Oro-Nasal Communication

Treatment of Adenoid Cystic Carcinoma of the Palate and Reconstruction of Defect With Nasoseptal Flap: A Clinical Case and Review of Literature

Adenoid cystic carcinoma (ACC) is a malignant tumor arising from the salivary glands. While surgery is the mainstay of treatment for ACC of the palate, adjuvant radiotherapy and/or chemotherapy should be considered in high-risk cases. Oronasal fistula, a complication of palatal surgery, may cause speech disturbance and food regurgitation; the nasoseptal flap is a potential option to repair this defect as it is readily available and reliable. Here, we present a case of locally advanced ACC of the palate in a patient who underwent endoscopic-assisted transoral tumor excision with nasoseptal flap reconstruction postoperative chemoradiotherapy.

Managing massive palatial defect secondary to palatoplasty failures: an in-depth analysis

PURPOSE OF REVIEW

Massive palatal defects resulting from palatoplasty failures arising from cleft palate repair complications present ongoing challenges in clinical practice. The purpose of this review is to provide up-to-date insights into aetiology, risk factors, surgical techniques, and adjunctive therapies, aiming to enhance the understanding of such complex cases, and optimize patient outcomes.

RECENT FINDINGS

Primary palatoplasty has fistula recurrence rates ranging from 2.4% to 55%. Factors such as cleft width, surgical repair method, and patient characteristics, influence the likelihood of failure. Classifications such as the Pakistan Comprehensive Classification and Richardson's criteria aid in assessing defects. Surgical options range from local flaps and revision palatoplasty to regional flaps (e.g., buccinator myomucosal, facial artery-based flaps, tongue flaps, nasal septal flaps) to free microvascular flaps. Alternative approaches include obturator prostheses, and acellular dermal matrix has been used as an adjuvant to multiple repair techniques. Hyperbaric oxygen therapy has emerged as an adjunctive therapy to enhance tissue healing.

SUMMARY

This comprehensive review underscores the intricate challenges associated with massive palatal defects resulting from palatoplasty failures. The diverse range of surgical and nonsurgical options emphasizes the importance of patient-centric, individualized approaches. Practitioners, armed with evidence-based insights, can navigate these complexities, offering tailored interventions for improved patient outcomes.

Palatal Stent Following Tumor Ablative Surgery

Mucoepidermoid carcinoma is one of the most prevalent malignant tumors of the salivary glands. Resection of this tumor can result in postsurgical morbidity, affecting the patient's quality of life and normal oral functioning. This study aimed to present a successful case of postsurgical rehabilitation following mucoepidermoid carcinoma resection in the palate. Following tumor ablative surgery, the 32-year-old patient experienced impairments in both speech and feeding due to the surgical wound. A protective stent that covered the entire extent of the palate and teeth was made. This esthetic device was fabricated in a single session and provided sealing and protection of the surgical site, ensuring comfort, functionality, and, consequently, a higher quality of life during the postoperative period. The simplicity and low cost of the custom palatal stent make it applicable for use in a diverse range of postsurgical oncology patients, providing protection for surgical wounds and reducing postoperative morbidity.

Oral Gastric Heterotopia: First Reported Case in the Hard Palate

Gastric heterotopia is characterized by the presence of mature gastric tissue outside the stomach, yet its occurrence in the palate has not been previously documented. We describe a case of gastric heterotopia in the hard palate of an elderly female patient, presenting as a swollen mass with associated secretion. Given the patient's age and clinical symptoms, a presumptive diagnosis of a malignant tumor originating from the minor salivary glands was made. An incisional biopsy of the mass revealed gastric heterotopia. Subsequently, the extended excision of the lesion was performed, leading to the full resolution of the patient's symptoms. After a two-year follow-up period, no evidence of recurrence was observed. The importance of this case, underscored by the unprecedented location of gastric heterotopia, emphasizes the critical need for thorough evaluation to avert misdiagnosis, as well as the complete surgical excision of the lesion to prevent recurrence.

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.

Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

Reconstruction of persistent oronasal communication using an anteriorly based tongue flap following failed cleft palate repair-Report of two cases

The tongue flap is a suitable alternative to local mucoperiosteal flaps in closure of wide, persistent oronasal communications, surrounded by scarred and fibrotic tissue as a result of previously attempted palatoplasty. Herein, we report two cases with large recurrent oronasal communication closed using the anteriorly based dorsal tongue flap.

Auricular Cartilage Graft, An Alternative for Bony Palatal Defect? A Case Report

A 51 year old male patient reported with a chief complaint of nasal regurgitation of fluids since a period of 1 year. Patient was operated once earlier with soft tissue palatal closure following which there was recurrence of symptoms. In this case, the defect was managed with an auricular cartilage graft followed by palatal mucosal closure. The healing was uneventful till the latest follow-up. Rationale of this case report lies in its approach to manage an oronasal communication which recurred following a soft tissue closure. Various management strategies have been applied in literature which included grafts, alloplastic materials and vascular free tissue transfer. Following informed and written consent, Patient was operated under General Anaesthesia and was observed for a follow-up period of 2 years. There was uneventful healing along with improvement in patient's phonation and diet. Complete resolution of nasal regurgitation was achieved. The auricular cartilage graft used for reconstruction in this case is comparatively less invasive and provides an additional advantage of a double layered closure.

Obturator Manufacturing for Oronasal Fistula after Cleft Palate Repair: A Review from Handicraft to the Application of Digital Techniques

An oronasal fistula (ONF) is an abnormal structure between the oral and nasal cavities, which is a common complication of cleft palate repair due to the failure of wound healing. When some patients with ONF are unsuitable for secondary surgical repair, the obturator treatment becomes a potential method. The objectives of the obturator treatment should be summarized as filling the ONF comfortably and cosmetically restoring the dentition with partial function. The anatomy of patients with cleft palate is complex, which may lead to a more complex structure of the ONF. Thus, the manufacturing process of the obturator for these patients is more difficult. For performing the design and fabrication process rapidly and precisely, digital techniques can help, but limitations still exist. In this review, literature searches were conducted through Medline via PubMed, Wiley Online Library, Science Direct, and Web of Science, and 122 articles were selected. The purpose of this review was to introduce the development of the obturator for treating patients with ONF after cleft palate repair, from the initial achievement of the obstruction of the ONF to later problems such as fixation, velopharyngeal insufficiency, and infection, as well as the application of digital technologies in obturator manufacturing.

Buccal fat pad as a sealant in palatal mucosa tearing: technical note

For patients with a dentofacial deformity undergoing a planned segmentation of the maxilla for the management of a transverse maxillary arch discrepancy, palatal mucosa tearing may occur during sawing or palatal expansion traction, giving rise to an oronasal communication. This technical note describes the covering of a tear in the palatal mucosa using a buccal fat pad (BFP) flap, in the context of maxillary segmentation during Le Fort I osteotomy. Through the limited buccal incision used for the Le Fort I osteotomy, a small incision is made in the right periosteum posteriorly, and a supraperiosteal dissection is performed to access the BFP. After a sufficient amount of flap is made available, it is gently introduced through the osteotomy gap until it reaches the palatal mucosa defect and is then sutured. In the patient case presented, the palatal mucosa healed fully within 18 days, and the patient reported no nasal regurgitation of food, defective speech, fetid odour, bad taste, or upper respiratory tract or ear infection during the postoperative period. This technique using a BFP flap should therefore be considered in the context of unexpected tearing of the palatal mucosa in patients undergoing a segmented Le Fort I osteotomy.

Melolabial interpolated island flap for reconstruction of an anterior oronasal fistula after horseshoe Le Fort I osteotomy with iliac bone grafts interposition - A case report

INTRODUCTION

Horseshoe Le Fort I osteotomy (HLFO) in combination with iliac bone grafts interposition is an established and very effective procedure for reconstructing the severely atrophic maxilla. However potential complications connected to this method, such as oronasal fistula (ONF), have not been described in the literature to date.

CASE PRESENTATION

We report the case of a female patient with severe atrophy of the edentulous maxillary alveolar ridge with type 2 diabetes (T2D). Initially, a sinus floor augmentation was performed, followed by a failed placement of dental implants. Afterwards, HLFO with simultaneous interposition of iliac bone grafts was conducted. Subsequently, an oronasal communication occurred in the antral maxilla. As several local flaps had not achieved sufficient results, a melolabial interpolated island flap was carried out, yielding satisfactory results.

DISCUSSION

Failed implant treatment or bone augmentation procedures in combination with T2D may have resulted in significant tissue irritation and subsequent wound healing complications in the antral maxilla, leading to an ONF.

CONCLUSION

In this case, an ONF occurring after HLFO was described for the first time. The melolabial interpolated island flap proved to be an outstanding long-term solution for the management of an anterior ONF occurring after HLFO over a period of 10 years. Less invasive treatment options including zygomatic implants should be taken into consideration for the treatment of such patients.

Two-Layer Palatal Reconstruction Reduces Postoperative Intraoral Complications in Head and Neck Surgery

BACKGROUND

Although microvascular free flaps are commonly performed and have high success rates, postoperative oronasal fistulas or infections do occur. The authors hypothesized that a two-layer closure is effective for prevention of intraoral complications.

METHODS

Patients who underwent palatal reconstruction with a microvascular free flap were evaluated retrospectively. The cases were divided into two groups (palatal reconstruction with or without a two-layer closure). A two-layer closure involves unilateral reconstruction with a free flap, then reconstruction of the nasal lining with a local flap or folding free flap. The postoperative complication rates between these two groups were compared.

RESULTS

One hundred fifty-five cases were evaluated. A two-layer closure was performed in 65 cases (41.9 percent). The incidence of infections, dehiscence of the recipient site, and oronasal fistula were significantly higher in the single-layer closure group than in the two-layer closure group [10.0 percent versus 0 percent (p = 0.011); 15.6 percent versus 4.6 percent (p = 0.036); and 17.8 percent versus 4.6 percent (p = 0.013), respectively].

CONCLUSIONS

A two-layer closure in palatal reconstruction was shown to reduce the rate of infection, intraoral wound dehiscence, and oronasal fistula in the current study. A two-layer closure provides greater support and stability and reduces the risk of failure in reconstruction of the palate with a microvascular free flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Soft Palate Fistula in a Patient With Normal Palate as a Rare Complication After Septoplasty

ABSTRACT

While the formation of a palatal fistula after septoplasty has been reported previously, it is a rare occurrence, especially in a patient with a normal palate. In most of the previous reports, the palatal fistulas were located on the hard palate and associated with various underlying conditions. Here, we present a case of soft palate fistula which developed in a patient with a normal palate after septoplasty. The 20-year old woman complained of liquid regurgitation after her septoplasty procedure. A pin-point size fistula opening was observed on the soft palate. A shallow depression was identified at the junction between the hard and soft palate by a computed tomography scan done before surgery. The fistula was subsequently repaired through a palatal flap. After surgery, the defect was completely closed, and the patient had no more symptoms. In addition, we review the previously reported cases of palatal fistula after septoplasty.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction

OBJECTIVE

To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas.

DESIGN

A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted.

PATIENTS

A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities.

MAIN OUTCOME MEASURES

Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss.

RESULTS

Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions.

CONCLUSIONS

The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Closure of Oronasal Fistula by Palatal Rotational Flap: Case Report with Two Years follow-up

Background/Aim: Hard palate fistulas are due to pathologies such as noma, syphilitic gom, leprosy, leishmaniasis, radiotherapy, removal of cysts or tumors of the sinus or palate, trauma or tooth attraction. Symptoms of palatal fistulas include hypernasality in the phonation due to nasal air escape during a speech, nasal cavity fluid flow, and infection due to food accumulation. Surgical repair of palatal perforations is technically difficult and complicated. Different surgical methods can be used depending on the size and location of the defect. Among these techniques, the locoregional flap types used are palatal flap, nasolabial flap, a buccal fat pad and tongue flap.

Case Report: In this case report, we presented a patient with oronasal fistula due to a previous surgical operation, which was surgically closed by a palatal rotational flap.

Conclusions: As a result, the oronasal communucation was relieved by successful closure of the defect and the donor area healed uneventfully.

Double Tongue Flaps for Anterior Huge Palatal Fistula Closure

Even though it is widely accepted that the tongue flap is effective and feasible for repair of huge palatal fistula, there still exist a few failed cases due to the severity or complicated situation. The aim of this paper is to report the validity and feasibility of using double tongue dorsal flaps to repair a huge anterior fistula. A 10-year-old boy diagnosed with Van de Woude syndrome with repaired bilateral cleft lip and palate presented with a huge anterior fistula divided by septum. A double tongue dorsal flap was designed to cover the fistula. The huge unusual anterior palatal fistula was repaired successfully by usage of double pedicle tongue flaps with a follow-up period of 1 month. The double tongue flap is an alternative choice to handle a large residual fistula in anterior part of palate which was divided into 2 fistulas by septum. This technique was indicated in the situation of large residual fistula in anterior part of palate which was divided into 2 fistulas by septum after bilateral cleft palate repair.

Purse String Suture Closure: A Useful Double-Layer Technique for Closure of an Oronasal Communication

Introduction

Various treatment modalities are reported in the literature for the management of oronasal communication. Single-layer closure often leads to failure and persists a major concern to an operative surgeon. Therefore, double-layer closure is one of the keys to successful management of oronasal communication.

Meterial and Method

A continuous intramucosal running purse string suture at submucosal depth was placed circumferentially around the defect margin with 3-0 round body polyglactin suture as a first layer. Pedicled palatal rotation axial flap based on greater palatine artery was used as the second layer of closure, above the first palatal submucosal layer.

Conclusion

Intramucosal purse string suture technique provides adjacent local tissue for closure of oronasal communication. This technique is easy and can be used as an alternative option for double-layered closure of an oronasal communication, without donor site morbidity and minimal patient discomfort.

The Spectrum of Scarring in Craniofacial Wound Repair

Fibrosis is intimately linked to wound healing and is one of the largest causes of wound-related morbidity. While scar formation is the normal and inevitable outcome of adult mammalian cutaneous wound healing, scarring varies widely between different anatomical sites. The spectrum of craniofacial wound healing spans a particularly diverse range of outcomes. While most craniofacial wounds heal by scarring, which can be functionally and aesthetically devastating, healing of the oral mucosa represents a rare example of nearly scarless postnatal healing in humans. In this review, we describe the typical wound healing process in both skin and the oral cavity. We present clinical correlates and current therapies and discuss the current state of research into mechanisms of scarless healing, toward the ultimate goal of achieving scarless adult skin healing.

Airway management in pediatric tongue flap division for oronasal fistula closure: A case report

Oronasal fistulae (ONF) could remain after surgery in some patients with cleft palate. ONF ultimately requires intraoral surgery, which may lead to perioperative airway obstruction. Tongue flap surgery is a technique used to repair ONF. During the second surgery for performing tongue flap division, the flap transplanted from the tongue dorsum to the palate of the patient acts as an obstacle to airway management, which poses a great challenge for anesthesiologists. In particular, anesthesiologists may face difficulty in airway evaluation and patient cooperation during general anesthesia for tongue flap division surgery in pediatric patients. The authors report a case of airway management using a flexible fiberoptic bronchoscope during general anesthesia for tongue flap division surgery in a 6-year-old child.

Closure of fistula of the hard palate with two layers of mucoperiosteum

OBJECTIVE

Oronasal fistula represents a functional problem, as it may result in nasal regurgitation of food and fluids and it also leads to hypernasal speech. Many methods have been proposed for its closure with a high recurrence rate. The aim of this study was to assess the efficacy of closure of hard palate fistula by two layers of mucoperiosteal flaps.

METHODS

Eighteen patients with fistula of the hard palate were included. The fistula was repaired by two layers of mucoperiosteal flaps; the first layer was created from the mucoperiosteum surrounding the fistula as bilateral hinge flaps and the second layer was formed of a rotational flap based on the greater palatine artery. Pre- and postoperative clinical assessment was performed.

RESULTS

The etiology of fistulas was previous cleft palate repair in 13 patients, previous nasal septal surgery in 3 patients, and untreated sharp accidental trauma to the palate in 2 patients. All patients presented with nasal regurgitation and hypernasal speech. Complete closure of all fistulas was achieved at first attempt, with no recurrence through the follow up period.

CONCLUSIONS

Closure of oronasal fistula by two layers of mucoperiosteal flaps is an effective method and it has neither complications nor recurrence.