Oronasal Fistula Research Articles

Detection of Oronasal Fistula Using a Fluorescent Water Passing Test.

The confirmation of a connection between the oral and nasal cavities provides a definitive diagnosis for an oronasal fistula (ONF). However, visual detection is difficult in patients with small fistulas. This study examined whether fluorescein sodium could be used to detect small ONFs. The study included 25 dogs that underwent dental examination and had confirmed periodontal pockets at the Amica Pet Clinic, Japan, between 2020 and 2022. Saline containing fluorescein sodium was injected into the periodontal pocket, termed a fluorescent "water-passing test," followed by detection of fluid discharge from the external naris using an examination light. Of the 25 dogs, 13 showed symptoms consistent with an ONF and of these, 12 were positive and one was negative on the fluorescent water-passing test. Of the 12 asymptomatic dogs, 3 tested positive and 9 tested negative on the fluorescent water-passing test. The fluorescent water-passing test enhanced visibility and facilitated the detection of small volumes of the discharged fluid. The results of this study confirmed the fluorescent water-passing test was useful for the detection of small ONFs.

A Two-Stage Approach to Alveolar Clefts Repair with Combined Cortical and Cancellous Bone Grafting

Background: Achieving optimal efficacy in secondary alveolar bone grafting (SABG) poses a considerable challenge for patients with alveolar clefts post-canine eruption. This study introduces a novel technique called the "two-stage SABG" to improve the treatment outcomes for patients who have missed the optimal timing for bone grafting. Methods: Patients aged 12 and above, presenting with unilateral, complete alveolar clefts after canine eruption, were divided into two cohorts: conventional and two-stage groups. The two-stage group underwent oronasal fistula closure and mucoperiosteal sealing during the initial stage, followed by particulate cancellous bone marrow (PCBM) and mandibular cortical bone grafting in the second stage after a three-month interval. Six months after surgery, the SABG was evaluated quantitatively and qualitatively using computed tomography (CT). Results: A total of 81 patients (median age: 14 years; male/female: 49/32) were included in the conventional group, while the two-stage group consisted of 33 patients (19 years; 20/13). The two-stage group exhibited significantly superior outcomes (P < 0.01) in terms of radiographic healing rate (> 4 points) (96.97% vs. 55.56%), bone bridge height (12.17mm, IQRs=4.26mm), bone bridge width (9.09mm, IQRs=2.74mm), bone formation rate (69.73%, IQRs=22.73%), and bone resorption rate (48.85%, IQRs=22.57%). Additionally, the average three-dimensional deviations greater than 3.5mm at the affected piriform aperture margin. Conclusions: The novel two-stage SABG approach demonstrates significant benefits in the repair of alveolar clefts and pyriform foramen deformities through combined cortical and cancellous bone grafting.

Response of Spontaneous Oral Tumors in Canine Cancer Patients Treated with Stereotactic Body Radiation Therapy (SBRT).

To describe outcome and toxicity for dogs with oral tumors, specifically oral malignant melanoma (OMM), squamous cell carcinoma (SCC), and soft tissue sarcoma (STS) after stereotactic body radiation therapy (SBRT). A single institution retrospective study was conducted. Outcomes were analyzed using Kaplan-Meier analysis and Cox proportional hazard analysis. Treatment responses at different time points were evaluated with Pearson's Chi-squared test to identify prognostic factors. Acute and late toxicities were recorded according to VRTOG criteria and were analyzed to identify risk factors. Adverse events other than acute and late toxicities were recorded. A total of 98 patients met the inclusion criteria (OMM n = 37; SCC n = 18; STS n = 43). The SBRT prescription was 1-6 fractions, with a total dose range of 12-40 Gy. Local progression-free survival (PFS) for OMM, SCC, and STS was 187, 253, and 161 days, respectively. Overall PFS was 152 days and median survival time (MST) was 270 days, with no statistical difference between tumor types. The presence of lymph node metastasis and the use of elective nodal irradiation (ENI) were associated with shorted PFS and MST. Severe acute toxicities to organs at risk affected 10/85 (11.8%) of patients. Osteoradionecrosis and oronasal fistula formation occurred in 23/81 (28.4%) of patients and was significantly associated with tumor type (SCC, P = 0.006). BRT can be offered as a treatment option for oral tumors in dogs. Toxicities were common and warrant risk factor considerations and adjustments to current SBRT protocols.

A Case of Oronasal Fistula Repaired With Inferior Turbinate Rotational Flap

Oronasal fistula is a rare but significant complication that diminishes the quality of life for patients undergoing treatment for cleft palate and head and neck cancer. Various surgical reconstruction methods can be used based on the size and location of the oronasal fistula. The intranasal inferior turbinate rotational flap is a simple and safe method for reconstructing the defect of nasal cavity. In this case report, we experienced a small oronasal fistula of a 50-year-old female caused by osteoradionecrosis after treatment for her malignant melanoma. Successful reconstruction was achieved with inferior turbinate rotational flap alone. For small oronasal fistula in the hard palate, the inferior turbinate flap alone can be a useful option for reconstruction.

Accelerating Oral Wound Healing Using Bilayer Biomaterial Delivery of FTY720 Immunotherapy.

Orofacial clefts are the most common congenital craniofacial anomaly. Adverse healing following cleft palate repair can lead to oronasal fistula (ONF), a persistent connection between the oral and nasal cavities. Although human allograft tissues are currently the gold standard for ONF repair, these methods carry risks of infection and rejection, often requiring surgical revision. Immunoregenerative therapies present a novel alternative approach to harness the body's immune response and enhance the wound healing environment. An FDA-approved immunomodulatory drug, FTY720, is repurposed to reduce lymphocyte egress and induce immune cell fate switching toward pro-regenerative phenotypes. In this study, a bilayer biomaterial system is engineered using Tegaderm to secure and control the delivery of FTY720-nanofiber scaffolds (FTY720-NF). The release kinetics of the bilayer FTY720-NF is optimized to maintain drug release for up to 7 days, ensuring safe transdermal absorption and tissue biodistribution. The comprehensive immunophenotyping results demonstrate a regenerative state transition in hybrid immune cells recruited to the wound site. Further, histological evaluations reveal a significant ONF closure in mice by day 7 following bilayer FTY720-NF implantation. These findings demonstrate the utility of immunomodulatory strategies for oral wound healing, better positing the field to develop more efficacious treatment options in pediatric patients.

Clinical Outcomes after Cleft Palate Repair at a Major Referral Hospital in Addis Ababa, Ethiopia

Background: The two most common complications after primary palatoplasty are oronasal fistula and velopharyngeal insufficiency (VPI). To the best of our knowledge, there have been no studies examining postpalatoplasty speech outcomes in Ethiopia. Methods: A hospital-based retrospective cross sectional study design was used. A total of 149 patient records were reviewed, and 103 patients fulfilled all the inclusion criteria. These 103 cleft lip and palate patients who had undergone cleft palate repair at Yekatit 12 Hospital Medical College and who had undergone long-term speech assessment with the speech therapy department from January 2019 to December 2021 were included in this study. The bivariate/multivariate logistic regression was used to compare between different groups of patients, with the level of significance set at a P value of less than 0.05. Results: Moderate and severe hypernasality was seen in 45.7% of patients. Age at time of palatal surgery has significant association with incidence of hypernasality (P = 0.01). The type of cleft, sex of the patient, and type of surgery had no significant association with incidence of hypernasality. Oronasal fistula was seen in 25% of patients, with Pittsburgh type VI being the most common (40%). Conclusions: There is a high rate of VPI and oronasal fistula in this cohort of patients who underwent palatoplasty at Yekatit 12 Hospital. One of the factors for higher complication rate was older age at time of surgery. Therefore, patient education and strengthening the cleft care with training are paramount to ensure better results.

Evaluating the Efficacy and Complications of the Scapular Osseous Free Flap for Head and Neck Reconstruction: Results from a Population-based Cohort

IntroductionThe scapular osseous free flap (SOFF) is being increasingly used for complex head and neck reconstructions. This study examined the surgical outcomes, focusing on post-operative complications and sequelae in patients who underwent SOFF for maxillary and mandibular reconstructions. Material and MethodsThis retrospective, observational, population-based study included patients who underwent SOFF reconstruction at a tertiary referral centre, the Department of Otorhinolaryngology-Head and Neck Surgery, Skåne University Hospital, Sweden, from November 2016 to March 2023. All patients were followed-up for at least six months after surgery. ResultsForty-two of the 44 consecutive patients (60 % men) consented to the study and were evaluated with a median follow-up time of 49 months (range 8–85 months). The study divided the patients into two groups; maxillary (n = 29) and mandibular (n = 13) reconstructions. The World Health Organisation performance status and the Charlson comorbidity index were lower in the maxillary group (p = 0.025 and p = 0.011, respectively). The maxillary group experienced high complication rates including six total flap failures and nine oronasal fistulas. Conversely, the mandibular group had no flap failures but a similar rate of general post-operative complications were observed. Dental rehabilitation was more common in the maxillary group. ConclusionThe SOFF is an option for complex reconstructions of the maxilla but is associated with a relatively high rate of complications. Methods that can prevent or minimise sequelae, e.g., oronasal fistulas, in future patients are warranted. The SOFF is an excellent alternative for mandibular reconstructions.

Delayed maxillary reconstruction following mucormycosis: A comprehensive analysis of surgical strategies and outcomes

Study designThis study is a prospective observational study conducted over two years from December 2020 to March 2023 at the Department of Plastic and Reconstructive Surgery. ObjectiveTo evaluate the outcomes of delayed reconstruction in patients with maxillectomy defects post-COVID-19 associated mucormycosis, focusing on safety, morbidity, and aesthetic results. MethodsFifty patients with post-COVID-19 mucormycosis and maxillectomy defects without skin involvement were included. These patients underwent radical debridement and were treated with Amphotericin B followed by Posaconazole therapy until clinical and radiological resolution of the disease. Reconstruction was performed after a minimum of six months post-maxillectomy. Flaps used for reconstruction included the radial forearm free flap (RAFF), anterolateral thigh flap (ALT), and free fibula osteomyocutaneous flap, planned using a 3D-printed model. Follow-up was conducted weekly for the first month and monthly for the next two months, with semiannual visits thereafter. ResultsOf the 50 patients, 42 % were male, and 58 % were female, with a mean age of 43 ± 8.75 years. Most patients (88 %) were diabetic. Maxillectomy defects were categorized as type IIA, IIB, IIIA, IIIB, and IV based on the Cordeiro classification. Four flaps (8 %) required re-exploration, with three salvaged. Complications included marginal flap necrosis (4 %) and oro-nasal fistula (2 %). The average hospital stay was six days, extended to ten days for re-explored cases. Flap dimensions varied with the largest being 62 cm² for the free fibula flap. ConclusionsDelayed reconstruction using free flaps in patients with post-COVID-19 mucormycosis maxillectomy defects without skin involvement is a safe approach with minimal morbidity. This method allows confirmation of disease resolution before major reconstructive surgery, resulting in excellent aesthetic and functional outcomes.

The utility and outcomes of the temporalis muscle flap for palate reconstruction after maxillectomy for malignancy

Back groundA common pedicled facial technique in head and neck reconstruction is the TMF It can be utilised to replace missing tissues in a variety of conditions, including oral deformities of the hard and soft palate.Aim of the study was to document the utility and outcomes with the reconstruction of the palate using TM flaps following Maxillectomy For maxillary sinus malignancies MethodologyThe study included 24 patients who were operated on for cancer maxilla and eligible for maxillectomy and reconstruction of the Palate using temporalis flap. Follow-up was planned for at least 12 months postoperative. Postoperative physical and speech therapy are initiated to help improve speech and swallow outcomes and to prevent trismus ResultsThe current study included 24 cases with Maxillary sinus cancer with a mean age of 42.34±4.67. The mean operative time was 5.4±1.22 hours with no reported intraoperative bleeding or injury of important structures .No cases of facial palsy or trismus were reported while partial flap loss was reported in one case where oronasal fistula was evident. The donor site complications were minimal where seroma occurred in two patients and alopecia , wound infection and dehiscence were reported in one case each. The donor site depression was evident in 25% of cases ConclusionTMF is an excellent option for the reconstruction of many craniofacial defects, it is easy to be harvested with good blood supply with minimal postoperative complications

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review.

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes. A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All study designs were included. Non-English articles were excluded. Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula. Free tissue transfer for a palatal fistula repair. Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained. Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies. Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Immediate rehabilitation of a palatal defected edentulous patient by implant-supported overdenture: a case report

BackgroundImmediate rehabilitation is a considerable therapeutic challenge but is necessary for edentulous patients with oronasal fistulas, especially those with inadequate residual bone and a history of radiotherapy.Case presentationWe report a rare case of a 63-year-old patient who was missing the majority of his maxillary teeth and who had a defect due to palatal mucoepidermoid carcinoma resection. The patient also received radiotherapy twice within one year postoperatively. An implant-supported prosthesis with an obturator was fabricated immediately.ConclusionThis technique improved patients’ oral function, enhanced the aesthetic effect, and increased their confidence.

“Long term speech outcomes after using the Sommerlad technique for primary palatoplasty: a retrospective study in the Wilhelmina Children’s Hospital, Utrecht.”

ObjectivesAfter cleft lip and/or palate (CL/P) repair, children may develop velopharyngeal insufficiency (VPI) leading to speech imperfections, necessitating additional speech correcting surgery. This study examines the incidence of VPI and speech correcting surgery after Sommerlad’s palatoplasty for CL/P, and its association with various clinical features.Materials and methodsA retrospective cohort study was performed in the Wilhelmina Children’s Hospital in Utrecht and child records from 380 individuals with CL/P registered from 2008 to 2017 were retrospectively reviewed. Inclusion criteria comprised the diagnosis of CL/P, primary palatoplasty according to Sommerlad’s technique, and speech assessment at five years or older. Association between cleft type and width, presence of additional genetic disorders and postoperative complications (palatal dehiscence, fistula) were assessed using odds ratios and chi squared tests.ResultsA total of 239 patients were included. The VPI rate was 52.7% (n = 126) and in 119 patients (49.8%) a speech correcting surgery was performed. Severe cleft type, as indicated by a higher Veau classification, was associated with a significant higher rate of speech correcting surgeries (p = 0.033). Significantly more speech correcting surgeries were performed in patients with a cleft width >10 mm, compared to patients with a cleft width ≤10 mm (p < 0.001). Patients with oronasal fistula underwent significantly more speech correcting surgeries than those without fistula (p = 0.004). No statistically significant difference was found in the incidence of speech correcting surgery between patients with and without genetic disorders (p = 0.890).Conclusions/clinical relevanceVariations in cleft morphology, cleft width and complications like oronasal fistula are associated with different speech outcomes. Future research should focus on creating a multivariable prediction model for speech correcting surgery in CL/P patients.

Estimated Time of Arrival: Impact of Healthcare Disparities on Access to and Outcomes of Multidisciplinary Cleft Lip and Palate Care.

To determine the impact of sociodemographic and clinical factors on patient presentation into the cleft care pathway and determine how delayed interventions may affect post-surgical outcomes. Retrospective study. Multidisciplinary craniofacial clinics of two university hospitals. 135 patients with cleft lip and/or palate. Primary cheiloplasty, primary palatoplasty. Age at initial presentation, age at first surgery, lag time, delayed surgery, rate of return to the emergency department (ED), readmission rate, reoperations, and oronasal fistula development. Patients referred by OBGYN who underwent cheiloplasty had an earlier age at initial presentation (p < 0.01), earlier age at first surgery (p = 0.01), and a shorter lag time (p < 0.01) compared to children from other referral pathways. African American children had an older age at first surgery (p = 0.01) and a longer lag time (p = 0.02) when compared to non-African American children. Children with syndromes had an older age at first surgery (p < 0.01) and a longer lag time (p < 0.01) than children without syndromes. Patient race, cleft type, and syndromic status increased the odds of receiving delayed surgery. Patients who received delayed palatoplasty returned to the ED at a higher rate than patients who received non-delayed palatoplasty (p = 0.02). Our data suggest that referral source, race, and syndromic status influence the timeliness of cleft care. Surgeons should develop strong referral networks with local OBGYNs and hospitals to allow for an early entry into the cleft care pathway.

30 Does the Use of Antibiotics Prophylaxis Affect the Rate of Postoperative Fistula Rates in Cleft Palate Patients?

Abstract Aim Assess whether post-operative antibiotic prophylaxis affected the incidence of oronasal fistula formation in cleft palate patients. Design and setting: Institutional retrospective study using data from patients undergoing primary palatoplasty. Gold standard Fistula rate of no more than 8-10%. Method In the first cycle, there were two groups (A and B). In group A, the patients had antibiotics on induction and 24 hours after, in group B, the patients had further antibiotics for a week. Our work from the cleft collective showed no evidence of change in fistula rates in relation to the antibiotic regime. Therefore, group A surgeon changed practice had antibiotics only on induction and group B remained the same from the first cycle. Results In cycle 1, we found little evidence to suggest a difference in fistula rate between the use of an antibiotic regimen as binary variables: Grp A(P=0.171) and Grp B (P=0.69). Cycle 2 also demonstrated the following: Grp A (P=0.557) and Grp B(P=0.443). Conclusions The use of antibiotics and differing regimes, postoperatively do not influence the incidence of postoperative fistulae in cleft palate.

Large Anterior Oronasal Fistula with Short Palate: New Technique for Fistula Closure and Palatal Lengthening

Large Anterior Oronasal Fistula with Short Palate: New Technique for Fistula Closure and Palatal Lengthening

Lateral palatal sliding flap for closure of post traumatic oronasal fistula

Lateral palatal sliding flap for closure of post traumatic oronasal fistula

A novel approach in orthodontics: Archwise distraction osteogenesis

Distraction osteogenesis can be described as a procedure that is based on the principles of physiologic remodeling and indirect fracture healing. In dentoalveolar level, conventional appliances may present some difficulties such as the need for multiple stages of DO to achieve a good occlusion due to distraction on a straight vector; incompetency to reduce the oronasal fistula in cleft patients; and the difficulty in achieving complete hard and soft tissue reconstruction, especially in cases with large alveolar defects.ArchWise Distraction Appliance (AWDA) have been developed to overcome these limitations and obtain a regenerated bone curvilinear in shape, similar to the original alveolar bone configuration. This article aims to introduce and explain the AWDA method in detail so that every clinician will be able to perform the treatment. The reader can observe the application of the procedure on a variety of cases including cleft lip and palate, trauma, and bone pathology. Possible complications and their solutions are also explained on actual cases.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study

BackgroundThe aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing the postoperative complications. This study aimed to compare the long-term outcome of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. MethodsA retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. ResultsA total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were eligible in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% versus 4.6%, p =0.01), and the VPI prevalence was not significantly different (9.2% versus 7.9%, p =0.62). Patients who developed fistula had significantly higher likelihood of having VPI than patients without oronasal fistula (50.0% versus 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. ConclusionBoth modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension facilitated to lower the risk of oronasal fistula.

Introduction to Amniotic Membranes in Maxillofacial Surgery-A Scoping Review.

Background: Amniotic membrane (AM) holds significant promise in various medical fields due to its unique properties and minimal ethical concerns. This study aims to explore the diverse applications of the human amniotic membrane (HAM) in maxillofacial surgery. Methodology: A comprehensive search was conducted on databases, namely Google Scholar, PubMed, and Scopus, from January 1985 to March 2024. Articles in English, Polish, and Spanish were included, focusing on keywords related to amniotic membrane and oral surgery. Results: Various preservation methods for HAM were identified, namely fresh, decellularized, cryopreserved, lyophilized, and air-dried formats. Clinical studies demonstrated the efficacy of HAM in repairing oral mucosal defects, vestibuloplasty, oronasal fistula closure, cleft palate treatment, bone defect repair, and medication-related osteonecrosis of the jaw (MRONJ). Surgeon evaluations highlighted the ease of handling but noted challenges in suturing and stability during application. Conclusions: Amniotic membranes offer a versatile and effective option in maxillofacial surgery, promoting wound healing, reducing inflammation, and providing a scaffold for tissue regeneration. Further research, including randomized trials and comparative studies, is warranted to validate the efficacy and optimize the utilization of HAM in clinical practice.

Management of oronasal fistula using L-PRF and palatal flap due to residual cyst in maxilla: A case report

Study Design: Case Report. Oronasal communication can be a result of congenital disorders, pathological lesions, or inadequate treatment. It consists of abnormal communication between the nasal and oral cavities. Objective: This paper aims to present a case report of a female patient who intended for dental implants but was referred to the maxillofacial surgery department presenting a cone beam computed tomography with incidental finding in the anterior part of the maxilla. Methods: The first surgical procedure consisted of the resection of the lesion associated with bone graft with buccal fat pad flap and posterior histopathological study. After three months the patient developed an oronasal fistula. During the second surgical management, the authors chose platelet concentrates (L-PRF) to fill the bone defects associated with the palatal flap. Results: After one year of follow-up, the patient presented definitive soft tissue healing, no exposure of bone tissue, and the closure of oronasal communication. The new CT scan and panoramic x-ray showed satisfactory bone healing. Conclusion: The present study demonstrated the association of L-PRF with xenograft and palatal flap can be a viable method for the management of patients with oronasal fistula. This report adheres to the SCARE guidelines for the reporting of surgical cases in medical literature.