[Oronasal fistula in sequels of labialalveolarvelopalatine clefts]

Current insights in the preclinical study of palatal wound healing and oronasal fistula after cleft palate repair

Poor palatal wound healing after cleft palate repair could lead to unfavorable prognosis such as oronasal fistula (ONF), which might affect the patient's velopharyngeal function as well as their quality of life. Thus, restoring poor palatal wound healing for avoiding the occurrence of ONF should be considered the key to postoperative care after cleft palate repair. This review provided current insights in the preclinical study of poor palatal wound healing after cleft palate repair. This review comprehensively introduced the animal model establishment for palatal wound healing and related ONF, including the models by mice, rats, piglets, and dogs, and then demonstrated the aspects for investigating poor palatal wound healing and related treatments, including possible signaling pathways that could be involved in the formation of poor palatal wound healing, the related microbiota changes because of the deformity of palatal structure, and the studies for potential therapeutic strategies for palatal wound healing and ONF. The purpose of this review was to show the state of the art in preclinical studies about palatal wound healing after cleft palate repair and to show the promising aspects for better management of palatal wound healing.

[Palato velar fistulae in cleft palate]

Palatal fistulas after primary closure of a cleft palate are extremely variable ranging from 15 to 35%. When they are symptomatic, these fistulas affect feeding (nasal regurgitation to liquids, discharge, bad smells) and phonation (hypernasality that can hinder the precise assessment of velar incompetence). First of all, it is important to analyze the cause of the fistula, it helps to avoid early recurrences. The correction must apply to respect the 2 mucosal planes (nasal mucosa and oral mucosa), the only guarantee of surgical success. Different techniques are usually described: lingual flap, lifting of all palatal mucosa, flap hinge, blaster, FAMM. In all cases, postoperative care plays a key role in the success of the surgical correction.

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.

Impact of obturation of palatal fistulae on speech quality and aerodynamic parameters in patients with cleft palates

OBJECTIVES

The aim of this prospective study was to measure nasal and oral airflow during speech, before and after obturation.

PATIENTS AND METHODS

Included were children aged 3-18 years with nonsyndromic clefts and palatal fistulae. The corpus used was: syllable /pi/; a sentence containing stop consonants and a nasal phoneme; and the description of a picture of a scene. Analysis criteria were: percentage of nasality; value of average flow for the explosion; perceived nasality and intelligibility; and tolerance of the proposed device.

RESULTS

Only 5 children were included due to the observation of an increase in the percentage of nasality after obturation. The value of average flow for the explosion increased in all patients. A decrease in perceived nasality was noted in all but 1 patient. An improvement in intelligibility was observed in 3 out of the 5 children. The tolerance of the device was good.

CONCLUSION

While the small number of patients studied does not permit firm conclusions concerning the efficiency of the obturation, the method described, as well as the introduction of 'speed of explosion' of stop consonants, offer new perspectives to prospectively study obturator effects on speech.

Therapeutic thoughts on the treatment of sequellae of labial-alveolar-palatal clefts in adult patients-part 2

With a worldwide incidence of 1/750 live births, facial clefts rank as the second most frequent congenital malformation. The term "sequelae" is used here to designate the conditions, which follow and are the result of labial-alveolar-palatal clefts. Most sequelae stem in fact from primary treatment and not from the initial malformation. However, there is no consensus regarding a management protocol. Among the 201 European centers treating this type of malformation, 194 different protocols are used for unilateral facial clefts alone! Unfortunately, primary surgery can trigger a wide range of harmful repercussions. It is for this reason that secondary surgery is called for, generally after the adolescent growth spurt. The aim is to correct the damage done by primary surgery, which can affect the nose, lips, teeth and jaws and impact functions such as speech, breathing and swallowing, as well as morphological and psychological development. Nonetheless, the children concerned are sometimes lost to treatment only to re-emerge in adulthood, aware of the resultant defects and looking for facial esthetic improvement. The sequelae of labial-alveolar-palatal clefts take very different clinical forms according to whether the cleft has been treated or not and the type and timing of the procedures performed. The surgeon's experience will be paramount in the management of such cases, which draws heavily upon dento-maxillo-facial orthopedics. In this context, we intend, in this paper, to propose modalities for the management of labial-alveolar-palatal clefts supported by information currently available in the literature. Management of labial-alveolar-palatal clefts requires an interdisciplinary rather than the only multidisciplinary approach. The practitioner coordinating the management must, like an orchestra conductor, ensure both the rhythm and the tempo of the treatment. The rhythm will determine the choice of chronological protocol and the tempo will govern the timing and importance given to each of the specialists involved. Practices vary from country to country but the orthodontist may be called on to assume this responsibility.

Therapeutic thoughts on the treatment of sequellae of labial-alveolar-palatal clefts in adult patients - Part 1

With a worldwide incidence of 1/750 live births, facial clefts rank as the second most frequent congenital malformation. The term "sequelae" is used here to designate the conditions, which follow and are the result of labial-alveolar-palatal clefts. Most sequelae stem in fact from primary treatment and not from the initial malformation. However, there is no consensus regarding a management protocol. Among the 201 European centers treating this type of malformation, 194 different protocols are used for unilateral facial clefts alone! Unfortunately, primary surgery can trigger a wide range of harmful consequences. It is for this reason that secondary surgery is called for, generally after the adolescent growth spurt. The aim is to correct the damage done by primary surgery, which can affect the nose, lips, teeth and jaws and impact functions such as speech, breathing and swallowing, as well as morphological and psychological development. Nonetheless, the children concerned are sometimes lost to treatment only to re-emerge in adulthood, aware of the presence of the resultant defects and looking for facial esthetic improvement. The sequelae of labial-alveolar-palatal clefts can take on very different clinical forms according to whether the cleft has been treated or not and the type and timing of the procedures performed. The surgeon's experience will be paramount in the management of such cases, which draws heavily upon dento-maxillo-facial orthopedics. In this context, we intend, in this paper, to propose modalities for the management of labial-alveolar-palatal clefts supported by information currently available in the literature. Management of labial-alveolar-palatal clefts requires an interdisciplinary rather than a multi- or pluridisciplinary, approach. The practitioner coordinating the management must, like an orchestra conductor, ensure both the rhythm and the tempo of the treatment. The rhythm will determine the choice of chronological protocol and the tempo will govern the timing and importance given to each of the specialists involved. Practices vary from country to country but the orthodontist may be called on to assume this responsibility.

[Repair of palatal fistulae in cleft patients]

OBJECTIVES

Treatment of oronasal fistulae in cleft patients remains a surgical challenge because of its high failure rate. The authors report the results of an aggressive surgical technique using the total elevation of palatal mucoperiosteum, even for small fistulae.

METHODS

This approach was used on twelve consecutive patients, from five to 33 years of age, presenting with a Pittsburgh classification type IV palatal fistulae. The surgical procedure was total elevation of the hard palate mucoperiosteum starting from the dental sulcus combined with sealed double layer sutures. Clinical and photographical control was made at least 6 months after to detect a possible relapse.

RESULTS

The success rate was 100%. No relapsing fistula was observed with follow-up ranging from 6 to 36 months.

DISCUSSION

This technique allows wide exposure and safe closure of the nasal layer. It is simple and leaves no raw bone surface exposed and no additional scar. The authors think it can be used in all type IV fistulae less than 1cm wide. Several other surgical techniques have been described to close palatal fistulae: local turnover flaps, pedicled flaps from adjacent oral tissue, tongue flaps, tissue expansion, and even free flaps. Obturator prostheses have also been used. The technique we report, even if more aggressive, seems to be more reliable with fewer relapse and sequelae.