Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals

Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals

Jyotsna Murthy
Department of Plastic Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India

Correspondence Address:
Jyotsna Murthy
Department of Plastic Surgery, Sri Ramachandra Medical College and RI, Porur, Chennai-600 116, Tamil Nadu
India

DOI: 10.4103/0970-0358.81447

Objective: Palatal fistula is a significant complication following cleft palate repair. The guidelines of management of the palatal fistula is dependent on the type of cleft, site of fistula, condition of surrounding tissue and associated problem. We studied the management and outcome of 194 cleft palate fistula in our institute. Design: We present the descriptive hospital-based study of management of palatal fistula in 194 cleft patients. We have excluded all the syndromic children and children whose anterior palate was not operated as per protocol. Settings : Of 194 cleft palate fistula, 37 had palate repair in our hospital and 157 were refereed with fistula following palate repair.The patients were evaluated by interdisciplinary team and plan of management was decided. Result : Various parameters like types of cleft, site of fistula and management of fistula were studied in all the patients. Fifty-two percent were in unilateral CLP and 30% in bilateral CLP because unilateral CLP is the commonest type of cleft. Postalveolar and hard palate region contributing to 67% of all fistulae, followed by junctional in (9%). Seventy-two percent of fistula were amenable for repair by local available tissue, 28% needed tongue flap due to shortage of tissue. Minor numbers have failure of procedure for fistula closure needing further management. Conclusions : This descriptive study present analysis of management of fistula in our institute. It also reinforces that patient with bilateral cleft lip and palate more likely to have shortage of local tissue needing the local flaps like tongue flap compare to other cleft types. The surgical management of fistula can be combined to tackle the associated problems.

Keywords: Palatal fistula; tongue flap; post alveolar fistula

How to cite this article:
Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals. Indian J Plast Surg 2011;44:41-6
How to cite this URL:
Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals. Indian J Plast Surg [serial online] 2011 [cited 2011 May 23];44:41-6. Available from: http://www.ijps.org/text.asp?2011/44/1/41/81447

One of the expected outcomes of palate repair is to achieve complete partition between nasal and oral cavity in addition to good speech. Any failure of achieving complete structural integrity of palate is labeled as an oronasal (palatal) fistula with persistent passage between oral and nasal cavity. The term, palatal fistula, is normally used for residual non-repaired cleft palate or result of breakdown of repaired palate. [1]

Every visible palatal fistula does not need surgical repair. The indications for a fistula repair depend on the associated symptoms, which are in turn related to the size and location of the fistula. The common symptoms which have been extensively discussed in the literature are: 1. Nasal emission causing speech distortions, 2. Leakage of fluid and food into the nasal cavity leading to poor oral hygiene and foul smell. The timing of the fistula repair depends on symptoms like nasal regurgitation, effect on speech and concerned of the patient. It is generally agreed that fistulae causing disturbances in speech should be repaired as soon as possible. A fistula leading to significant regurgitation of fluid/food into the nose, resulting in inflammation of nasal lining and malodor also needs to be repaired early. However, the repair of a small fistula with no effect on speech and occasional regurgitation of fluid/food into nose, can be delayed to be combined with other procedures. Many attempts have been made to classify palatal fistulae according to the site and is the best presented by Cohen et al. [2] Smith et al, presented modified classification and presented fistula in VII categories according to its site with more details. [3]

The speech evaluation by the speech pathologist is essential to diagnose if the fistula is contributing to the speech problems. The speech pathologist also provides information regarding the associated Velo-pharyngeal incompetence (VPI) which may or may not be due to the fistula after closing the fistula with chewing gum temporarily. [4] Similarly, evaluation and suggestions by an orthodontist are essential for a perialveolar fistula. In certain cases, orthodontic treatment e.g., expansion of arches and removal of deciduous or supernumerary teeth may be necessary. This additional information is vital for combining fistula closure with another procedure like VPI correction, alveolar bone graft or lip revision. The factors which need to be studied and examined before fistula repair are presented in [Table 1]. The concerns and complaints of the patients need to be elicited in detail and to be taken into consideration while planning the management.

We analyzed the management of palatal fistula in 194 fistulae in our institute since 2002. Of total 194 fistulae, 37 patients had palate repair in our institute, 157 patients were referred to our institute for fistula repair. Of referral patients, 80% were either detected during camps in rural area or referred by the health workers from rural areas and 20% approached directly to our center for help. Our data were collected as alveolar (which also includes prealveolar and postalveolar), hard palate, combined postalveolar extending to hard palate, junction, soft palate and combination of hard and soft palate fistula. In view of this being a retrograde study, we presented the data according to these sites mentioned above. A small uvular notching or bifid uvula was not considered as fistula, but uvular breakdown was considered as soft palate fistula because majority of them will need repair of soft palate. Of 2387 palate repairs in our institute, 2067 patients were followed up at least once postoperatively within 1 year and 75 had fistula. Out of 75 patients, we have excluded 38 patients with small, non-symptomatic postalveolar defect which was not repaired as the protocol (no anterior palate repair with lip repair) in our institute between 2001 and 2003. However, the significant postalveolar fistulae in these patients which needed closure were considered as a fistula and included in the study. This protocol was changed thereafter due to higher percentage of postalveolar fistula needing closure. Hence, 37 patients had cleft palate repair in our institute, needing fistula repair were included in this study. We also excluded syndromic cleft lip and palate patients having associated with cardiac anomalies, ectodermal dysplasia and Pierre Robin sequence with compromised airway. Eight patients with total breakdown of palate with severe shortage of tissue, who needed the simultaneous tongue flap and pharyngeal flaps, [5] were excluded from this study.

As discussed above, the decision for surgical repair of palatal fistula was done after proper evaluation [Table 1]. The previous surgical techniques, scarring and shortage of tissue, inflammation of tissue and oral hygiene, availability of local tissue and concomitant planned procedures were considered to decide the timing and the surgical procedure for the fistula repair. For fistula in hard palate or junctional area, if adequate local tissue was available, it was closed by the mucoperiosteal flaps with releasing incisions like in Von Langenbeck palatoplasty. [6] In large fistulae and/or fistula extending in postalveolar and alveolar region were closed by two-flap technique and preferably with alveolar extended palatoplasty. [7],[8] Alveolar extension palatoplasty (AEP) flaps were extremely useful [Figure 1]a for fistula in postalveolar region. The AEP flaps could be raised cautiously even in the presence of the previous scars between mucoperiosteum flaps and its extension into alveolus [Figure 1]b. However, an interval of 6 months or more between the palate repair and the fistula repair by AEP flaps is necessary. Figure 1a: Incision for alveolar extension palatoplasty
Figure 1b: Fistula repair by alveolar extended palatoplasty

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For the large fistulae with a shortage of tissue and/or severe scarring preventing mobilization of the palatine tissue, an additional tissue was imported as local flaps according to the site of fistula. For postalveolar or anterior hard palate fistulae, where additional tissue was needed, an anteriorly based tongue flap were done [9] [Figure 2]. The tongue flaps provided oral lining, while the nasal lining was repaired with turn-over flaps from the fistula edges (hinge flaps) and this step was of paramount importance to prevent recurrent fistulae. The tongue flaps were routinely divided between 10 and 12 days, postoperatively.

Patients needing VPI correction and/or with a scarred/broken soft palate with fistula had nasoendoscopy for the structural evaluation. In severely scarred and broken soft palate with large nasopharyngeal defect on endoscopy, a superiorly based pharyngeal flap was used to add tissue for the nasal lining for the soft palate which also helps to improve velopharyngeal competence.

In a situation with failure of multiple attempts of fistula repair, refusal for surgery by patients and associated demands for a tooth prosthesis, prosthetic cover for a fistula was used.

We have analyzed the type of cleft, location of fistulae and type of surgeries performed in all the patients.

We studied distribution of fistula in various types of cleft lip and/or palate as shown in [Table 2]. In our institute, we had comparatively higher fistula occurrence in submucous cleft (6% of total 37 patients). In retrospection, it was noticed that sutures were put in thinner hypoplastic mucoperiosteum, which should have been excised.

The distribution of site of fistula in all 194 palatal fistulae showed most common site is hard palate and in postalveolar region contributing to 67% of all fistulae. This was followed by exclusive postalveolar region (9%) and junctional area [Table 3]. Table 3: Site of fistulae, procedures for fistula repair and adjuvant procedures

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As the majority of the fistula were repaired by different procedure depending on the size of fistula, the availability of local tissue and necessity of adjuvant procedures. The procedures like local flap, Von Lagenback repair, two flap, AEP, palate repair and tongue flap were done to close the fistula. In 65 patients fistula repair was combined with other procedure like VPI correction, ABG and lip revision [Table 3].

Out of total 194 patients had fistula repair, 48% had followed up and 10 patients had residual fistula. All these patients had very poor local condition and oral hygiene. Two of these were operated by AEP flap closure for postalveolar fistula and eight had tongue flap. Of two with AEP flap, one had successful closure with revision surgery while one had prosthetic rehabilitation. Eight out of 54 patients with tongue flap had postoperative problems. Five patients had flap detachment in postoperatively period. Four out of these five patients were resutured in the first 10 days, and two had complete closure while two had persistent fistula. One patient has revision tongue flap after duration of 8 months successfully. Remaining three patients had residual fistula at the posterior border of tongue flap observed during follow-up.

Although palatal fistula is a common morbidity after cleft palate repair, minimal literature is available regarding the guidelines of management. Palatal fistula is a complication of cleft palate repair observed in different studies ranging from 0 to 34%. [2] We have analysed the descriptive data of type of cleft, site of fistula and management of fistula in our institute. From this data, we learned that smaller fistula are tend to be managed in the same hospital, while the larger fistula are more likely to go to specialized center or tertiary center due to difficulty in management and needing multidisciplinary care. The larger fistulae in difficult site like perialveolar region tend to be neglected and need interdisciplinary care in tertiary centers.

Management of cleft palate fistula is multidisciplinary approach and proper evaluation of speech and dental arch in addition to the local tissues are very essential. The functional aspect of the fistula should be given appropriate attention before a decision is reached on its structural surgical repair. After proper evaluation and decision regarding surgical repair, one needs to pay attention to the local tissue condition. The previous surgical techniques, scarring and shortage of tissue, inflammation of tissue and oral hygiene, availability of local tissue and concomitant planned procedures will decide the type of procedure for the fistula repair [Figure 3]. This approach will help to decide the proper timing and appropriate technique for surgical repair. Tongue flap has been a work horse for difficult palatal fistula with shortage of tissue. Similarly, buccal flaps also known as facial mayo-mucosal flap, is the most appropriate for junction fistulae if there if shortage of tissue. We have used the buccal flap for VPI correction but not for fistula repair. However, if utilized in junctional fistula, this will also help to lengthen the palate for VPI correction at the same time. [10],[11] Other flaps which has been described and utilized very rarely in specific indication are, temporalis muscle flap and free microvascular free flaps. [12],[13] However, the later options are more commonly utilized in closing non-cleft palatal reconstruction.

In certain situation like failure of multiple attempts of fistula repair, refusal for surgery by patients and associated demands for tooth prosthesis, the prosthetic cover for fistula can be applied. However, prosthesis can never provide nature barrier like tissue repair and has implication on oral hygiene and dental health.

 
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Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: A multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991;87:1041-7.  
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[PUBMED]  [FULLTEXT]  Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, et al. Papaioannoua: incidence of cleft palate fistula: An institutional experience with two-stage palatal repair. Plast Reconstr Surg 2001;10:1515-8.  
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[PUBMED]  [FULLTEXT]  

[Figure 1], [Figure 2], [Figure 3]

[Table 1], [Table 2], [Table 3]

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Management of palatal fistulae

Management of palatal fistulae

Michael H Carstens
Associate Professor of Plastic Surgery, Saint Louis University, Missouri, USA

Correspondence Address:
Michael H Carstens
Department of Plastic Surgery, Saint Louis University, Missouri
USA

DOI: 10.4103/0970-0358.81445

How to cite this article:
Carstens MH. Management of palatal fistulae. Indian J Plast Surg 2011;44:46-9

This retrospective analysis presented by the Sri Ramachandra craniofacial team raises several important issues for all cleft surgeons. First, palatal fistulae continue to be a common management problem. Second, the classification systems currently applied to cleft lip and palate are empiric, archaic, and misleading. Third, without a classification system based on embryologic mechanism, accurate appreciation of outcomes data generated by cleft palate (CP) surgery (i.e., surgical complications and speech) will remain chaotic. Fourth, the distribution pattern of fistulae is directly related to the technical problems engendered by the primary surgery. Fifth, the low incidence of fistulae reported in the Sri Ramchandra Medical College (SRMC) patients vs. those referred from other location points out the importance of surgical protocol and concentration of expertise. Sixth, the best treatment for palate fistula is prevention using dissection techniques based on developmental anatomy of the cleft and executed with precision. Seventh, established fistulae require the same careful embryologic analysis; closure unusually involves a reapplication of techniques that should have been employed at the primary operation.

Fistula rates reported in the literature range as high as 58% with a recurrence rate of nearly 33%. [1] These by definition result from a prior surgical procedure. Does particular operation predispose to fistula formation? The problem is complicated by a worldwide lack of consensus regarding a treatment protocol. Surgical management has been studied from the standpoint of timing (early vs. late) [2],[3] and staging [4],[5] but not by embryologic mechanism. In short, raw data regarding what factors are associated with a fistula is difficult to interpret.

The problem comes from our inability to stratify clefts by embryologic mechanism. A CP resulting from a small vomer is different from one involving a deficient palatine bone. Soft palate clefts involving the tensor alone can have perfectly good constrictor function. A submucous cleft with global involvement of third arch muscles will have a radically different prognosis. In short, continuing to compare apples with oranges makes outcome analysis unreliable.

CPs come in different flavours. Anatomic defects seen in CP involve distinct developmental fields, each of which contains a variety of tissues: epithelium, dermis and submucosa, cartilage, bone, fascia, and muscle. Regardless of content, the tissues in each developmental field share a common neurovascular supply. Knowledge of the nerve supply to any given field allows one to determine precisely where it originates in the embryo. [6],[7]

Two types of mesenchymal structures contribute to development of the hard and soft palate: neural crest bone fields and paraxial mesoderm muscle fields. These, in turn, can be related to the developmental sector of the CNS that supplies innervation. These sectors are known as neuromeres and their individual nomenclature comes from the names applied to the original three-part embryonic brain.

All components of the hard palate, both hard and soft, are supplied by nerves having their nuclei within the hindbrain or rhombencephalon. The bones and muscles of the palate are developmentally linked to 12 rhombomeres (r0-r11). For example, all bones of the palate are innervated by V2, the nucleus of which resides in the second rhombomere. Thus, neural crest cells destined to become premaxilla, vomer, inferior turbinate, prepalatine, palatine, and maxilla all rise in the neural fold directly above r2. Clefts involving the hard palate result when deficits in one or more of these populations create palatal bone fields that are malformed, small, or downright absent.

In a similar way, all striated craniofacial muscles develop from paraxial mesoderm (PAM) lie down along both sides of the CNS. PAM begins with the hindbrain at the level of r0 (the future isthmus and pituitary) and extends backward all the way to the tail. Just as the neuraxis is segmented into neuromeres, PAM is also segmented into hollow balls called somitomeres. Sm1-Sm7 give rise to the extraocular muscles and the muscles of pharyngeal arches 1-3. Since these somitomere are incompletely separated, a potential confluence of the mesenchyme exists. This explains why the muscles of the second arch migrate widely over (and under) those of the first arch.

Beginning with the eighth somitomere, the mesoderm undergoes a further rearrangement. The result is that Sm8 becomes the first somite. All somites are surrounded by epithelium and contain subunits: bone-forming sclerotomes, dermis-forming dermatomes, and muscle-forming myotomes. The muscle content of all mammalian somitomeres and somites has been mapped out. Thus, Sm4 provides tensor veli palatini. All remaining soft palate muscles (including superior constrictor) arise from Sm7. Clefts of the soft palate result when deficits in one or more of these mesodermal populations create muscle fields that are malformed/mal-innervated, small, absent, or downright absent.

Fistulas are man-made creations. They result from inadequate surgical dissection of soft tissues from the margins of the cleft. Two anatomic sites are typically involved. Trouble is most often seen along the primary palate, with overlap into the adjacent secondary palate. In the SRMC series, anterior hard palate fistulae were encountered in 77.5% cases. In most cases, this results from failure to achieve control of the anterior nasal floor. Primary surgery, be it for the cleft palate or for an associated cleft lip, is the "golden opportunity" to access the anterior palate. After the primary repair (and with further growth) approximation of the palate margins makes dissection of the nasal layer more difficult.

The other common site of fistula formation is the posterior margin of the hard palate. Here, once again, the problem is one of the inadequate mobilization. The horizontal plate of the palate bone, normally having a rectangular shape, is often attenuated into a triangle. The mucoperiosteum of the nasal floor is tractioned forward. Confluence of soft tissues between the vomer and the hard palate presents difficulties as well. The stakes get higher when a Furlow Z-plasty is used for a primary palate repair. Clefts of moderate to severe width do not lend themselves well to this technique. Tissue loss and breakdown at the junction pose challenges for the most experienced operator.

SRMC reports one-year follow-up in 2067 patients with only 37 fistulae (1.9%). This number is no accident. First and foremost, reduction of fistulae by SRMC team is designed with extensive experience and careful dissection. However, it must be stated that any cleft surgeon can achieve similar results, provided that she/he slows down and targets dissection of the anterior and posterior palate margins to achieve a tension-free, watertight closure.[Table 1], [Table 2]

With these results as a benchmark, what steps can be taken to prevent fistula formation? Recalling the sporting dictum "the best defense is a good offense," the goal should be to seal up the nasal lining of the anterior palate. This is done by dissecting out, and uniting, two adjacent neuroangiosomes: medial sphenopalatine and lateral sphenopalatine. This concept lies at the heart of DFR (developmental field reassignment) cleft surgery. [8],[9]

The Medial Sphenopalatine artery (SPA M ) flap consists of mucoperiosteum of the vomer in continuity with that of the posterolateral "shoulder" of the premaxilla. These two components are, in turn, continuous with the soft tissues of the non-philtral prolabium (NPP). Lateral Sphenopalatine artery flap SPA L is the mucoperiosteal lining of the nasal hard palate. After SPA M and SPAM are united, NPP is folded sideways 90 degrees and sutured anteriorly, thus lengthening the nasal floor. The NPP flap contains mesenchyme originally designated for the premaxilla, specifically the lateral incisor zone and frontal process zones.

Elevating the mucoperiosteum from the nasal aspect of the palate is like putting the bell on the tiger; it sounds easy in theory but proves difficult in execution. Intraoral access gets trickier the more anterior one proceeds. Extraoral access proves a useful alternative. An incision in the lateral nasal wall just anterior to the inferior turbinate (and behind the nostril sill) accomplishes two goals: (1) external rotation of the nostril sill and (2) direct access to the piriform rim and the palatal shelf. One first slides an amalgam packer or angled elevator posteriorly just beneath the turbinate anterior and proceeds posteriorly all the way to the soft palate. Next, one takes the dissection medially elevating the nasal mucoperiosteum from lateral to medial. Finally, one incises along the cleft margin to elevate the flap.

Note that the above manoeuvres can be readily accomplished during initial surgery in three scenarios: (1) complete closure of the CP (with cleft lip repair performed secondarily; (2) as part of a lip adhesion procedure for a wide alveolar cleft; and (3) during DFR (developmental field reassignment) cleft lip repair.

Turning our attention to the posterior margin of the hard palate, let us see how the nasal lining can be mobilized. Achieving a complete release may require subperiosteal elevation of lateral nasopharyngeal mucosa. This is accomplished by carefully freeing the nasal lining from the posterior margin of the palatine bone. One then proceeds laterally until encountering the medial pterygoid plate. Here the subperiosteal elevation follows the pterygoid cephalad toward the cranial base. If required, the release can be taken up to the nasal roof. The oral tissues are often tethered with the greater palatine neurovascular pedicle. Under direct vision, the pedicle can be readily isolated. If required, osteotomy of the foramen with a 2-mm osteotome is fast and straightforward. The cuts are U-shaped and directed medially, taking care that the osteotome does not slip downward into the canal.

Regarding secondary fistula closure, we shall proceed from posterior to anterior. A posterior fistula will require release of nasal mucoperiosteum as discussed above. Should it occur in the context of a failed Furlow repair, one may need import of posteriorly based buccinators flaps to fill the deficit. Fistulae in the midportion of the hard palate require isolation of nasal lining, turning it inward carefully. Advancement of mucoperiosteal for oral closure is assisted by an Alveolar Extension Palatoplasty (AEP) -type gingival release. The extra tissue harvested from the lingual margins makes AEP flaps wider that those produced by Von Langenbeck technique. [10] When the fistula is anterior, AEP flaps need to be taken anteriorly, all the way to the cleft margin. Since the AEP flaps can be so readily mobilized, one should "cheat" when incising along the cleft margin. The incision can be designed to favour the oral side of the cleft by several millimetres, thus providing extra tissue to turn into the floor of the nose.

Finally, it is worth noting that the preponderance of patients in this paper presents as outside referrals (cleft camps, etc.). These patients are more likely to have recalcitrant fistulae. In many instances, their previous surgical management is unknown. In like manner, the fistula rate for this subset of patients is unknown. Those patients collected from within the SRMC system are a much smaller fraction of the total clefts performed. Their surgical treatment follows a known protocol. It would be interesting to separate out the distribution of clefts between the two groups to see if the fistulae seen in the SRMC versus those of the referral patients follow different patterns.

In summation, this reviewer would like to congratulate the SRMC team for a careful analysis of palatal fistulae. The two groups represent very different surgical approaches (eclectic vs. standardized). Further study of this experience will undoubtedly prove rewarding. This commentary is designed to highlight common anatomic pitfalls in CP repair and how these can contribute to a fistula. Surgical techniques based upon an understanding of developmental anatomy are valuable to prevent fistula formation and to reconstruct fistulae when these are encountered.

 
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Carstens MH. Sequential cleft management with the sliding sulcus technique and alveolar extension palatoplasty. J Craniofac Surg 1999;10:503-18.  
[PUBMED]    

[Table 1], [Table 2]

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