Ahmed Sabry Ahmed

VOL 13 , NO 1 , JANUREY 2015

SURGICAL CORRECTION OF POSTPALATOPLASTY FISTULAE Ahmed Sabry Ahmed Reconstructive and Plastic surgery Division, General Surgery Department, Faculty of Medicine, AlAzhar University, Damietta.

‫ـــــــــــــــــــــ ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ـــــــــــــــــــــــــــــــــــــ‬ ABSTRACT Palatal fistula, an epithelialised opening in the repair between the mouth and nasal cavity . Palatal fistulation is a common complication after cleft palate repair, it could occur at any site along the line of cleft closure. Postpalatoplasty fistulae represents a functional problem after cleft palate repair. The purpose of the study was to evaluate the results of the methods of palatal fistula using different methods . This study carried out on 15 patients; (one females and 14 males) with, their ages 5 to 28 years. All of them were admitted to our department at Al-Azher University Hospital, Damietta during the period from April 2007 to November 2013. The primary cleft palatoplasty repairs were performed at another institution in 60% of these patients. Many techniques have been proposed for its repair. We also discuss and evaluate the various techniques of repair. The fistulae were completely closed in 13 cases (87%) with breakdown in two cases in group four. Keywords: Cleft palate, Palatal fistulae Correspondence: Dr. Ahmed Ahmed Hassan, El Gawashna Diarb Negm, Sharkia, Egypt. E-mail: [email protected] INTRODUCTION Palatal fistulae after reconstructive cleft palate surgery are a problem for patients and surgeons. The presence of scarred tissues, the absence of local virgin tissues and high rates of recurrence have forced surgeons to consider surgical treatment only for symptomatic patients. (Vanderkolk, 2000) The incidence of after primary repair of cleft palate is relatively high, averaging 10-20% even in experienced hands. These usually occur at the junction of the hard and soft palate According to the location, fistulae are described as anterior fistula, midpalatal fistula, fistula at the junction of the soft palate and hard palate and soft palate fistula (Diah et al, 2007). Another classification based on their size, fistulas may be classified as small (< 2mm), medium (3-5mm) or large (>5mm) (Muzaffar et al, 2001). Palatal fistulae are often symptomatic, depending on the size and location of the fistula. Symptoms include hypernasality of phonation due to audible nasal air escape during speech, leakage of fluids into the nasal cavity, and lodging of food with risk of infection (Honnebier et al, 2000). The main goals of reconstruction of these fistulas are to restore internal oral lining, preserve or improve the function of residual structures (Shetty et al, 2013). Several methods of surgical repair have been described. The choice of these procedures is influenced not only by the amount and condition of the tissue available for repair but

posteriorly or at the premaxillary- maxillary junction anteriorly (Sadove and Eppley, 2006). Its incidence varies widely, ranging from 0% to 68% (Kirschner et al, 2006). Fistula of the palate may occur as a complication for cleft palate repair, it is the second most common complication after velopharyngeal insufficiency, Factors that may contribute to fistula formation are the type of cleft, type of repair, wound tension, single-layer repair, infection and dead space deep to the mucoperiosteal flap. (Tiwari and Sujata, 2006) also by the size and location of the defect (Lee et al, 2003). AIM OF THE STUDY To evaluate the results of the methods of postpalatoplasy fistulae repair using different methods. PATIENTS AND METHODS We have operated on 15 patients, of which 14 were male and one was female aged 5 to 28 years. All of them were admitted to our department at Al-Azhar University Hospital, Damietta during the period from April 2007 to November 2013. The primary cleft palatoplasty repairs were performed at another institution in 60% of these patients . The original defects in our patients included ten cases of unilateral cleft lip and palate and five cases of bilateral cleft lip and palate, the palatal defects were closed - in all cases-by two flap von Langenbeck’s primary push back palatoplasty using mucoperiosteal flaps for unilateral complete clefts of the primary and secondary palate.

36 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL Previous trials at repair of the fistulae were reported in three of our patients. The minimum time interval between fistula repair and last surgery was 6 months . All clinical data were gathered including gender, type of cleft, age at palate repair, symptoms, size, location, type of fistula repair. Severity of palatal tissue scarring was also obtained. Laboratory investigations in the form of complete blood count, renal and liver function tests, serum proteins, blood sugar level. Well informed written consents were taken from the parents. The patients were classified according to the location of the fistula into: Group 1: at labial alveolar ( three cases ). (Fig.1) Group 2: at lingual alveolar fistula (three cases). (Fig. 2) Group 3: at hard palate fistula (four cases). (Fig. 3) Group 4: at junction of soft hard palate fistula (five cases). (Fig. 4) Operations were performed under general endotracheal anesthesia. After placement of Dingman mouth gag palate is infilterated with 0.5% Xylocaine with 1:100,000 epinephrine into the palate mucosa ; In all cases fistula tract was excised to separate the nasal from the oral mucosa at the plane of the palatal bone. In case of fistula of labial alveolar: A myomucosal pedicled flap from buccal surface of the upper lip or the oral surface of the cheek was elevated up to the gingivo-labial fold. The edges of the palatal fistula. The flap was fixed on to the raw area of the palate with fistulous opening in the center. The flap was sutured to the raw desquamated area using the Vicryl sutures 5/0 rounded needle by simple interrupted sutures . The buccal donor site was closed primarily with interrupted 5-0 Vicryl sutures. the crossing pedicles of the flaps crossed the alveolar margin at the site of alveolar margin defects. These pedicles were used to repair the defects after de-epithelialization of the defected sites (El-Leathy and Attia, 2009). In case of lingual alveolar fistula: The closure was carried out in two layers, the first layer is the oral mucoperiosteum which was elevated 1 mm from the edge of the fistula

VOL 13 , NO 2 , APRIL 2015 and inverted so that the mucosal after closure of the nasal side with mucoperiosteum hinge flap,. then the edges sutured together. The second layer is the myomucosal flap from the inner surface of the superior lip near to the fistula. The base of the flap was selected to be medially to facilitate its rotation towards the fistula, dependant on its blood supply from anastomosis between superior labial and lateral nasal branches of facial artery. The length and width of the flap was tailored according to the site and size of the fistula. The flap was rotated backwards passing between the teeth over the site of repaired alveolar cleft and their distal end was then sutured to the refreshed edges of the oral mucoperiosteum around the fistula ( AbdelAziz et al, 2008). In case of fistula in the hard palate: The first layer is the oral mucoperiosteum which was elevated from tissues to the left side of the fistula, the incision started at the anterior end of the fistula and ended at its posterior limit, it was curved and configured to take the size and shape of the fistula, it was inverted as a hinge flap so that the mucosal surface become facing the nasal side, then its free edge sutured to the nasal surface of the right fistula edge. The second layer is the myomucosal flap from the inner surface of the cheek to the right side of the fistula (Abdel-Aziz, 2008). In case of fistula at junction of soft and hard palate: The fistula is closed by raising a hinged semicircular full-thickness mucoperiosteal palatal flap on one side of the fistula. This is sutured to the nasal mucosa around the remainder of the fistula to provide the nasal layer. A transposition flap from the opposite side of the fistula is used for the oral coverage (Anavi et al. 2003). Intravenous fluids were given postoperatively for 24 hours, fluid diet was allowed for one week then oral semisolid foods for another one week before normal feeding was achieved. RESULTS In all cases, the fistula was completely healed at first attempt, with excellent functional results and no evidence of recurrence with a follow up of at least 24months in the first three groups one, two and three. In last group there breakdown of line of repair in two cases . Patients were seen postoperatively at 1 week, with follow-up appointments at 3, 6, 12 and 24 months. 37 | P a g e

Ahmed Sabry Ahmed DISCUSSION Various techniques and treatment modalities have various advantages and disadvantages. The advantage of the buccal flap method is that it can be used when the alveolar ridge is very low and when it is impossible to apply the method of interseptal alveotomy, but buccal flap reduces the depth of the vestibular sulcus, and therefore needs for a vestibuloplasty. The palatal rotation flap is generally accepted that the greater palatine vessels ensure a good blood supply and promote satisfactory healing of the flap. The palatal rotation flap is a reliable and relatively simple method for the repair of oroantral communications in or anterior to the second molar region. However, difficulty usually exists when closure of defects in the third molar area is attempted because rotation is hampered by the vascular pedicle (Lee et al, 2002). Double layered closure provides adequate coverage, added strength and vascularity of the flap and is often desirable (Ahmed et al, 2012). Our results in the first three groups (located anteriorely in hard palate) were 100% this similar to the results were obtained by ElLeathy and Attia, because of using virgin highly vascular new tissue from the neighboring buccal surface of the upper lip up to the gingivo-labial fold or buccal surface of the cheek. The used flap has a double blood supply, first supply is from the pedicle and the second supply is from the raw de-epithelialised surface all around the fistula opening ( El-Leathy and Attia, 2009). While Abdel-Aziz et al, (2008) series has success rate was 91% while 3 cases remained with fistula due to necrosis of the tip of the flap. This due to two factors in the 3 failed cases might have led to the recurrence of fistula, the first is that they had repaired bilateral cleft lip and palate with more tissue fibrosis which may affect wound healing and the second is the large size of the fistula (their lengths were 15 mm for each). Other study done by Tiwari and Sujata, (2006) reported a success rate of 92% for closure of anterior palatal fistula using orbicularis oris musculomucosal flap, while Rintala (1979) treated the condition before by the use of labiobuccal mucosal island flap introduced to the defect along the nasal floor in 5 cases with partial failure only in one. Nakakita, et al (1990) closed palatal fistula by the use of a buccal musculomucosal flap. Complete closure at the first attempt was

VOL 13 , NO 1 , JANUREY 2015 obtained in 69% of the cases though, when the fistulas were large and extended to the anterior hard palate; the results were not as good (36%). In our study in the fourth group (posterriorly located in hard palate) there was complete closure in 60% of cases and complete breakdown in two cases after four weeks postoperatively, most often due to the paucity of local tissue for closure (Guzel and Altintas, 2000) or excessive scarring in the same area as a result of the previous repair or repairs ( Arora et al, 2015). A palatal flap of full thickness enables the closure of a fistula opening with the mucous membrane of the hard palate. Palatal flap contains blood vessels which enable a good blood supply, and with its thickness and width, it covers the site of the fistula better and safer. An advantage of this method compared to the buccal flap method is that no lowering of the vestibule occurs and the flap is firmer and more resistant to trauma and infection (Ehrl, 1980). Disadvantages of this method are the denudation of the palatal surface, pain, and the later appearance of roughness and deepening of this area as a result of secondary epithelization over 2–3 months. The unpleasant complication is necrosis of the palatal flap (Solker et al, 2002). CONCLUSION Oronasal fistula is the commonest complication of cleft palate surgery. The incidence is highly variable though almost always the primary cause remains the same i.e. closure under tension. Symptomatic oronasal fistula is associated with nasal regurgitation and hypernasality of speech. Principle of repair of oronasal fistula is apposition of wellvascularised tissue without tension. Different techniques, starting from local flaps to free tissue transfer have been employed to repair oronasal fistula depending on its site, size and tissue available. In general the recurrence rate of oronasal fistula is around 25%. With better technique and skill, the incidence and recurrence rate of oronasal fistula can both be minimized. REFERENCES 1. Abdel-Aziz, M. (2008): The use of buccal flap in the closure of posterior postpalatoplasty fistula .International Journal of Pediatric Otorhinolaryngology ;72, 1657—1661.

38 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL Abdel-Aziz, M., Abdel-Nasser, W., ElHoshy, H., Hisham, A., Khalifa, B. (2008): Closure of anterior postpalatoplasty fistula using superior lip myomucosal flap.International Journal of Pediatric Otorhinolaryngology 72, 571— 574. 3. Ahmed, M. V., Naz, F., Chand, M. A. U. H., Tambuwala, A., Kaul, D. (2012): Repair of iatrogenic oronasal fistula after periapical surgery. Univ. Res. J. Dent., 2, 83–86. 4. Anavi, Y., Gal, G., Silfen, R. and Calderon, S. (2003): Palatal rotationadvancement flap for delayed repair of oroantral fistula: A retrospective evaluation of 63 cases .Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 96:527-3. 5. Arora, S., Kaul, D., Sayed, A., Sheikh, S., Pingal. C. (2015): Surgical management of oronasal fistula by using two different techniques palatal rotational and labial advancement flap. Universal Research Journal of Dentistry. Vol 5 · Issue 2;140144. 6. Diah, E., Lo, L. J., Yun, C., Wang, R., Wahyuni, L. K. and Chen, Y. R. (2007): Cleft oronasal fistula: A review of treatment results and a surgical management algorithm proposal. Chung Gang Med J. ;30:529–37. 7. Ehrl, P. A. (1980): Oroantral communication: Epicritical study of 175 patients, with special concern to secondary operative closure. Int J Oral Surg.; 9: 351– 8. 8. El-Leathy, M. and Attia, M. (2009): Closure of Palatal Fistula with Buccolabial Myomucosal Pedicled Flap. Annals of Pediatric Surgery, Vol 5, No 2, PP 104108. 9. Guzel, M. Z and Altintas, F. (2000) : Repair of large, anterior palatal fistulas using thin tongue flaps: long-term followup of 10 patients, Ann. Plast. Surg. 45 109—117. 10. Honnebier, M. B., Johnson, D. S., Parsa, A. A., Dorian, A. and Parsa, F. D. (2000): Closure of palatal fistula with a local mucoperiosteal flap lined with buccal mucosal graft, Cleft Palate Craniofac. J. 37 ,2127—129. 11. Kirschner, R. E., Cabiling, D. S., Slemp, A. E., Siddiqi, F., LaRossa, D. D. and

VOL 13 , NO 2 , APRIL 2015

2.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Losee, J. E. (2006): Repair of oronasal fistulae with acellular dermal matrices. Plast Reconstr Surg.; 118:1431–40. Lee, J. J., Kok, S. H., Chang, H. H., Yang, P. J., Hahn, L. J., Kuo, Y. S. (2002): Repair of oroantral communications in the third molar region by random palatal flap. Int. J. Oral Maxillofac. Surg. ; 31: 677– 680. Muzaffar, A. R., Byrd, H. S., Rohrich, R. J., Johns, D. F., LeBlanc, D., Beran, S. J. et al (2001): Incidence of cleft palate fistula: An institutional experience with two stage palate repair. Plast Reconstr Surg. ;108:1515–8. Nakakita, N., Maeda, K., Ando, S. Ojimi, H., Utsugi, R. (1990): Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair, Br. J. Plast. Surg. 43 (4) 452—456. Rintala, A. (1979): Labiobuccal mucosal island flap for closure of anterior palatal fistulae. Case report, Scand. J. Plast. Reconstr. Surg. 13 (3) 480—482. Sadove, A. M. and Eppley, B. L. (2006): Cleft lip and palate, in: J. L. Grosfeld, J.A. O’Neill, A.G. Coran, E.W. Fonkalsrud, A.A. Caldamone (Eds.), Pediatric Surgery, 6th ed., Mosby Elsevier, Philadelphia, pp. 803—812. Shetty, R., Lamba, S. and Gupta, A. K. (2013): Role of Facial Artery Musculomucosal Flap in Large and Recurrent Palatal Fistulae. The Cleft Palate-Craniofacial Journal 50(6) pp. 730– 733. Solker, K., Vuksan, V., Lauc, T. (2002): Treatment of oroantral fistula. Acta Stomatol Croat; 36:135–40. Tiwari, V. K. and Sujata, S. (2006): Orbicularis oris musculomucosal flap for anterior palatal fistula, Indian J. Plast. Surg. 39148—151. Vanderkolk, C. A. (2000): Cleft Palate. In: Achauer BM, Eriksson E, Guyuron B, Coleman 3rd JJ, Russell RC, VanderKolk CA, eds: Plastic Surgery: Indication, Operation, and Outcomes. Mosby: 799– 807.

`

39 | P a g e

Ahmed Sabry Ahmed

VOL 13 , NO 1 , JANUREY 2015

Table 1:clinical series Group

Nasal layer

Group 1 (labial alveolar)

Oral mucoperiosteum from edge of the fisula

Group 2 (lingual alveolar) Group 3 in the hard palate:

Oral mucoperiosteum from edge of the fisula

Group 4 at junction of soft and hard palate:

Oral layer Myomucosal flap from buccal surface of upper lip or oral surface of cheek Myomucosal flap from the cheek

No. of cases

Ooutcome

3

All closed completely

3

All closed completely

Oral mucoperiosteal flap

Myomucosal flap from inner surface of the cheek

4

All closed completely

Oral mucoperiosteal flap from one side of the fistula

Oral mucoperiosteal flap from the opposite side of the fistula

5

three closed completely

Fig.1: A 6 year-old female presented buccalalveolar fistula.

40 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL

VOL 13 , NO 2 , APRIL 2015

a

b Fig.2: A 8 year-old female with lingual alveolar fistula. (a) preoperative view (b) postoperative view after closure of the fistula.

41 | P a g e

Ahmed Sabry Ahmed

VOL 13 , NO 1 , JANUREY 2015

a

b Fig.3: A 5 year-old male presented mid hard palatal fistula. (a) preoperative view (b) postoperative view

Fig.4: A 22 year-old female presented with soft palate junctional fistula.

42 | P a g e

‫‪VOL 13 , NO 2 , APRIL 2015‬‬

‫‪AL-AZHAR ASSIUT MEDICAL JOURNAL‬‬

‫العالج الجراحي للناصور الناشئ عن إصالح سقف الحلق المشقوق‬ ‫أحمد صبري أحمد‬

‫وددة جسادت الخجوٍل و الذسوق‪ ,‬لسن الجسادت العبهت كلٍت طب األشهس دهٍبط‬ ‫إى العالج الجسادً للٌبصؤز الٌبشئ عي حصلٍخ سمف الذلك سىاء كبًج على جهت واددة هي الشفبٍ أو على الجهخٍي ‪ .‬حعخبس أدد‬ ‫الخذدٌبث لجساح الخجوٍل دٍذ أًهب ال حُسضً الجساح أو الوسٌض أو الىالدٌي ‪ ,‬وٌوكي حفبدي ددود الٌبصىز أرٌبء إجساء حصلٍخ سمف‬ ‫الذلك الوشمىق فً هسادلهب األولى كلوب أهكي ذلك‪.‬‬ ‫ُ‬ ‫أُجسٌج الدزاست على ‪ 15‬هسٌض ٌعبًىى هي هرٍ العبهبث‪ .‬أجسٌج عدة عولٍبث حخٌىع دسب هكبى الٌبصىز بئضبفت شسٌذت هي‬ ‫الغشبء الوبطي للشفت العلٍب أو هي الشدق ‪.‬و كبًج الٌخبئج الخئبم كبهل للٌبصىز فً‪ 13‬دبلت‪.‬‬

‫‪43 | P a g e‬‬