermal matrix have been advocated for closure of palatal fistulas [3].
When speech disturbance occurs as a result of a fistula of significant size
especially after failure of repeated surgical closure, prosthetic obtura-
tion of the fistula (even temporary) can be considered [6]. The aim of
this study was to assess the efficacy of closure of hard palate fistula by
two layers of mucoperiosteal flaps.
2. Methods
The study included 18 patients with fistulas of the hard palate. The
ages of the patients ranged from 7 years to 25 years (with a mean of 14
years), 11 males and 7 females. The patients were referred to our in-
stitutes in the period from June 2012 to October 2016. Patients who
subjected before to fistula repair were excluded from the study.
Informed consents were obtained from the parents of young patients,
while they were obtained from adult patients themselves, and the
principles outlined in the Declaration of Helsinki were followed. In
addition, the research protocol was approved by the Research Ethics
Committee of our institute.
All patients were subjected to the following:

☆
The study was conducted on the Departments of Otolaryngology of Cairo University, Beni Suef University, Sohag University and Fayoum University, Egypt.
∗
Corresponding author. 2 el-salam st., King Faisal, above el-baraka bank, Giza, Cairo, Egypt.
E-mail address: mosabeez@yahoo.com (M. Abdel-Aziz).

http://dx.doi.org/10.1016/j.ijporl.2017.10.037
Received 27 August 2017; Received in revised form 23 October 2017; Accepted 24 October 2017
Available online 31 October 2017
0165-5876/ © 2017 Elsevier B.V. All rights reserved.
M. Abdel-Aziz et al. International Journal of Pediatric Otorhinolaryngology 104 (2018) 43–46

Fig. 2. Illustration for the procedure. The shaded area is the donor site for the hinge flaps
on both sides of the fistula, and the non-shaded area is the donor site for the rotational
flap.

Fig. 1. A patient with fistula of the hard palate after nasal septal surgery.

2.1. Preoperative assessment

Thorough history taking with special emphasis on nasal regurgita-

tion of food and/or fluid was conducted. Also, speech resonance was
assessed by listening and parent's questionnaire [3]. Full ear, nose and
throat, and head and neck examination was performed for detection of
other associated lesions. Oral examination was done to assess the status
of the palate, site and size of the fistula (Fig. 1), and nasal examination
was accomplished to exclude impacted foreign bodies and/or infection.

2.2. Operative procedure

Under general anesthesia with oral endotracheal intubation, a

Davis-Boyle mouth gag was inserted, the site of the incisions was
marked with methylene blue. The hard palatal mucoperiosteum is in-
jected with 0.5% Xylocaine in adrenaline (1:100,000). The mucoper-
iosteum around the fistula is incised and elevated as bilateral hinge
flaps based medially towards the edge of the fistula, the width of the
flaps is determined by the width of the fistula, both flaps are inverted so
that the mucosal surface faced the nasal cavity and sutured together;
this is to form the first layer of closure. The mucoperiosteum of the hard
palate to one side of the fistula is incised and elevated as a rotational
flap based posteriorly on the greater palatine artery, it is rotated
medially and sutured to the opposite new edge of the defect to form the
second layer of closure (Figs. 2 and 3). The raw area which was created
after rotation of the flap was left to heal with granulation tissues.
2.3. Postoperative follow up
Patients were seen postoperatively at one week interval for three
weeks, with follow up appointments monthly for at least 6 months.
Healing of the palate and closure of palatal fistulas were assessed.
Speech listening and patients' questionnaire about symptoms of or-
onasal fistula was conducted and recorded.
3. Results
Eighteen patients diagnosed to have fistula of the hard palate were
enrolled in the study. The etiology of fistulas was previous cleft palate
repair in 13 patients, previous nasal septal surgery in 3 patients, and
untreated sharp accidental trauma to the palate in 2 patients. All
Fig. 3. Bilateral hinge flaps were created from the mucoperiosteum on both sides of the
fistula. The rotational mucoperiosteal flap was dissected from the bone of the hard palate.
fistulas were in the midline of the hard palate, their lengths ranged from
5 to 17 mm (mean of 9 mm) and their widths varied from 2 to 5 mm
(with a mean of 3 mm). All patients presented with nasal regurgitation
of food and fluid, and hypernasal speech.
No intraoperative or postoperative complications were detected. In
all patients, the fistula was completely closed at first attempt (Fig. 4),
with no evidence of recurrence through the follow-up period.
Nasal regurgitation improved in all patients. However, speech has
been improved in 5 patients whose fistulas were traumatic caused by
nasal septal surgery and sharp palatal trauma. Patients whose fistulas
were consequences to cleft palate repair showed residual hypernasality,
those patients needed further assessment of velopharyngeal function
after closure of their fistulas.
4. Discussion
Oronasal fistula represents a functional problem, as it may result in
nasal regurgitation of food and fluids and it also leads to hypernasal
speech. Surgical closure is a challenge for craniofacial surgeons, as the
fistula is usually surrounded by fibrosis with difficult dissection of
mucoperiosteal flaps. Different techniques have been described for

44
M. Abdel-Aziz et al.
Fig. 4. A patient after closure of his fistula.
fistula closure, the methods currently used can be divided into four
groups; those that use mucoperiosteal flaps in one form or another such
as rotational and hinge flaps, those that use additional tissue to close
the defect as pedicled flaps from elsewhere in the mouth such as tongue
and buccal mucosa flaps [7], those that use free tissue transfer as free
radial forearm flap and free scapular flap which have been documented
to be used to close large oronasal fistula where the local surrounding
tissues are not available [5], and those that use bone or cartilage grafts,
or even acellular dermal matrix in combination to one of the previous
flaps to ensure competent closure of the defect [5,8].
Fistula size has been divided according to its greatest diameter into
small; 1–2 mm, medium; 3–5 mm, and large; > 5 mm [9]. The critical
limit of fistula size that may have adverse effect on speech is a deba-
table issue, some authors suggest that an area exceeding
4.5 mm2–5 mm2 could interfere with speech. It usually causes hy-
pernasality, audible nasal escape and weakness of pressure consonants.
However, other authors have found that a fistula of only a few milli-
meters square can affect speech resonance [4,8,10]. In our study, all
patients presented with hypernasal speech in addition to nasal regur-
gitation of food and fluid. The palate should close the nasopharyngeal
airway tightly during articulation of oral consonants to prevent escape
of air, so fistula of any size may affect the speech resonance [3].
Palatal fistula may develop as a complication to cleft palate repair;
by far this is the commonest cause. However, it may be caused by
surgical or accidental trauma, inflammatory or neoplastic diseases, and
after radiotherapy [2,3,11]. In our study, the palatal fistula of 13 pa-
tients was a consequence to cleft palate repair, it was a complication to
nasal septal surgery in 3 patients, and it was caused by accidental
trauma to the palate in 2 patients. Causes of fistula development after
cleft palate repair may be related to the type of cleft, type of repair,
wound tension, single-layer closure, infection and dead space deep to
the mucoperiosteal flap [8]. Palatal perforation is a rare complication to
surgery of the nasal septum, some authors attributed the cause to the
presence of preoperative palatal abnormality such as high arched palate
or submucous cleft palate [2,12], however, none of our patients who
had traumatic fistula showed anatomical abnormality and fistula de-
velopment may be caused by excessive dissection on the maxillary crest
and nasal floor. Neglected palatal trauma may result in fistula forma-
tion [3,13], so, early repair is required to avoid this sequel.
In this study, hard palate fistula has been repaired by 2 layers of
mucoperiosteal flaps; the first layer was created by bilateral hinge flaps
45
International Journal of Pediatric Otorhinolaryngology 104 (2018) 43–46
from the mucoperiosteum surrounding the fistula and the second layer
was formed of a rotational flap based on the greater palatine artery, all
patients showed complete closure of their fistulas. In a previous study,
we treated post-palatoplasty oronasal fistula of 14 children with double
layer of mucoperiosteal flaps, the first layer was the same of our present
study, while the second layer was created by redo V-Y palatoplasty; we
achieved complete closure of all fistulas [8]. However, redo palato-
plasty is difficult and tedious procedure with excessive fibrosis, so, we
did not use this method in our present study. In addition, redo pala-
toplasty is not needed in patients who have palatal fistulas without
previous history of cleft palate repair.
Anani and Aly [14] used similar technique for closure of oronasal
fistulas of 8 patients, they achieved cure rate of 100%. Sadhu [5] re-
commended usage of two layer closure; a turn over mucoperiosteal flap
to close the nasal surface and a rotational mucoperiosteal flap from the
other side of the palate to close the oral surface. Honnebier et al. [7]
treated 7 patients with oronasal fistula using a local mucoperiosteal flap
lined with buccal mucosal graft placed on the nasal surface of the flap,
they achieved complete closure of all fistulas, however, their patient's
sample was small with the addition of a new wound on the inner aspect
of the cheek which may increase the postoperative pain. Irrespective of
the technique used, a two layer closure should be performed to avoid
failure and recurrence [4,5,11], even Murrell et al. [15] recommended
a 3-layer closure of oronasal fistula with inserting bone or cartilage
graft between both mucosal flaps. Many authors obviate usage of a
single layer closure as it carries the risk of dehiscence and failure
[3,5,8,10].
Closure of oronasal fistula with this presented technique has many
advantages; it is a simple, single stage procedure, with one wound in
the oral cavity unlike using tongue or buccal flap, it does not need
transfer of a free vascular flap from another area in the body as the used
flaps in our present technique are pedicled and vascular. In addition,
the mucoperiosteum is tough and strong tissue that is already lining the
hard palate, and its use does not affect the mouth opening as it may
cause other local (tongue and mucosal) or free vascular flaps.
A limited point in our study is that we did not use objective methods
for speech evaluation. As most of our patients have repaired cleft pa-
late, the presence of oronasal fistula may not be the only cause of ve-
lopharyngeal insufficiency and hypernasal speech. So, speech error may
be due to short palate, limited mobility of the palate, or any other
abnormality. For this reason, the policy of our institute is correction of
palatal fistula first before speech assessment.
5. Conclusion
Closure of oronasal fistula by two layers of mucoperiosteal flaps is a
simple one stage procedure. It is an effective method with a high suc-
cess rate and it has neither complications nor recurrence.
Conflict of interest
The authors declare that they have no conflict of interest.
Financial support
Self funded.
Financial disclosure
There are no financial disclosures.
References
[1] J.C. Posnick, S.B. Getz, Surgical closure of end-stage palatal fistulas using ante-
riorly-based dorsal tongue flaps, J. Oral Maxillofac. Surg. 45 (1987) 907–912.
[2] O. Gökdemir, A. Bal, Palatal perforation, the most rarely observed complication
M. Abdel-Aziz et al.
after deviated septum surgery, J. Pak Med. Assoc. 64 (2014) 1322–1323.
[3] M. Abdel-Aziz, M. Hegazi, H. Ghandour, Velopharyngeal dysfunction, in:
A.P. Nazario, J.K. Vermeulen (Eds.), Handbook of Pharyngeal Diseases, Nova
Science, New York, 2010, pp. 109–135.
[4] E. Diah, L. Lo, C. Yun, R. Wang, L.K. Wahyuni, Y. Chen, Cleft oronasal fistula: a
review of treatment results and a surgical management algorithm proposal, Chang.
Gung Med. J. 30 (2007) 529–537.
[5] P. Sadhu, Oronasal fistula in cleft palate surgery, Indian J. Plast. Surg. 42 (2009)
S123–S128.
[6] J. Pinborough-Zimmerman, C. Canady, D.K. Yamashiro, L. Morales Jr., Articulation
and nasality changes resulting from sustained palatal fistula obturation, Cleft Palate
Craniofac. J 35 (1998) 81–87.
[7] M.B. Honnebier, D.S. Johnson, A.A. Parsa, A. Dorian, F.D. Parsa, Closure of palatal
fistula with a local mucoperiosteal flap lined with buccal mucosal graft, Cleft Palate
Craniofac J. 37 (2000) 127–129.
[8] M. Abdel-Aziz, V–Y two-layer repair for oronasal fistula of hard palate, Int. J.
Pediatr. Otorhinolaryngol. 74 (2010) 1054–1057.
[9] S.R. Cohen, J. Kalinowski, D. LaRossa, P. Randall, Cleft palate fistulas: a
46
International Journal of Pediatric Otorhinolaryngology 104 (2018) 43–46
multivariate statistical analysis of prevalence, etiology, and surgical management,
Plast. Reconstr. Surg. 87 (1991) 1041–1047.
[10] J. Erdenetsogt, G.N. Ayanga, D. Tserendulam, R. Bayasgalan, The closure of post-
palatoplasty fistula with local turn-down flap, Ann. Maxillofac. Surg. 5 (2015)
271–273.
[11] N.K. Sahoo, A.P. Desai, I.D. Roy, V. Kulkarni, Oro-nasal communication, J.
Craniofac Surg. 27 (2016) e529–e533.
[12] B. Ersoy, S. Ylmaz, H. Sirinoglu, O. Celebiler, A. Numanoglu, A rare complication
after septoplasty procedure in a misdiagnosed submucous cleft palate case: palatal
fistula, J. Plast. Reconstr. Aesthet. Surg. 63 (2010) 1382–1384.
[13] S.B. Alabi, S.K. Aremu, A.Y. Abdulkadir, J.N. Legbo, H.J. Akande, Palatal avulsion
injury by a foreign body in a child, BMJ Case Rep. (2012), http://dx.doi.org/10.
1136/bcr.10.2011.5006.
[14] R.A. Anani, A.M. Aly, Closure of palatal fistula with local double-breasted muco-
periosteal flaps, J. Plast. Reconstr. Aesthet. Surg. 65 (2012) e237–e240.
[15] G.L. Murrell, R. Requena, D.W. Karakla, Oronasal fistula repair with three layers,
Plast. Reconstr. Surg. 107 (2001) 143–147.