Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience

Abstract

Summary: 

Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE: 

Therapeutic, IV.

The prevalence of oronasal fistula following cleft palate repair is reported at 6% to 9%.^1,2 The reported recurrence rate of fistula following surgical repair is between 25% and 37%.^3,4 Anterior palatal fistulas pose particular challenges, being prone to recurrence because of a paucity of adjacent, mobile palatal tissue. Whereas local flaps may be useful for small fistulas,^5–8 larger fistulas may require regional flaps from the tongue or buccal region or free flaps for repair.^9–11 Each of these techniques has associated donor site morbidity, may require two stages, and can result in bulky flaps.

Nasal septal flaps pedicled on the posterior nasal septal artery have been used for more than a decade in repair of defects of the skull base,⁹ oropharynx, and soft palate. While these flaps have been widely used in skull base reconstruction, little literature exists regarding their application in cleft fistula repair. Ardehali and Farshad¹⁰ reported the use of a composite nasal septum flap in repair of an adult oronasal fistula. Noel et al.¹¹ reported the use of a mucoperichondrial septal flap for closure of an oroantral fistula. Here we report the first case series of palatal fistula repair using nasal septal flaps in patients with cleft palate.

PATIENTS AND METHODS

Ethics approval was granted from the Queensland Children’s Hospital Human Research Ethics Committee (HREC reference no. LNR/20/QCHQ/65259). A retrospective review of the period from January of 2016 to January of 2020 identified 14 cases in which a nasal septal flap had been used for cleft palate fistula repair.

Outcome Measures and Statistical Analysis

All patients underwent preoperative assessment by the multidisciplinary cleft team. Preoperative and postoperative assessment of nasal regurgitation was recorded using our unit’s standardized questionnaire. Patients were assessed as speech pathology outpatients both before and after the procedure using the Cleft Audit Protocol for Speech–Augmented (CAPS-A) tool.¹² Video records and review of live patient assessment reports were analyzed by a senior speech pathologist at Queensland Children’s Hospital (H.C.M.). Assessment of postoperative healing was determined through direct examination and photographic review by the lead surgeons (R.J.T. and Y.S.P.).

Descriptive statistics and patient characteristics were analyzed. Preoperative and postoperative nasal regurgitation and speech scores were analyzed using paired t tests in Prism (GraphPad) for MacOs version 9.1.0. All significance levels were set at P < 0.05.

Surgical Technique

We use a two-team approach. Endoscopic endonasal nasoseptal flap harvest is undertaken by an appropriately trained otolaryngologist. Two parallel sagittal incisions are made in the mucosa of the nasal septum. The inferior incision begins at the lateral aspect of the choanal arch, inferior to the sphenopalatine pedicle, and extends medially to the posterior septum and anteriorly along the junction of septum and nasal floor. The superior incision extends at least 10 mm below the superior-most aspect of the septum, preserving the olfactory epithelium. The anterior extent is just proximal to the mucocutaneous junction. The flap is mobilized in an anterior to posterior direction in the submucoperichondrial plane (Fig. 1). Outfracture of the turbinates or an endoscopic septoplasty may be required to improve visualization. Septal cartilage is not harvested because mucoperiosteum provides adequate bulk. The flap is passed into the oral cavity (Fig. 2, above). Intraoral flap inset is undertaken by the plastic surgery team using a Dingman retractor. The edges of the fistula are incised, and the oral and nasal mucosal layers are separated. Direct apposition of the flap edge to palatal mucosa is obtained circumferentially (Fig. 2, center). [See Video (online), which demonstrates harvest and placement of the nasoseptal flap.] A palatal splint is used for 2 weeks postoperatively, and patients undertake regular nasal care, if tolerated, until the septum remucosalizes.¹³

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Fig. 1.: Spatial relationship of nasal septal flap to typical fistula of hard palate. Note anatomic boundaries of flap in relation to nasal septum.

Fig. 2.: (Above) Anterior palatal fistula with one previous repair; maximum dimension 14 mm. The nasal septal flap is delivered into the oral cavity. (Center) The flap is inset into the oronasal fistula defect. (Below) Healed nasal septal flap.

RESULTS

Fourteen patients underwent palatal fistula repair with a nasoseptal flap. The average age at the time of operation was 10 years (range, 4 to 23 years). Mean operative time was 155 minutes (range, 97 to 201 minutes). Mean follow-up was 21 months. Seven patients had previously undergone fistula repair. The mean fistula size was 12 mm in maximal width (range, 7 to 18 mm) and all fistulas were of Pittsburgh V or VI classification.

Flap healing with complete or near-complete closure of fistula was achieved in 13 out of 14 patients (93%) (Fig. 2, below). Five of these patients had a small, slit-like residual fistula that was asymptomatic. One adult patient in whom six previous fistula repairs had been performed had near-total fistula recurrence (Table 1). Thirteen patients (93%) had improvement of nasal regurgitation symptoms postoperatively, with 10 patients experiencing complete resolution of symptoms. The mean reduction in nasal regurgitation score was 1.7 (1.0 to 2.4; P < 0.001; SD 1.28). All patients for whom speech data were available demonstrated statistically significant improvements in resonance [mean reduction in vocal resonance score 0.75 (0.2 to 1.3; P = 0.01; SD 0.86)] and nasal emission [mean reduction in nasal emission score 0.75 (0.2 to 1.2; P < 0.006; SD 0.75)] as measured on the CAPS-A speech assessment protocol¹² (Table 2).

Table 1. - Patient Characteristics

Characteristics	Mean (Range) or n (%)
Age, yr	10 (4–23)
Diagnosis
BCLP	5/14 (36)
UCLP	6/14 (43)
CPO	3/14 (21)
Previous fistula repair
0	7/14 (50)
1	6/14 (43)
>1	1/14 (7)
Pittsburgh classificationa
IV	1/14 (7)
V	7/14 (50)
VI	6/14 (43)
Fistula size, mm
<5	1/14 (7)
10–15	11/14 (79)
>15	2/14 (14)
Healing outcomeb
0	7/14 (50)
1	6/14 (43)
3	1/14 (7)
Complications
None	11/14 (79)
Anyc	3/14 (21)

BCLP, bilateral cleft lip and palate; CPO, cleft palate only; UCLP, unilateral cleft lip and palate.

^aPittsburgh classification: type I, bifid uvula; type II, soft palate; type III, junction of the soft and hard palate; type IV, hard palate; type V, junction of the primary and secondary palates; type VI, lingual alveolar; and type VII, labial alveolar.

^bHealing outcome: 0, complete healing of fistula with no residual oronasal communication; 1, small, slit-like fistula, asymptomatic; 2, residual fistula, asymptomatic; 3, residual fistula, symptomatic.

^cComplications were fistula recurrence, change in nasal contour, or postoperative epistaxis.

Table 2. - Speech Outcomes

Outcome	Mean Preoperative Score	Mean Postoperative Score	Mean Reduction in Score	SD	P
Nasal regurgitationa	2.5	0.8	1.7	1.28	<0.001
Nasal emissionb	1.82	1.1	0.75	0.75	<0.006
Vocal resonancec	2.25	1.5	0.75	0.86	0.01

^aNasal regurgitation scale: 0, never; 1, once a month; 2, once a week; 3, once a day; 4, every time.

^bNasal emission scale: 0, absent on pressure consonants; 1, occasionally heard on pressure consonants, <3 examples on different sounds; 2, frequently heard on pressure consonants, >3 examples on different sounds.

^cVocal resonance scale: 0, absent; 1, borderline minimal; 2, mild, evident on closed vowels; 3, moderate, evident on open and closed vowels; 4, severe, evident on vowels and voiced consonants.

One adult patient who had a large fistula recurrence ultimately had no improvement in symptoms. Complications included postoperative epistaxis in one patient and a mild dorsal nasal contour change in another. All patients achieved healing of the septal donor site without septal perforation. No patient required flap debulking.

DISCUSSION

This is the first case series reporting the technique of nasal septal flaps for palatal fistula repair. This novel flap provides thin, durable, vascularized mucoperichondrial tissue that can reliably close difficult palatal fistulas in a one-stage operation. In our series, more than 90% of patients achieved near complete closure of their fistula and an improvement in symptoms.

In adults, the flap can be harvested with dimensions of up to 7 × 4 cm.¹⁴ Anatomic studies suggest that flaps of up to 5 cm in length can be obtained in the pediatric population before rapid septal growth at 10 to 13 years.¹⁵ Thus, there is sufficient tissue to repair large anterior palatal fistulas.

Five patients had a residual, slit-like fistula. In the initial stages of using the nasal septal flap for fistula repair, only the three free edges of the flap were sutured to the fistula margin, to avoid potential vascular compromise to the flap. Subsequently, it became apparent that the flap was sufficiently robust to allow circumferential inset, although with care taken to avoid full-thickness suturing through the base of the flap. This resulted in fewer residual slit-like fistulas in the latter half of the series.

Complete data examining the effect of nasal septal flap harvest on nasal and midfacial growth is not yet available. There is some evidence demonstrating that septoplasty with unilateral elevation of the mucoperichondrium of the septal cartilage does not negatively affect facial growth, provided that the cartilage proper and septal growth centers remain undisturbed. These issues are addressed in a detailed review.¹⁶

CONCLUSIONS

Nasal septal flaps represent a reliable, single-stage technique for the repair of large or recurrent fistulas in patients with cleft palate. The technique is learned readily and undertaken using a two-team approach. Symptomatic fistula closure was achieved in 13 out of 14 patients (93%) with a low complication rate. Larger case volume and longer duration of follow-up is required to determine the true utility of this procedure, which may represent an ideal approach to a difficult clinical problem.