Ear, Nose & Throat Journal2023, Vol. 102(4) 268–271© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/0145561321997607journals.sagepub.com/home/ear
Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).
Keywordsoronasal fistula, cleft palate, recurrence, repair, endoscopic
The untreated alveolar cleft may be associated with concomitant oronasal fistulae, crowded dentition, and a lack of bony support for the anterior teeth.1 The techniques used for fistula repair include local palatal flaps, modified palatoplasty techniques, regional flaps, and vascularized tissue transfers. Recently, inter-positional barriers have been used as an adjunct to repair fistulae.2,3 However, oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37%, and it remains a challenging problem for surgeons.4 Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity.
Therefore, we report our multilayered technique to close an oronasal fistula using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap, and the associated minimal morbidity without recurrence.
A 47-year-old male patient presented to the otorhinolaryngology clinic with an upper gingival opening unexpectedly detected while he was having a denture fitted. An upper alveolar sulcus opening and another opening at the nasal floor were confirmed by oral cavity examination and under nasal endoscopy, respectively (Figure 1). To examine structural abnormalities, such as fistula, we performed a paranasal sinus computed tomography. Radiologic examination revealed a fistulous track in the anterior maxilla that eroded into the upper alveolar sulcus, leading to nasolabial communication, nasal septal deviation to the right, and concha bullosa in the right middle turbinate on radiologic examination (Figure 2). The consultation progressed to debridement and flap coverage of the upper alveolar sulcus. Surgery to repair the nasolabial fistula was performed by a plastic surgery team. To determine the flap size, the nasal floor side opening of the nasolabial fistula was measured with a tapeline. After the injection of 2 to 3 mL of lidocaine containing 1:100 000 adrenaline, the inferior turbinate was partially excised with turbinate scissors inserted through a nostril. The anterior part of the inferior turbinate was partially removed for a composite graft to cover the fistula opening in the nasal cavity (Figure 3). The operation of the upper alveolar sulcus aspect of debridement and local advance flap was completed using the design of the plastic surgery team. The placement of the incisions in designing palatal mucoperiosteal flaps is influenced by the width of the defect and availability of the oral mucosa. Sufficient mucosa should be retained at the edge of the cleft to the tension-free margin. After infiltration of 0.5% lidocaine with adrenaline 1:100 000, an incision was made along the edge of the palate. The edge of the fistula was debrided with a no. 15 blade, and the decision regarding the nasal and oral lining was based on the defect width. The mucoperiosteal flaps were elevated starting from the defect edges and proceeding to the oral mucosa of the lip (Figure 4). After incision in the oral mucosa, the fistula lining was released using a right-angled periosteal dissector. Repair with a composite-free graft under the nasal endoscope was performed by suturing the inferior turbinate flap in the opening after a debridement (Figure 5A). On follow-up, 3 weeks after the surgery, there was no specific finding on the nasal flap site with a well-healed state (Figure 5B, see Video, Supplemental Digital Content 1, which demonstrates the whole procedure).
An alveolar cleft is a common congenital deformity with an incidence of 0.18-2.50 per 1000 births and presents in approximately 75% of cleft lip and palate patients.5 Genetic and environmental factors may cause incomplete fusion of the maxillary and intermaxillary prominences, resulting in an alveolar cleft.6,7 The existence of an alveolar cleft may impact facial symmetry, development of the dentition, speech, and oral hygiene.8 However, oronasal fistula following cleft palate repair is a considerable complication with a high recurrence rate.4 Oronasal fistula is a persistent opening between the nasal and oral cavities, as defined by Cohen et al, due to a failure of healing or a breakdown of the primary surgical repairs.9 Significant functional consequences of palatal fistula include nasal regurgitation of liquid/food, chronic inflammation, hypernasality, and velopharyngeal incompetence as well as hearing loss. Multiple etiologies have been proposed for the formation of fistula, including tension along the palate repair, hemorrhage, absent multilayer closure, upper respiratory infection, and increasing cleft severity.9,10 Various factors have been reported to influence the occurrence of such fistulae, such as experience of the operating surgeon, age of the patient, and type of palate repair being performed.11 Due to scarring and poor vascularity of adjacent tissues from prior surgical procedures, recurrence rates increase in the second or further procedures. Small fistulae can be managed by local turnover flaps, pedicled flaps from the oral mucosa, buccal fat pad flaps, inter-positional cartilage grafts, and larger fistulae can be treated with tongue flaps, temporalis muscle flaps, musculo-mucosal flaps, nasal septal flaps, and free flaps. These procedures are often cumbersome and render a raw nasal or oral surface, which may increase the incidence of postoperative complications or some flaps can be bulky and may require a second-stage procedure. Therefore, we had to choose an appropriately sized nearby flap for nasal fistula closure.
In our case, the patient had a small fistula during observation. However, after removing the superficial scarring and debridement, we observed a defect of more than 2 cm. The depth was approximately 1 cm because of a bony defect. We decided to perform a multilayered closure including bone grafting to prevent recurrence. We designed the endoscopic nasal composite graft and oral mucoperiosteal flap simultaneously.
There are several reasons for choosing an endoscopic nasal composite graft with multilayered repair. First, the endoscopic procedure was useful in repairing the nasal area because the nasal cavity is narrow and the fistula is 3-dimensional. Therefore, an angled endoscope is effective in sorting through the shape, depth, and margin of the nasal fistula in detail. We can gain a good field of vision through the endoscope and a good angle for measuring the defect shape and performing a tight repair. It can be continued to prevent recurrence and minimize morbidity.
Second, We chose the composite graft because of the bony buttress to support the nasal floor, sealing the dead space between the nasal and oral cavities. The composite graft had a bulky soft tissue. Therefore, we could fill the dead space using these tissues. Although the ICBG is considered the gold standard graft for the secondary alveolar bone graft (SABG) procedure, it has some noted disadvantages. Donor site morbidity at the iliac crest is significant, such as postoperative pain and sensory disturbance, and this results in a prolonged hospital stay.12 There is also unavoidable bone absorption of the ICBG. It has been reported that the bone absorption rate could be more than 40% at 1 year after SABG, which may increase the need for reoperation.13,14 However, a nasal composite graft can easily attach the oral flap to the defect and lead to a reduction in the fistula reoccurrence rate.
Third, the nasal composite graft includes the turbinate bone and mucosa, which is the same tissue in the receipt site. Therefore, for nasal blocking, the postoperative crust and nasal dryness are decreased after the operation. We can see an increase in quality of life.
Nasal graft materials eliminate the need for a second surgical site for bone harvesting, thereby avoiding donor site morbidity. The nasal autogenous graft material is similar to the receipt site on the histological side. After grafting, the healed site had the same nasal mucosa. Therefore, there are minimal crusts, few nasal obstructions, and few postoperative pain. We can close the fistula using an endoscope in the nasal cavity. Therefore, there are no scars cosmetically in the receipt and the donor site.
However, our procedure has several disadvantages. The inferior turbinate composite graft is limited in size. Therefore, it is difficult to cover a large fistula using our tools. It is difficult to cover a fistula that had previously undergone nasal surgery because of the lack of a nasal graft. In addition, a professional ENT surgeon who can suture freely in the nasal cavity using an endoscope is needed.
No standard techniques have been presented, and up to 65% of oronasal fistulae have been reported to reoccur. Therefore, our technique is worth sharing with other surgeons. It will increase the success rate after closure using the small-sized oronasal fistula surgery without complications or recurrence.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea(NRF) funded by the Ministry of Education(2017R1D1A1B04030364).
Boo-Young Kim https://orcid.org/0000-0003-3807-2125
Supplemental material for this article is available online.
1 Department of Otolaryngology, School of Medicine, Ewha Womans University of Korea, Seoul, South Korea
2 Department of clinical Plastic surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
Received: January 29, 2021; revised: January 29, 2021; accepted: February 03, 2021
Corresponding Author:Boo-Young Kim, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Ewha Womans University, Seoul Hospital, Gangseo-gu, Gonghangdaero 260, Seoul 03760, South Korea.Email: 81ungii@hanmail.net
