The Pittsburgh Fistula Classification System: A Standardized Scheme for

the Description of Palatal Fistulas

Darren M. Smith, M.D., Lisa Vecchione, D.M.D., M.D.S., Shao Jiang, M.D., Matthew Ford, M.S., C.C.C., S.L.P.,
Frederic W.B. Deleyiannis, M.D., M.Phil., M.P.H., Mary Ann Haralam, R.N., M.S.N., C.R.N.P., Sanjay Naran, B.S.,
Christine I. Worrall, B.A., Jason R. Dudas, B.A., Ahmed M. Afifi, M.D., Mary L. Marazita, Ph.D.,
Joseph E. Losee, M.D.

Objective: Vague terminology is a problem in cleft palate research. No clas-

sification scheme for palatal fistulas has been proposed to date. Although a
well-healed velum is a significant outcome of palatoplasty, it is nearly impos-
sible to compare fistula-related palatoplasty results in the literature or in med-
ical records without a standardized vocabulary. We endeavor to devise a pal-
atal fistula classification system that may have clinical and research applica-
bility.
Design: PubMed was searched for definitions and classifications of palatal
fistula as well as incidence and recurrence rates of this outcome. Next, a 25-
year retrospective review of our Cleft Center’s records was performed, and
fistulas were identified (n ⴝ 641 charts reviewed). The fistula descriptions
yielded by this chart review were evaluated in the context of anatomical de-
scriptions in the literature, and a clinician-friendly classification scheme was
designed.
Results: A literature review failed to reveal a standardized fistula classifi-
cation system. An anatomically based numerical fistula classification system
was devised: type I, bifid uvula; type II, soft palate; type III, junction of the soft
and hard palate; type IV, hard palate; type V, junction of the primary and sec-
ondary palates (for Veau IV clefts); type VI, lingual alveolar; and type VII, labial
alveolar.
Conclusions: We propose a standardized numerical classification system for
palatal fistulas. Its clinical adoption may prospectively clarify ambiguities in
the literature and facilitate future cleft palate research and clinical practice.

KEY WORDS: classification, cleft palate, cleft palate fistula, fistula, fistula clas-
sification system

Palatal fistulas represent an important concern in the treat-
ment of cleft palates, and clear nomenclature is a prerequisite
to meaningful discussion, ongoing research, and evolving new
treatment strategies. Cleft palate surgeons would agree that,
next to achieving a competent velopharyngeal sphincter that
allows for the development of normal speech, the most im-
Dr. Smith, Dr. Vecchione, Dr. Jiang, Dr. Deleyiannis, Ms. Haralam, Mr.
Naran, Ms. Worrall, Mr. Dudas, Dr. Afifi, and Dr. Losee are at the Children’s
Hospital of Pittsburgh, Division of Pediatric Plastic Surgery, University of Pitts-
burgh, Pittsburgh, Pennsylvania. Dr. Marazita is at the Center for Craniofacial
and Dental Genetics and Department of Oral Biology, School of Dental Med-
icine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Presented at the annual meeting of the American Cleft Palate–Craniofacial
Association, Vancouver, Canada, spring 2006.
Submitted October 2006; Accepted March 2007.
Address correspondence to: Dr. Joseph E. Losee, Division of Pediatric Plastic
Surgery, Children’s Hospital of Pittsburgh, 3705 Fifth Avenue, G437 De Soto
Wing, Pittsburgh, PA 15213.
DOI: 10.1597/06-204.1
portant outcome of palatoplasty is a well-healed velum without
excessive scarring and fistulation. Unfortunately, the cleft pal-
ate literature surrounding postoperative fistulas is confusing
and difficult to interpret, in large part because of inconsistent
nomenclature for palatal fistulas.
A literature review dating from the 1950s, while producing
few suggested definitions for palatal fistulas (Folk et al., 1997;
Witt and Marsh, 1997), failed to identify any standardized and
widely accepted classification scheme. It has been stated that
‘‘until a uniform definition of palatal fistula is utilized, it will
be difficult to compare the results of different studies’’ (Emory
et al., 1997). The literature is replete with conflicting data,
which report the incidence of cleft palate fistula as ranging
from 0% to 76% (Oneal, 1971; Abyholm et al., 1979; Bardach
et al., 1984; Maeda et al., 1987; Hayward, 1988; Moore et al.,
1988; Shimizu et al., 1989; Cohen et al., 1991; Mann and
Sidman, 1994; Senders and Sykes, 1995; Emory et al., 1997;
Folk et al., 1997; Baker et al., 1999; Muzaffar et al., 2001;
Wilhelmi et al., 2001; Kirschner et al., 2006). In addition, the

590
 Smith et al., STANDARDIZED SCHEME FOR THE DESCRIPTION OF PALATAL FISTULAS
reported incidence for the recurrence of fistula after attempted
repair is described to reach nearly 100% (Thaller, 1995). Clear-
ly, postoperative fistulas remain a significant problem, and in-
consistent and vague literature impedes advances in their re-
pair. Given the current degree of confusion regarding nomen-
clature and classification of palatal fistulas, our aim was to
devise a simple, logical, and anatomically based classification
system that would standardize nomenclature and thereby result
in greater internal and external consistency in reporting data
while prospectively removing ambiguity from the literature.
METHODS
A search of PubMed for articles addressing cleft palate fis-
tulas was performed for the period from 1950 to the present;
articles found in this search and from review of these articles’
references were included in our analysis. Particular attention
was paid to reported definitions and classifications of palatal
fistulas as well as the incidence and recurrence rates. In ad-
dition, we conducted a retrospective chart review of a subset
of patients seen at the Pittsburgh Cleft-Craniofacial Center
(PittCCC) over the past 25 years. Our review was limited to
active patients of the PittCCC. These charts represented 18
surgeons using multiple treatment protocols (not specifically
addressed in this study). Charts were reviewed for any refer-
ence to palatal fistula along the course of treatment. Alveolar
fistulas, both lingual-alveolar and labial-alveolar, were exclud-
ed from the analysis, as it was impossible to reliably determine
if these fistulas were intentionally left patent. This chart review
was performed not to determine the incidence of palatal fis-
tulae but to obtain clinical data regarding the nature of palatal
fistulas and to ensure that the resultant classification scheme
would be informed by descriptions used in clinical practice.
Based on the information regarding palatal fistulas obtained
from the literature, combined with the anatomical description
of palatal fistulas from our limited chart review, an anatomi-
cally based and clinically oriented numerical fistula classifi-
cation system was devised. This study was reviewed and ap-
proved by the University of Pittsburgh Institutional Review
Board.
RESULTS
Literature Review
Articles found in the PubMed search, along with relevant
articles selected from their references, were included in this
review. The descriptions applied to palatal fistulas in the lit-
erature were found to be incomplete, anatomically inexact, and
subjective in general. Due largely to these qualities, it was
extremely difficult, if not impossible, to effectively compare
the results of these studies in reference to fistula formation as
an outcome of palatoplasty.
591
FIGURE 1 The Pittsburgh Fistula Classification System. A type I fistula
is a bifid uvula. A type II fistula is in the soft palate. A type III fistula is
at the junction of the soft and hard palates. A type IV fistula is in the hard
palate. A type V fistula is at the incisive foramen, at the junction of the
primary and secondary palates; this designation is reserved for Veau IV
clefts. A type VI fistula is in the lingual-alveolar region. A type VII fistula
is in the labial-alveolar region.
Pittsburgh Fistula Classification System
Based on the data found in the literature and obtained from
our chart review, a simple, anatomical, numerical classification
system was devised. This anatomical classification system does
not address functionality (i.e., whether a fistula is symptom-
atic). The Pittsburgh Fistula Classification System includes
seven fistula types (Fig. 1). Fistulas at the uvula, or bifid uvula,
are considered a type I fistula. Type II fistulas occur within
the soft palate. Type III fistulas are found at the junction of
the soft and hard palates. Type IV fistulas are located within
the hard palate. Type V fistulas are defined as fistulas at the
incisive foramen (junction of the primary and secondary pal-
ates) in the context of Veau IV clefts. Type VI fistulas are
lingual-alveolar, and type VII fistulas are labial-alveolar fistu-
las.
Retrospective Chart Review
More than 640 charts representing 18 surgeons using mul-
tiple treatment protocols and spanning 25 years were reviewed.
The identified fistulas were stratified according to their des-
ignation by Pittsburgh Fistula class (see Fig. 1). In cases in
which one patient had more than one simultaneous fistula, each
fistula was considered a discrete entity. If a fistula evolved
through various stages, its most recent classification was re-
corded.
A degree of difficulty was encountered when attempting to
classify the identified fistulas in our chart review. It was not
uncommon to have inadequate records secondary to a lack of
sufficient description of the fistulas, specifically in reference
to their location and functionality. As our chart review was
not intended to determine an accurate incidence of palatal fis-
tulas, and as the records of most patients contained inadequate
and incomplete descriptions of palatal fistulas, statistical anal-
yses were not attempted. Moreover, the data obtained from the
592 Cleft Palate–Craniofacial Journal, November 2007, Vol. 44 No. 6
TABLE 1 Fistula Incidence*
Fistula n %
I 36
II 27
III 45
IV 119
V 28
* In cases where one patient had more than one simultaneous fistula, each fistula was con-
sidered a discrete entity. If a fistula evolved through various stages, its most recent classifi-
cation was recorded. Type VI (lingual-alveolar) and type VII (labial-alveolar) fistulas were not
analyzed because gingivoperiosteoplasties were not routinely performed, and it was impossible
to reliably determine if these fistulas were intentionally left patent.
chart review provided clinical and anatomic information re-
garding palatal fistulas and allowed us to assess the usability
of the devised classification system. After anatomically clas-
sifying fistulas identified in our chart review (Table 1), we
found that the classification system was useful in the context
of a retrospective chart review. For the 640 patients with cleft
palate repairs reviewed, the most common fistula type was type
IV (within the hard palate), present in 119 palates (46.7% of
all fistulas). The next most common fistula type was type III
(at the junction of the hard and the soft palate), present in 45
palates (17.6% of all fistulas).
DISCUSSION
It is widely recognized that palatal fistulas remain a signif-
icant clinical problem, with an incidence of up to 76% and
recurrence rate of up to 96% in some studies (Bardach et al.,
1984; Senders and Sykes, 1995; Thaller, 1995). The magnitude
of this problem is underscored by the myriad techniques span-
ning the reconstructive ladder evolved to address palatal fis-
tulas (Guerrero-Santos and Altamirano, 1966; Berkman, 1978;
Rintala, 1980; Schultz, 1986; Coghlan et al., 1989; Schultz,
1989; Batchelor and Palmer, 1990; Chen et al., 1992; Assun-
cao, 1993; Ohsumi et al., 1993; Emory et al., 1997; Ninkovic
et al., 1997; Honnebier et al., 2000; Fukuda et al., 2003; Denny
and Amm, 2005; Krimmel et al., 2005; Cole et al., 2006;
Kirschner et al., 2006; Steele and Seagle, 2006). Palatal fistulas
may result from wound breakdown, secondary to closure under
tension, infection, flap trauma, hematoma, or compromise of
the vascular pedicle resulting in tissue ischemia. Fistulas are
clinically significant—functional or symptomatic—when they
lead to nasal air escape, speech distortion, hearing loss, or
regurgitation of fluid and food (Isberg and Henningsson, 1987;
Amaratunga, 1988; Muzaffar et al., 2001; Wilhelmi et al.,
2001). These problems are compounded by the fact that fis-
tulas are difficult to definitively repair.
To date, no standard definition and classification system for
palatal fistulas has been adopted in the literature or widely used
clinically. Some general descriptions are offered, referring to
a fistula as an abnormal communication between two cavities
(Folk et al., 1997). Fistulas have been defined in a narrower
sense as a complication of palatoplasty, occurring along the
site of a palate repair (Witt and Marsh, 1997). We favor a
definition that is both anatomically specific and independent
of etiology or functionality: a fistula is a patency between the
oral and nasal cavities. Our approach to classification, which
is independent of etiology and functionality, allows one to use
14.1
10.6
the Pittsburgh Fistula Classification System to anatomically re-
17.6 port, and consistently describe, fistulas present not only after
46.7 palatal repair but also those due to other circumstances such
11.0
as trauma and congenital deformities.
The literature is rife with subjective descriptions of palatal
fistulas. On review, we found only a few studies that main-
tained internal consistency by offering clear anatomical de-
scriptions of fistula location. In a report from the Children’s
Hospital of Philadelphia, Cohen et al. (1991) described fistulas
as occurring at the level of the uvula, soft palate, hard-soft
palate junction, hard palate, postalveolar, alveolar, and preal-
veolar regions. Folk et al. (1997) described fistulas as occur-
ring at the level of the soft palate, junction of the hard and
soft palate, hard palate, incisive foramen, or anterior to the
incisive foramen. Despite these anatomic descriptions, no
widely accepted and regularly used standardized classification
system for palatal fistulas exists; thus, external consistency in
describing fistulas between studies is impossible. For example,
one author’s ‘‘alveolar fistula’’ might be another’s ‘‘lingual al-
veolar-fistula’’ and yet another’s ‘‘labial-alveolar fistula’’; or
one surgeon’s ‘‘hard palate fistula’’ may be another’s ‘‘incisive
foramen fistula’’ and yet another’s ‘‘junction of the hard and
soft palate fistula.’’
Upon initial review, one might question the necessity of a
numerical classification system, suggesting that clinicians sim-
ply rely on a thorough anatomical description of palatal fistulas
identified. However, in our daily clinical experience, and re-
view of the literature, as well as the records of the PittCCC,
this type of strategy has historically failed for several reasons.
When expected to routinely report thorough anatomical de-
scriptions of their outcomes, and specifically their complica-
tions, surgeons have been found to be lacking. Our chart re-
view revealed that in most cases, fistulas were often mentioned
but not adequately described. In several instances, the fistula
was noted by the speech pathologist and not commented on
by the treating surgeon. When a fistula was mentioned, com-
ments such as ‘‘a fistula was noted’’ would frequently be the
extent of the description found in the medical record. Obvi-
ously, this did not address the location, size, or functionality
of this important finding. Similarly, our literature review re-
vealed no consensus regarding the anatomical description of
reported fistulas; this shortcoming results in a significant lack
of internal and external consistency, making intercenter, sur-
geon-specific, and procedure-related comparisons impossible.
Therefore, it is our contention that an anatomically based
numerical classification system is necessary. By simply re-
porting a type III fistula, all clinicians will immediately un-
derstand this description to represent a ‘‘fistula at the junction
of the hard and soft palates.’’ It is highly likely that adopting
this system will result in more accurate reporting of data and
prospectively remove ambiguity from the literature. In addi-
tion, the Pittsburgh Fistula Classification System will allow for
intercenter, as well as clinician-specific and technique-specific,
 Smith et al., STANDARDIZED SCHEME FOR THE DESCRIPTION OF PALATAL FISTULAS
reporting of outcomes data. Furthermore, with the addition of
a prefix, ⫹ or ⫺, one could denote the functionality of the
fistula. Functional or symptomatic fistulas, resulting in nasal
air escape or nasal regurgitation of liquid or food, could be
reported with a ⫹, and nonfunctional or asymptomatic fistulas,
not clinically significant, could be noted with a ⫺. Ultimately,
a ⫺type IV fistula would therefore be universally known to
represent a ‘‘nonfunctional or asymptomatic fistula at the junc-
tion of the primary and secondary palates in a Veau IV cleft.’’
Similarly, a suffix could be added to indicate intentionality; for
example, if one did not perform a gingivoperiosteoplasty, then
type VI (lingual-alveolar) and type VII (labial-alveolar) fistulas
would be expected and described as intentional. The only ad-
ditional information to be recorded by the clinician could be
the size of the fistula in millimeters if desired. A standard chart
(see Fig. 1) can be included with the cleft center data collection
forms that would prompt clinicians to note, and accurately re-
cord, the presence or absence of palatal fistulas.
The Pittsburgh Fistula Classification System presented here
is intended to establish both internal and external consistency
to clinical practice and outcomes research by introducing nu-
merical, and thus unambiguous, verbiage to the fistula vocab-
ulary. Indeed, the need for a consistent vocabulary became
increasingly obvious during our literature and chart review. If
vagaries within the charts of our single cleft-craniofacial center
hinder us from collecting accurate data, how can definitive
conclusions be drawn from the resultant analysis? Moreover,
even the clinician with the best intentions is bound to ulti-
mately confuse the future clinician or researcher reviewing re-
cords at a later date, as many different but equally accurate
descriptions may be applied to a given fistula. For example,
an individual fistula might correctly be described as ‘‘anterior
to the incisive foramen’’ or ‘‘lingual-alveolar.’’ Adopting a
standardized numerical vocabulary should obviate such con-
fusion. Furthermore, not only are the numerical assignments
intrinsic to this classification system important as they empha-
size the discrete nature of the categories used, but they are also
essential as guarantors of the system’s longevity. It has been
the authors’ experience that the busy clinician is likely to use
the most efficient system available in recording medical re-
cords. A simple numerical scheme is thus more sustainable in
clinical practice than a system based entirely on verbal de-
scriptions. We have found that at the PittCCC, the Fistula Clas-
sification System has quickly and easily integrated itself into
the daily practice of comprehensive cleft care. Moreover, with-
in a very short period of time, it has become a very useful
tool, analogous to the Veau classification of clefts.
A detailed statistical analysis of fistula incidence was unable
to be performed because of the inadequate descriptive nature
of the data, and as mentioned earlier, such an analysis is not
the goal of this report. The tentative fistula incidence data pre-
sented here are the product of a review of nonconsecutive pa-
tients whose charts were on site and active, and they are in-
tended to demonstrate the potential usefulness of this classifi-
cation system in research endeavors. In many instances during
our chart review, all of the available data regarding the noted
593
fistula was obtained (speech, orthodontics, dental, etc.), and a
best guess was made when assigning a Pittsburgh fistula type.
As well, these data represent 18 different surgeons with mul-
tiple evolving treatment protocols and surgical techniques,
spanning a 25-year period, including, for example, a two-stage
palatoplasty technique resulting in a high type III fistula rate.
This technique was abandoned more than a decade ago. Be-
cause of the many variables, the specific details regarding sur-
gical technique (straight-line, z-plasty, relaxing incisions, in-
travelar veloplasty), treatment protocol (single versus two-
stage palate repair), or surgeon (junior versus senior attending,
resident assistance versus teaching case) were not analyzed as
part of this study. In addition, type VI (lingual-alveolar) and
type VII (labial-alveolar) fistulas were not analyzed because
of the assumption of their existence, as gingivoperiosteoplas-
ties were not routinely performed. Moreover, asymptomatic
bifid uvulas (⫺type 1) and nonfunctional incisive foramen de-
fects (⫺type 4) were included in this statistic. Finally, differ-
entiation between symptomatic (⫹) fistulas and those fistulas
that were not functional (⫺) was not attempted.
Despite the limitations of the chart review performed as part
of this study, when looking at all classified fistulas, it was
interesting to find that type IV fistulas within the hard palate
were most common (46.7% of all fistulas) and type III fistulas
at the junction of the hard and soft palates were the next most
commonly found fistulas (17.6% of all fistulas). This is coun-
terintuitive to the authors, as it would be logical that type III
fistulas at the junction of the hard and soft palates would be
most common, given that the greatest degree of wound tension
is in this region for any method of palatoplasty. This unusually
high rate of type IV fistulas may be due in part to a lack of
adequate description in the medical records, as some type V
fistulas at the junction of the primary and secondary palates,
as well as some type III fistulas at the junction of the hard and
soft palates, may have been captured in the type IV group and
falsely elevated the incidence of type IV fistulas. In addition,
it is unknown how many of the type IV fistulas were a result
of orthodontic palatal expansion and not an immediate com-
plication of palatoplasty. These findings support our contention
that a standardized numerical classification system needs to be
prospectively applied to cleft palate outcome data, so that true
incidences may be elucidated.
CONCLUSION
Palatal fistulas represent an important concern in the treat-
ment of cleft palates, and clear nomenclature is a prerequisite
for meaningful discussion, ongoing research, and evolving new
treatment strategies. The Pittsburgh Fistula Classification Sys-
tem is presented as a standardized scheme whose widespread
clinical adoption will help to prospectively clarify ambiguity
in the literature, establish internal and external consistency in
reporting, and thus facilitate future research in this field.
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