Palatal Fistula Research Articles

Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients.

This study presents a large consecutive institutional experience with primary cleft palate repairs. The purpose of this study was to determine the incidence of early complications after cleft palate surgery in a series of nonsyndromic children treated at the authors' comprehensive cleft center. This retrospective analysis includes 709 consecutive patients with cleft palate treated by 6 different staff surgeons at Guwahati Comprehensive Cleft Care Center between April 2011 and December 2012. Secondary cases were excluded from this study. The patients were initially followed up between 1 week and 1 month after surgery. The overall incidence of early complications was determined, and the effect of the extent of clefting, the type of repair, the age at repair, and the operating surgeon were analyzed. Early complications in this study include dehiscence of the wound, fistula formation, hanging palate, and total or partial flap necrosis. There was a 2.4% rate (17/709) of take-back to the operating room in the immediate postoperative period for control of bleeding, although no blood transfusions were required. The incidence of postoperative fistulas in this series was 3.9% (20/512). There was a statistically significant increase in the incidence of cleft palatal fistula for Veau IV clefts, but there were no significant differences with respect to operating surgeon, patient sex, patient age, and type of palatoplasty. The complication and fistula rate is consistent with other published reports from developed countries and provides evidence for the value of this model for surgical delivery in the developing world.

Incidence of palatal fistula formation after primary palatoplasty in northern Finland.

The purpose of this retrospective study was to determine the incidence of palatal fistulas after primary cleft palate repair. The study included 136 patients who were treated at the Oulu University Hospital cleft lip and palate center between 1998 and 2011. All patients were treated by the same surgeons with 1-stage palatoplasty closing the hard and soft palate concurrently. The overall frequency of postoperative fistula was 9.6% of patients. Patients with cleft lip and palate (20.0%) were more likely to develop postoperative palatal fistulas than patients with cleft palate (6.6%). Surgical technique and cleft severity were not significant factors for the development of palatal fistulas. The majority of patients undergoing primary palatal repair do not develop palatal fistulas.

Stabilization of premaxilla repositioned during secondary bone grafting in complete bilateral cleft lip and palate patients.

Secondary bone grafting simultaneous to premaxillary repositioning is a well-recognized surgical procedure for the management of bilateral cleft lip and palate patients. Proper stabilization of the repositioned premaxilla is considered as a key factor for the success of secondary bone grafting because the mobility of the premaxillary segment jeopardizes graft integration. This case series reports a reliable method of premaxillary stabilization that incorporated the intrasurgical application of resin bone cement to cover and reinforce the arch bars or orthodontic brackets applied on the maxillary teeth. Occlusal loads were reduced by application of posterior bite blocks on the mandibular teeth. The stabilization method was performed on 7 patients (5 women and 2 men) with a mean age of 12.4 years. During postsurgery follow-ups, the repositioned premaxillary segments did not show mobility in any of the patients. The palatal fistulae were completely closed. Panoramic radiographies taken 2 months after surgery demonstrated acceptable graft integration. The patients have now been followed up to 5 years. No evidence of relapse has been observed. This technique seemed to be undemanding, included minimal laboratory procedure, and maintained the labial mucosa overlying the repositioned segment intact.

Morbidities and Quality of Life after Maxillary Swing Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma

Background: The maxillary swing approach provides a good access that allows maximal resection of recurrent NPC. The aim of the current study was to report the morbidities and quality of life of patients after surgery. Methods: A prospective study of the early and late morbidities after surgery was performed. A longitudinal investigation of the quality of life before and 1 year after surgery was performed using the self-reported, EORTC questionnaire. Results: Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. There was no hospital mortality. The morbidities were actively prevented by modifications of surgical techniques, leading to a significant reduction in the incidence of postoperative trismus (42.1 vs. 9.2%, p = 0.01) and palatal fistula formation (24.0 vs.3.7%, p = 0.01). Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had higher chance of facial numbness, nasal blockage, and swallowing problem after surgery. There was no significant change in the mean global health system score after surgery, except those after palliative resection requiring adjuvant chemoradiation. Social functioning had the lowest scores among the five functioning scales in all groups of patients. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of the patients. Conclusions: QOL of patients after salvage nasopharyngectomy.

Morbidities after maxillary swing nasopharyngectomy for recurrent nasopharyngeal carcinoma

The purpose of this study was to investigate the complications after maxillary swing nasopharyngectomy. Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. Patient and tumor characteristics, perioperative and intraoperative information, and long-term morbidities were analyzed. There were significantly more patients with locally advanced tumors (rT3 and rT4) operated during the recent study period (2002-2012). However, the mean operative time and blood loss was significantly lower than in the earlier period (1990-2001). There was no hospital mortality. There was a significant reduction in the postoperative trismus and palatal fistula formation. Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had a higher chance of facial numbness, nasal blockage, and swallowing problems after surgery. Salvage nasopharyngectomy via the maxillary swing approach is safe with acceptable long-term morbidities. Prevention of complications associated with surgery, particularly for patients with locally advanced tumors, is crucial to ensure the best outcome of surgery.

Outcomes of cleft palatal repair for internationally adopted children.

Families in the United States adopted approximately 230,000 foreign-born children over the past two decades. Age at adoption and the presence of a cleft palate impact speech and language development. The authors' purpose is to document speech outcome after palatal closure in internationally adopted children. The authors reviewed internationally adopted children with cleft lip-cleft palate or cleft palate who had two-flap palatoplasty from 1987 to 2010. Data collected included date of birth, cleft palatal type, age at palatoplasty, palatal fistula, postoperative speech assessment, and need for secondary surgery. The authors identified 55 children adopted with unrepaired cleft palate. Palatal types were Veau I (n = 1), II (n = 1), III (n = 37), or IV (n = 16). Median age at palatoplasty was 25.6 ± 11.8 months; palatal fistula occurred in five patients (9 percent). Speech outcome was successful in 28 patients (51 percent), whereas a secondary operation was recommended for 27 patients (49 percent). Need for a secondary operation was independent of palatal type (p = 0.6). Children who required a pharyngeal flap were significantly older at the time of palatoplasty compared with those who did not (p = 0.009). There was a significant association between increasing age at palatoplasty and need for a secondary operation (OR, 1.07; 95 percent CI, 1.01 to 1.13; p = 0.01). Pharyngeal flap significantly improved speech (p < 0.001). International adoption with late palatoplasty can result in disordered speech. Velopharyngeal insufficiency is associated with increasing age at palatoplasty. The authors recommend palatoplasty and speech therapy soon after adoption. Risk, III.

Role of tongue flap in palatal fistula repair: A series of 41 cases.

Introduction:Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair.Materials and Methods:We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done.Observation and Result:None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases.Conclusion:Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.

Association Between Palatal Index and Cleft Palate Repair Outcomes in Patients With Complete Unilateral Cleft Lip and Palate

IMPORTANCE This study evaluates a technique to estimate cleft severity and tissue hypoplasia in patients with cleft palate. Current classifications are limited to the morphologic characteristics of the clefts. A new classification is proposed in relation to the palatal index, which allows more individualized surgical attention for the cleft palate. OBJECTIVE To evaluate the relationship of palatal index and cleft palate repair surgical outcomes (palatal fistula and velopharyngeal insufficiency) in patients with unilateral cleft lip and palate. DESIGN, SETTING, AND PARTICIPANTS Retrospective study performed by the Outreach Surgical Center Program Lima, Lima, Perú, of surgical outcomes of 152 consecutive pediatric patients, aged 12 to 15 months, with nonsyndromic unilateral complete cleft lip and palate treated during from 2001 to 2007. Findings were obtained at 1 to 5 years' follow-up. INTERVENTIONS Palatoplasty using the 2-flap technique plus intravelar veloplasty. Palate index was measured preoperatively with the patient under general anesthesia. MAIN OUTCOMES AND MEASURES Postoperative analysis via the χ2 test to assess the statistical significance of association between the palatal index and surgical outcomes. RESULTS Palatal fistula rates correlated directly with the cleft severity, as estimated by the palatal index (P = .01), but there was no association between postoperative velopharyngeal insufficiency and palatal index (P = .76). CONCLUSIONS AND RELEVANCE The palatal index was a good predictor of fistula development in the studied group. There was an association between the cleft severity and tissue deficiency (estimated using this index) and presence of palatal fistula. Further long-term study is needed to evaluate the relationship between the palatal index and maxillary growth.

Comprehensive Surgical Management of Cocaine-Induced Midline Destructive Lesions

This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries. This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdrawal and underwent surgical treatments to restore nasal and palatal morphology and function, and the fourth patient was referred because of acute cocaine-induced destructive lesions and was treated by aggressive debridement. An 18-month drug-free period is planned before beginning any reconstructive procedures in this latter patient. Long-term follow-up showed stable results without relapse of palatal fistulas and good esthetic nasal appearance in all 3 patients undergoing reconstruction. The fourth patient did not show any disease progression and will be monitored for drug withdrawal. Chronic cocaine consumption may cause multiple types of damage to the soft and hard tissues of the midface. Acute lesions must be addressed with aggressive debridement. As a result of chronic injury, the palate and nose are deformed in a very complex way and the vascularity of the remaining local tissues may be compromised or inadequate for flap harvesting. Palatal and nasal reconstructions are very delicate operations and should be addressed separately to maximize the predictability of the result.

Prevalence, Cause, and Location of Palatal Fistula in Operated Complete Unilateral Cleft Lip and Palate: Retrospective Study

To evaluate the prevalence of fistulas after palate repair and analyze their location and association with possible causal factors. Retrospective analysis of patient records and evaluation of preoperative initial photographs. Tertiary craniofacial center. Five hundred eighty-nine individuals with complete unilateral cleft lip and palate that underwent palate repair at the age of 12 to 36 months by the von Langenbeck technique, in a single stage, by the plastic surgery team of the hospital, from January 2003 to July 2007. The cleft width was visually classified by a single examiner as narrow, regular, or wide. The following regions of the palate were considered for the location: anterior, medium, transition (between hard and soft palate), and soft palate. Descriptive statistics and analysis of association between the occurrence of fistula and the different parameters were evaluated. Palatal fistulas were observed in 27% of the sample, with a greater proportion at the anterior region (37.11%). The chi-square statistical test revealed statistically significant association (P ≤ .05) between the fistulas and initial cleft width (P = .0003), intraoperative problems (P = .0037), and postoperative problems (P = .00002). The prevalence of palatal fistula was similar to mean values reported in the literature. Analysis of causal factors showed a positive association between palatal fistulas with wide and regular initial cleft width and intraoperative and postoperative problems. The anterior region presented the greatest occurrence of fistulas.

A Clinical Study of Various Buccinator Musculomucosal Flaps for Palatal Fistulae Closure After Cleft Palate Surgery

This retrospective study describes various buccinator musculomucosal flaps for the repair of palatal fistulae. Twenty-two palatal fistulae were repaired at our institution between 2002 and 2012 by buccinator musculomucosal flaps with superior-anterior or posterior pedicles. Seventeen patients were treated with posteriorly pedicled flaps, 7 of whom had lengthening of the soft palate and 10 of whom had simultaneously repaired severe lateral palatal scarring. Five patients with anterior or midpalatal fistulae were treated with superior-anteriorly pedicled flaps. All but 4 of the 22 patients had satisfactory results. Four patients had recurrent fistulae, 2 resulting from flap tip necrosis and 2 from wound dehiscence. Follow-up was from 5 to 72 months. None of the patients had facial nerve injury, limited mouth opening, or difficulty chewing. We evaluated the factors that could cause complications, such as flap pattern, location of fistula, and size of palate defect. No statistically significant differences were found in the complication rates among different groups. In conclusion, the buccinator musculomucosal flap is reliable and versatile, with rich vascularity and flexible design. The flap is a good option for fistula repair, especially for larger fistulae at the anterior portion of the hard palate or at the junction of hard and soft palate, where surrounding soft tissues are stiff, scarred, and difficult to mobilize.

Extensive nasopharyngeal angiofibromas: the maxillary swing approach

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibromas. A retrospective analysis in a tertiary care center revealed five cases with extensive nasal angiofibromas operated using the maxillary swing approach between 2010 and 2012. All patients had tumor extension to the lateral-most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus, while another had severe temporal lobe compression through the roof of the infratemporal fossa. All patients underwent tumor excision using the maxillary swing approach. Patients were followed up for a minimum period of 1 year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumor exposure and vascular control could be achieved in all cases resulting in complete tumor excision. The mean operative time was 4.5 h. Post-operative healing was satisfactory with palatal fistula formation in two cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibromas and leads to optimal anatomical exposure with minimal morbidity.

Buccinator myomucosal flap in cleft palate repair: Revisited

Objective: To present various ways of transfer and result of buccinator myomucosal flap (BMMF) in primary and secondary repair of palatal cleft and palate fistula. Design: This study has been designed on the basis of a clinical experience and literature search. Route of single or two BMMF(s) transfer was either lateral or posterior to the greater palatine neurovascular bundle. The flap has been used to repair defect in nasal layer, oral layer, or in combined nasal as well as oral layer of the palate. Materials and Methods: More than 160 palatoplasties have undergone palate repair with the use of BMMFs between 1999 and 2011. The analysis includes 98 palate repair. Unilateral flap was used most commonly in primary repair of nasal side of wide unilateral cleft palate (CP); whereas, two flaps were used mostly in primary repair of wide bilateral CP and in secondary palate repair for large fistula. Results: The fistula rate; in primary palatoplasty patients was 4.8% and in secondary palatoplasty patients, it was 8.3%. Good speech has been achieved in primary palatoplasty patients. After secondary palatoplasty also patients had good speech following therapy. Conclusion: The presented technique has been effective in anatomical and functional repair of wide palatal defects primary as well as secondary. The literature has been reviewed along with.

Complications of cleft palate repair and how to avoid them

Introduction: The cleft palate repair is commonly performed procedure in plastic surgery practices. In addition, this is also procedure done by trainees to the senior most surgeons. One of common procedure for trainee who are introduced to cleft lip and palate surgeries. Literature is flooded with articles on complication of cleft palate repair and probable factors influencing it till the latest one, which suggest that we are far from getting desirable results in cleft palate repair. Review: The common complications of cleft palate repair are fistulae, velopharyngeal insufficiency and detrimental effect on maxillary growth. Palatal fistula is commonly stated in literature with variable incidence ranging from 3-40% 1 , with an average of 7-10%. Other complications are poor speech outcome and poor growth potential of maxillary bone due to scars following palate repair. Every attempt needs to be made to avoid complications or reduce the rate of complications. This article reviews the factors and pitfalls that are likely to increase the chances of complication following palate repair. Conclusion: As surgeon we are duty bound to reduce the avoidable complication, specially related to judgment and techniques. However, the complication due to inherent deficiency of tissue like hypoplastic soft palate muscles and poor scarring tendencies leading to complications are not avoidable.

Repair of Oronasal fistula with Split-thickness Palatal graft

A graft is a non-living material or living tissue used for implantation or transplantation to replace a diseased part or compensate for a defect. We repaired a case with an oronasal fistula using split thickness palatal graft on oral side. A 55-year-old man presented an oronasal fistula of the hard palate, measuring 1.0 x 1.2 cm. The fistula was 2 cm posterior to the incisive foramen. The scar tissue around the fistula was unhealthy. A laterally based oral mucosal flap, 2.0 x 1.5 cm, was designed, raised, and transposed to the defect. The secondary defect was covered with palatal plate. The oral mucosal flap was viable, and no sign of recurrence of fistula was noted until one month postoperative. This method can be an alternative in repair of the oronasal defect when any local tissue for repair is not available or insufficient.

Role of Cone-Beam Computed Tomography in Diagnosis and Management of Nasopalatine Duct Cyst

Nasopalatine duct cysts (NPDCs) are the most common nonodontogenic cyst of the jaw, with a reported prevalence of between 1% and 11.6% of all jaw cysts.1 It is believed to arise from epithelial remnants of the nasopalatine duct, the communication between the nasal cavity and anterior maxilla in the developing fetus. For huge NPDCs, total excision is difficult, and there is an increase in the possibility of postoperative complications including submucosal hematoma, wound dehiscence, wound infection, injury to tooth roots, injury to nasopalatine neurovascular bundles, paresthesia of the anterior palate, facial swelling, and oronasal fistula formation. This article discusses a case with a large NPDC, which was managed surgically without any complication. Radiological findings emphasizing the importance of cone-beam computed tomography in diagnosis and optimized treatment planning of NPDCs are discussed.

Repair of large palatal fistula using tongue flap

Large palatal fistulas are a challenging problem in cleft surgery. Many techniques are used to close the defect. The tongue flap is an easy and reproductible procedure for managing this complication. The authors report a case of a large palatal fistula closure with anteriorly based tongue flap.

Comparison of Two Models of Surgical Care for Patients with Cleft Lip and Palate in Resource‐challenged Settings

The Peruvian health system is limited in providing specialized care for patients with clefts because there are an insufficient number of hospitals and few specially trained doctors in rural areas of the country. The most common model of care in these areas is the surgical mission wherein experienced cleft surgeons perform surgeries and teach local doctors. The purpose of this research was to identify the differences in outcome between the surgical mission trip and the referral center model of care provided by the same team. A retrospective analysis (2002-2012) was performed on data from surgical outcomes provided by the Outreach Surgical Center Lima that utilized both models of care (surgical mission and referral center). A total of 935 procedures were performed in 680 patients with clefts who were treated by the Outreach Surgical Center Program Lima since 2002. Patients in both groups were identified from our records (medical records and screening-day registries). All patients underwent a physical examination, had photographs taken, and any unfavorable results and complications were documented. Comparison of categorical variables (including outcomes) between care models was performed using Pearson's χ (2) test or Fisher's exact test when appropriate. In all cases a two-tailed test was performed and the p value for rejecting the null hypothesis (no difference or no association) was set at 0.05. We found significant differences between the two models of care with respect to unilateral cleft lip and cleft palate dehiscence (p = 0.02 and p = 0.04, respectively), palate postoperative hemorrhage (p < 0.01), and palatal fistula (p < 0.01) outcomes. Differences in observed surgical outcomes between the two models might be attributed to the surgeon's performance and/or the patient's age, and these factors are also considered with respect to the model of care. Limitations in long-term medical evaluation at each site should be identified and strategies to improve surgical outcomes must be developed to ensure that patients served by surgical missions obtain the same results achieved at a referral center.

Impact of Obturation of Palatal Fistulae on Speech Quality and Aerodynamic Parameters in Patients with Cleft Palates

Objectives: The aim of this prospective study was to measure nasal and oral airflow during speech, before and after obturation. Patients and Methods: Included were children aged 3-18 years with nonsyndromic clefts and palatal fistulae. The corpus used was: syllable /pi/; a sentence containing stop consonants and a nasal phoneme; and the description of a picture of a scene. Analysis criteria were: percentage of nasality; value of average flow for the explosion; perceived nasality and intelligibility; and tolerance of the proposed device. Results: Only 5 children were included due to the observation of an increase in the percentage of nasality after obturation. The value of average flow for the explosion increased in all patients. A decrease in perceived nasality was noted in all but 1 patient. An improvement in intelligibility was observed in 3 out of the 5 children. The tolerance of the device was good. Conclusion: While the small number of patients studied does not permit firm conclusions concerning the efficiency of the obturation, the method described, as well as the introduction of ‘speed of explosion' of stop consonants, offer new perspectives to prospectively study obturator effects on speech.

The use of heterogeneous acellular dermal matrix in the closure of hard palatal fistula

ObjectiveThe aim of this study was to evaluate the efficacy of closure of hard palatal fistula using Heal-All® Oral Biofilm, a heterogeneous acellular dermal matrix graft. Patients and methodsSuperior lip mucosal or myomucosal flap and buccal myomucosal flap were used in 20 patients (group 1) (2000–2005); whereas, heterogeneous acellular dermal matrix graft was performed in 18 patients (group 2) (2005–2013). The recurrence in the closed fistula and the obliteration of gingivolabial and gingivobuccal sulci were seen postoperatively with follow-up appointments at 1–3 months for all cases. ResultsThe recurrence rate of hard palatal fistula has been reduced from 25 to 11.1% with the use of heterogeneous acellular dermal matrix graft, and the rate of the obliteration of gingivolabial and gingivobuccal sulci has been decreased from 90 to 5.5%. ConclusionsClosure of hard palatal fistula using Heal-All® Oral Biofilm graft is a useful method with high success rate. It is a day-case procedure especially to avoid dividing the pedical of the flap after follow-up, and the gingivolabial and gingivobuccal sulci do not need further procedures to deep with follow-up.