Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs

The aim of this study was to compare the postoperative clinical and functional outcomes of palatoplasty with three soft palate cleft repairs and analyse the factors potentially impacting these outcomes. A retrospective analysis was conducted on a consecutive series of 337 patients who underwent primary cleft palate repair by palatoplasty modified with either Furlow Z-plasty (P-FZP, n = 77), intravelar veloplasty (P-IVV, n = 110), or combined intravelar veloplasty-Furlow Z-plasty (P-IVV-FZP, n = 150). The postoperative outcomes evaluated included wound healing (complete closure/fistula) and velopharyngeal function. Demographic and surgical data were analysed using both univariate and multivariate analysis. There was no significant difference between the groups with regard to the sex distribution, age at repair, cleft width, cleft type, or follow-up duration. However, relaxing incisions were significantly more common with P-FZP (26.0%) and P-IVV (29.1%) compared to P-IVV-FZP (10%) (P = 0.002 and <0.001, respectively). The complete wound closure rate was significantly higher with P-IVV-FZP (97.3%) compared to P-FZP (88.3%) (P = 0.012) and P-IVV (90%) (P = 0.015). The normal velopharyngeal function rate was comparable for P-IVV-FZP (86.7%) and P-FZP (83.1%), and both rates were significantly better than the rate with P-IVV (73.6%) (P = 0.039 and 0.029, respectively). The cleft type and width were identified as factors influencing postoperative outcomes. In conclusion, it may be appropriate to prioritize the palatoplasty with combined intravelar veloplasty-Furlow Z-plasty whenever feasible.

Oronasal fistula reconstruction using tongue flap with simultaneous iliac bone graft: a case report

The ultimate goal of cleft palate repair is to achieve an intact palate with the separation of the oral and nasal cavities. However, some patients develop an oronasal fistula in the secondary palate after palatoplasty. Postoperatively, a secondary palatal oronasal fistula may develop, leading to functional problems. In this study, we describe a patient with recurrent oronasal fistula and alveolar cleft with multiple failed previous reconstructions at another clinic. The oronasal fistula and alveolar cleft were repaired using a tongue flap and an iliac bone graft, respectively. The patient demonstrated excellent clinical progress with no recurrence of the oronasal fistula at the 1-year follow-up.

Effect of antibiotic pack on hard palate after fistula closure on nasal airflow and reoccurrence rate

This parallel blocked randomized controlled trial was done in two groups of 30 patients each to determine if placement of an antibiotic oral pack on the hard palate after hard palatal fistula repair reduces nasal air emission and fistula re-occurrence. Group A had an oral pack on the hard palate for 5 days post-operatively while group B did not. In group A, percentage of nasal air emission was tested using nasometry with and without pack. Paired t-tests were performed to compare nasal emissions for patients with and without pack. Recurrence of fistulas after 6 months between group A and B was tested using odds ratio. Effect of nasal air emission on fistula rates was tested using paired t-tests. There was a significant increase (p < 0.0001) in nasal emission after removal of the pack in group A. Fistula re-occurrence tended to be higher in group B (no pack) than group A but this was not significant (p = 0.242). There was no correlation between nasal air emission and fistula rates. In patients with recurrent fistulae, placement of an oral pack after fistula repair diminishes nasal air emission. Whether this has an impact on re-occurrence of fistulae needs to be investigated further.

Use of a buccinator myomucosal flap and bilateral pedicled buccal fat pad transfer in wide palatal fistula repair: a case report

Primary palatoplasty for cleft palate places patients at high risk for scarring, altered vascularity, and persistent tension. Palatal fistulas are a challenging complication of primary palatoplasty that typically form around the hard palate–soft palate junction. Repairing palatal fistulas, particularly wide fistulas, is extremely difficult because there are not many choices for closure. However, a few techniques are commonly used to close the remaining fistula after primary palatoplasty. Herein, we report the revision of a palatal fistula using a pedicled buccal fat pad and palatal lengthening with a buccinator myomucosal flap and sphincter pharyngoplasty to treat a patient with a wide palatal fistula. Tension-free closure of the palatal fistula was achieved, as well as velopharyngeal insufficiency (VPI) correction. This surgical method enhanced healing, minimized palatal contracture and shortening, and reduced the risk of infection. The palate healed with mucosalization at 2 weeks, and no complications were noted after 4 years of follow-up. Therefore, these flaps should be considered as an option for closure of large oronasal fistulas and VPI correction in young patients with wide palatal defects and VPI.

Three-layered repair with a collagen membrane and a mucosal rotational flap reinforced with fibrine for palatal fistula closure in children

The incidence of postoperative fistula following primary cleft palate repair ranges from 0% to 58%. The reported recurrence rate is between 33% and 37%, and the prognosis of a successful closure declines with each reoperation. Closure of palatal fistulas can be achieved by different techniques depending on its size and the experience of the surgeon. Local, regional and distant flaps are commonly used. Alternatively, or in addition to the previous ones, synthetic materials are becoming very popular nowadays. However, a scarcity of articles explains in detail a simple and effective method in children. We present a case report and the procedure proposed by our pediatric surgery team consisting of a three-layered repair, with a collagen membrane placed over the reconstructed nasal mucosa, and a rotational palatal mucosa flap reinforced with a fibrine sealant. This method is simple, easy to reproduce, effective and has a low rate of complications.

Effects of phenytoin spray in prevention of fistula formation following cleft palate repair

BACKGROUND

The effectiveness of topical phenytoin has been reported for the treatment of oral biopsy ulcers, chemotherapy-induced oral mucositis, and chronic periodontitis. This study aimed to investigate the effects of topical phenytoin 2% on the prevention of fistula formation after cleft palate repair.

METHOD

This randomized clinical trial studied patients with nonsyndromic cleft palate who were referred to a tertiary center and underwent cleft palate repair from March 2010 to February 2015. Patients in the phenytoin group received phenytoin spray 2% for 8 weeks and were compared with an age- and sex-matched control group.

RESULTS

A total of 160 patients in two phenytoin and control groups (n = 80 for each group) were recruited to the study. The mean ages of patients in the phenytoin and control groups were 11.42 ± 1.30 and 11.08 ± 1.25 months, respectively. The results showed that six patients (7.5%) in the phenytoin group and 15 patients (18.8%) in the control group formed fistulas during the 6-month follow-up period. There was a significant difference in fistula formation between the phenytoin and control groups (p = 0.035). Furthermore, fistula size was significantly smaller in the phenytoin group compared with the control group (p < 0.001).

CONCLUSION

More frequent use of phenytoin spray can be considered, although there is insufficient information on the long-term side-effects of the chosen drug.

[Multilayer repair of palatal fistula with an interpositional collagen matrix]

OBJECTIVE

Palatal fistula after the repair of cleft palate appears in 7.7-35% of patients. We present two cases of palatal fistula, detailing a multi-layer repair with an interpositional collagen graft.

MATERIAL AND METHODS

Patient 1: girl with a cleft palate operated using a Furlow technique. A reintervention was performed due to a Pittsburgh type III fistula. Patient 2: male with cleft palate operated using a Furlow technique. A reintervention was performed due to a type V fistula.

RESULTS

We used a multilayer repair with a local rotational flap and the interposition of a collagen matrix between the nasal and oral layers. The suture was reinforced with a fibrin hemostatic adhesive. No recurrence of the fistula after 2 years.

CONCLUSIONS

The three-layer closure is simple, safe, effective and avoids refistulizations. Interpositional grafts of a resorbable collagen membrane provide a "scaffold" for tissue growth, revascularization and epithelialization of the mucosa.

Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates

OBJECTIVE

The objective of this study is to determine whether placement of an antibiotic oral pack on the hard palate reduces fistula rates after primary cleft palatoplasty.

SUBJECTS AND METHODS

This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each with non-syndromic unilateral complete cleft lip, alveolus, and hard and soft palate that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR).

RESULTS

In 2% of the patients in group A, a fistula was found 6 months after palatal surgery. In contrast, in 21% of the patients in group B, a palatal fistula could be confirmed. The fistula occurrence in group A was statistically significantly lower than that in group B (OR = 0.0768, CI = [0.02 … 0.34], p < 0.001).

CONCLUSION

The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days.

CLINICAL RELEVANCE

The use of an antibiotic pack after cleft palate repair can be recommended to prevent occurrence of oronasal fistulae.

Double palatal flap for oro-nasal fistula closure

INTRODUCTION

The management of oral fistula to the nose depends on its etiology, its size and its location. Here, we describe a simple technique, inspired by the ones initially developed by Bardach for cleft palates repair. The surgical alternatives are discussed.

TECHNICAL NOTE

The double palatal flap is a simple technique, allowing closure in a single session of a central or centro-lateral palate fistula. The key of this technique is the dissection between nasal and palate mucous layers, providing a sufficient amount of laxity to close the defect without tension.

DISCUSSION

The double palatal flap can cover centro-lateral palate mucosal fistulae. It provides both aesthetic and functional results in a single stage. Reliability, simplicity and quickness are its main advantages. Outcomes are usually simple; Velar insufficiency may occur, that can be corrected by speech therapy.

Surgical management of lower lip pits in Van der Woude syndrome

Van der Woude syndrome (VDWS) is characterized by the presence of lower lip pits which may be of concern to patients due to aesthetic considerations. By presenting three clinical cases, we provide an overview of the surgical techniques currently available to treat labial pits. Fusiform excision with dissection of the entire pit is still the most commonly used procedure and it generally yields good functional and aesthetic outcomes. The split-lip advancement technique and the inverted T-lip reduction nonetheless represent good surgical alternatives. Proper management of the lower pits that occur with VDWS requires thorough knowledge of the available surgical procedures.

Acquired Palatal Fistula in Patients with Submucous and Incomplete Cleft Palate before Surgery

It is uncommon for a palatal fistula to be detected in individuals who have not undergone surgery, and only sporadic cases have been reported. It is even more difficult to find cases of acquired palatal fistula in patients with submucous or incomplete cleft palate. Herein, we present 2 rare cases of this phenomenon. Case 1 was a patient with submucous cleft palate who acquired a palatal fistula after suffering from oral candidiasis at the age of 5 months. Case 2 was a patient with incomplete cleft palate who spontaneously, without trauma or infection, presented with a palatal fistula at the age of 9 months.

Recurrent Extranodal NK/T-Cell Lymphoma Presenting as a Perforating Palatal Ulcer and Oro-Nasal Fistula

Nasal-type extranodal natural killer/T-cell lymphoma (ENKTL) is a rare disease presenting with non-specific symptoms, typically originating in the nasal cavity, palate, or midfacial region. Oral cavity is an extremely rare site for this type of lymphoma. In this report, we present a case of palatal perforation and oro-nasal fistula as a manifestation of recurrent ENKTL. Complicated disease entity should be considered when surgeons deal with palatal perforation and oro-nasal fistula.