Palatal fistulaPalatal fistula

Dr. Hayder H. HindawiDr. Hayder H. HindawiPlastic & reconstructive surgeonPlastic & reconstructive surgeon

Al-Yarmook teaching hospitalAl-Yarmook teaching hospital

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

Definition Definition

IncidenceIncidence

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

ClassificationClassification

1.1. Etiology … Etiology …

( congenital )( congenital )

( post traumatic ) ( post traumatic )

( post inflammatory )( post inflammatory )

( post surgical ) ( post surgical )

2. Size … ( 2. Size … ( Ohsumi-N classificationOhsumi-N classification ) : ) :

Type I … < 2 mm.Type I … < 2 mm.

Type II … 2 – 5 mm.Type II … 2 – 5 mm.

Type III … > 5 mm.Type III … > 5 mm.

ClassificationClassification

3. Site … ( 3. Site … ( Converse classificationConverse classification ) : ) :

- Anterior ( Alveolar ).- Anterior ( Alveolar ).

- Posterior ( Post-alveolar ).- Posterior ( Post-alveolar ).

ClassificationClassification

CausesCauses

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

ComplicationsComplications

1.1. Fluid and food escape.Fluid and food escape.

2.2. Speech defects.Speech defects.

3.3. Teeth mal-positioning and irregularities.Teeth mal-positioning and irregularities.

4.4. Nasal airway obstruction.Nasal airway obstruction.

AssessmentAssessment

- History & Cl. Examination.History & Cl. Examination.- Objective assess.Objective assess.- Imaging … ( lateral cephalometry ) Imaging … ( lateral cephalometry )

( video fluroscopy )( video fluroscopy )

- Nasoscopy … ( rigid ) ( flexible ).- Nasoscopy … ( rigid ) ( flexible ).

Timing of closureTiming of closure

Labio-nasal : - Labio-nasal : -

- Small … 2ndry lip surgery - Small … 2ndry lip surgery

or alveolar bone graft.or alveolar bone graft.

- Large ... < school age.- Large ... < school age. Palatal : - Palatal : -

- Small … ( spontaneous )( delayed ).- Small … ( spontaneous )( delayed ).

- Large … closed early.- Large … closed early.

Methods of closureMethods of closure

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

Methods of closureMethods of closure

* * SurgicalSurgical : :

1. Local tissue repair.1. Local tissue repair.

2. Regional tissue repair.2. Regional tissue repair.

3. Distal tissue repair.3. Distal tissue repair.

4. Free tissue transfer.4. Free tissue transfer.

Surgical repairSurgical repair

• Labio-nasalLabio-nasal … …

- Rotation f.- Rotation f.

- Advancement f.- Advancement f.• PalatalPalatal … …

Surgical repairSurgical repair

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

a – Soft palatal fa – Soft palatal f..

b – Longitudinal fb – Longitudinal f..

c – Transverse fc – Transverse f..

e – Round fe – Round f..

Closure of round fistula by lateral rotational or Closure of round fistula by lateral rotational or transpositional flaptranspositional flap

e – Round fe – Round f..

Closure of round fistula by ‘’ Closure of round fistula by ‘’ RintataRintata ‘’ method ‘’ method

f – Slit-like ff – Slit-like f..

‘’ ‘’ Reid ‘’Reid ‘’ method in closing a slit-like fistula method in closing a slit-like fistula

f – Slit-like ff – Slit-like f..

‘’ ‘’ Gabka ‘’Gabka ‘’ method in closing a slit-like fistuls method in closing a slit-like fistuls

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

Regional tissue transferRegional tissue transfer

1. 1. TongueTongue : :

a/ Free composite a/ Free composite graft.graft.

b/ Tongue flap. b/ Tongue flap.

Regional tissue transferRegional tissue transfer

2. 2. Cheek.Cheek.

3. 3. Lip ( buccal flap ).Lip ( buccal flap ).

4. 4. Nasal septum.Nasal septum.

5. 5. Pharynx.Pharynx.

Distal tissue repairDistal tissue repair

1.1. Naso-labial flap. Naso-labial flap.

22. Forehead flap.. Forehead flap.

33. Neck flap.. Neck flap.

44. Arm flap.. Arm flap.

55. Little finger flap.. Little finger flap.

Free tissue transferFree tissue transfer

1.1. Free radial forearm flap.Free radial forearm flap.

2.2. Free facial forearm flap.Free facial forearm flap.

Surgical closure of Oro-nasal fistula by Surgical closure of Oro-nasal fistula by ‘’ tissue interposition‘’ tissue interposition’‘ ’‘

1.1. Autogenous bone graft.Autogenous bone graft.

2.2. Cartilage graft ( Choncal )( Ohsumi & Cartilage graft ( Choncal )( Ohsumi & Onizuka ).Onizuka ).

3.3. Ossio-integrated implant.Ossio-integrated implant.

4.4. Closure using Closure using ( Dermal – Fat graft ).( Dermal – Fat graft ).

Dermal – Fat graftDermal – Fat graft

Dermal – Fat graftDermal – Fat graft

Dermal – Fat graftDermal – Fat graft

Cartilage graft

Cartilage graft

Conclusion Conclusion 1. THE CONCHAL GRAFT PRECLUDES THE NEED PRECLUDES THE NEED FOR EXTENSIVE LOCAL SURGERY.FOR EXTENSIVE LOCAL SURGERY.

2. MAY ACT AS SUBSTITUE FOR NASAL LINING 2. MAY ACT AS SUBSTITUE FOR NASAL LINING FLAPS.FLAPS.

3. ACTS AS A THIRD LAYER.3. ACTS AS A THIRD LAYER.4. FILL THE DEAD SPACE.4. FILL THE DEAD SPACE.

5. PREVENTS THE COMUNICATION BETWEEN 5. PREVENTS THE COMUNICATION BETWEEN TWO SUTURE LINES.TWO SUTURE LINES.