Palatal fistula Dr. Hayder H. Hindawi Plastic & reconstructive surgeon Al-Yarmook teaching hospital

Definition * Fistula is an abnormal communication between oral and nasal cavities lined by epithelial cells. * Heeling by first intention is the goal of the plastic surgeon. * Surgical failure is considered when fistula occurs anywhere along the site of repair.

Incidence After complete unilat. Cleft 7.7%. After complete bilat. Cleft 12.5% After incomplete cleft 4.6% After late closure 35%

Classification Etiology … ( congenital ) ( post traumatic ) ( post inflammatory ) ( post surgical )

Classification 2. Size … ( Ohsumi-N classification ) : Type I … < 2 mm. Type II … 2 – 5 mm. Type III … > 5 mm.

Classification 3. Site … ( Converse classification ) : - Anterior ( Alveolar ). - Posterior ( Post-alveolar ).

Causes 1. Local factors : - Tension. - Hematoma. - Infection. 2. General factors : - Systemic disease. - Steroids. - Resp. T. I.

Complications Fluid and food escape. Speech defects. Teeth mal-positioning and irregularities. Nasal airway obstruction.

Assessment History & Cl. Examination. Objective assess. Imaging … ( lateral cephalometry ) ( video fluroscopy ) - Nasoscopy … ( rigid ) ( flexible ).

Timing of closure Labio-nasal : - - Small … 2ndry lip surgery or alveolar bone graft. - Large ... < school age. Palatal : - - Small … ( spontaneous )( delayed ). - Large … closed early.

Methods of closure * Non-surgical … ( prosthesis ) ( palatal appliance ) ( Silver Nitrate cauterization ) * Surgical …

Methods of closure * Surgical : 1. Local tissue repair. 2. Regional tissue repair. 3. Distal tissue repair. 4. Free tissue transfer.

Surgical repair Labio-nasal … - Rotation f. - Advancement f. Palatal …

Surgical repair Palatal … a – Soft palatal f. b – Longitudinal f. c – Transverse f. d – Lateral defect f. e – Round f. f – Slit-like f. g – Large fistula in the anterior aspect of the hard palate.

a – Soft palatal f.

b – Longitudinal f.

c – Transverse f.

Closure of round fistula by lateral rotational or transpositional flap e – Round f. Closure of round fistula by lateral rotational or transpositional flap

Closure of round fistula by ‘’ Rintata ‘’ method e – Round f. Closure of round fistula by ‘’ Rintata ‘’ method

‘’ Reid ‘’ method in closing a slit-like fistula f – Slit-like f. ‘’ Reid ‘’ method in closing a slit-like fistula

‘’ Gabka ‘’ method in closing a slit-like fistuls f – Slit-like f. ‘’ Gabka ‘’ method in closing a slit-like fistuls

g – Large fistula in the anterior aspect of the hard palate.

Regional tissue transfer 1. Tongue : a/ Free composite graft. b/ Tongue flap.

Regional tissue transfer 2. Cheek. 3. Lip ( buccal flap ). 4. Nasal septum. 5. Pharynx.

Distal tissue repair 1. Naso-labial flap. 2. Forehead flap. 3. Neck flap. 4. Arm flap. 5. Little finger flap.

Free tissue transfer Free radial forearm flap. Free facial forearm flap.

Surgical closure of Oro-nasal fistula by ‘’ tissue interposition ‘’ Autogenous bone graft. Cartilage graft ( Choncal )( Ohsumi & Onizuka ). Ossio-integrated implant. Closure using ( Dermal – Fat graft ).

Dermal – Fat graft

Dermal – Fat graft

Dermal – Fat graft

C1,a

C1,b C1,c

C1,d C1,e

C1,f

C2,a

C2,b

C2,c

C3,a

C3,b Cartilage graft

Cartilage graft

C3,c

C4,a

C4,b

C4,c

C4,d

C5,a C5,b

C5,c

Conclusion 1. THE CONCHAL GRAFT PRECLUDES THE NEED FOR EXTENSIVE LOCAL SURGERY. 2. MAY ACT AS SUBSTITUE FOR NASAL LINING FLAPS. 3. ACTS AS A THIRD LAYER. 4. FILL THE DEAD SPACE. 5. PREVENTS THE COMUNICATION BETWEEN TWO SUTURE LINES.