Palatal fistula

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

2. * 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. Definition

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

4. Classification • Etiology … ( congenital ) ( post traumatic ) ( post inflammatory ) ( post surgical )

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

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

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

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

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

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

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

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

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

14. 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.

15. a – Soft palatal f.

16. b – Longitudinal f.

17. c – Transverse f.

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

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

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

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

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

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

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

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

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

27. 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 ).

28. Dermal – Fat graft

29. Dermal – Fat graft

30. Dermal – Fat graft

32. C1,a

33. C1,b C1,c

34. C1,d C1,e

35. C1,f

36. C2,a

37. C2,b

38. C2,c

39. C3,a

40. C3,b Cartilage graft

41. Cartilage graft

42. C3,c

43. C4,a

44. C4,b

45. C4,c

46. C4,d

47. C5,a C5,b

48. C5,c

49. 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.