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Use of cartilage grafts for closure of cleft palate fistulae
British Journal of Plastic Surgery (2000), 53, 551-554 9 2000 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3411
PLASTIC
SURGERY
Use of cartilage grafts for closure of cleft palate fistulae S. L. A. Jeffery, J. G. Boorman and D. C. Dive
Queen Victoria Hospital, East Grinstead, West Sussex, UK SUMMARY. We describe the results of using a free cartilage graft in the closure of cleft palate fistulae in 14 patients with a mean follow-up of 8.6 months. Complete closure of the fistula was achieved in 11 patients (79%), with partial closure in the remaining three patients. This technique is simple, causes relatively little discomfort, involves little tissue dissection and can be performed as a day-case procedure. The success rate is comparable with or better than other methods, and we consider it the treatment of choice for small cleft palate fistulae. 9 2000 The British Association of Plastic Surgeons
Keywords: cleft palate, fistula, cartilage graft. A fistula between the oral and nasal cavities following primary repair of the cleft palate can occur at any site along the line of the repaired cleft. The incidence of palatal fistulae following primary repair varies widely with figures quoted ranging from 18% to 34%. 1-5 Several factors are known to influence occurrence of fistulae. In general, the more severe the cleft, the more likely it is that a postoperative palatal fistula will occur. Tension at the site of closure, haemorrhage or infection can cause wound breakdown after cleft palate repair. Oronasal fistulae are not necessarily symptomatic. The most common complaint is regurgitation of fluid into the nasal cavity. Other reported symptoms include packing of food into the fistulous track, causing mucosal inflammation, malodour, 3 nasal catarrh 6 and hearing loss. 7 Reported speech symptoms are hypernasal resonance, audible nasal escape, weakness of pressure consonants 8'9 and retracted tongue placement in the articulation of speech sounds, l~ Speech and resonance have been shown to improve with temporary cover of the fistula. 11 Improvement in resonance, nasal emission and strength of consonants has been reported following surgical closure of fistulae. 9 Cinefluoroscopic studies have shown that the activity of the lateral pharyngeal walls and the soft palate increased during temporary cover of palatal fistulae. 8 A small asymptomatic fistula may become symptomatic when it enlarges after orthodontic treatment to expand the alveolar arch. 7 Fistulae have been classified according to size (small 1-2mm, medium 3-5mm, large > 5 m m ) 1 and Schultz has described them as pinpoint, slit, oval and total dehiscence. 7 Most fistulae are small and slit-like. Some symptomatic fistulae can be managed by obturators, but there are inherent problems with this approach, such as a sharp increase in the oral bacteria count, with a resultant increase in the incidence of dental caries. Because these dentures must fit closely around the necks of the teeth in order to be retained, chronic gingivitis also occurs with the use of these obturators. 6 Ideally fistulae should be closed if speech or social problems arise. Matsuo et a112 reported the use of conchal cartilage for the successful closure of a palatal fistula in a single patient
in 1990, and we have found no further papers describing the use of this technique. The senior author has been using this method since 1997, and we describe the early experience with this technique.
Patients Fourteen patients underwent closure of palatal fistula using cartilage grafting. The mean age was 7 years range 2-16 years). Patients had had one to four (mean 1.8) previous palatal operations, including the initial cleft palate closure (Table 1). Two fistulae were located in the postalveolar area, three at the incisive foramen, eight in the hard palate and one at the hard-soft palate junction. Twelve fistulae were classified as small (1-2mm), one was medium (2-5 mm) and one was large (2cm long). We have excluded from this study fistulae or unclosed clefts in the alveolar region, which we normally close at the time of alveolar bone grafting.
Surgical technique Patients are normally admitted as a day case, unless additional procedures are to be carried out. The palatal mucoperiosteum is dissected for 2-3 mm from the fistula margin, creating a pocket for the cartilage graft. An angled blade such as that made by Visitec (Warwickshire, UK) (Fig. 1) is of great help to make this pocket. An incision is then made in the crease behind one of the ears and a conchal cartilage graft a little larger than the fistula is harvested. This is then sutured into the pocket with absorbable sutures (Fig. 2). As access is inevitably limited, we find the small P-2 needle on 5-0 PDS most useful for this, alternatively a compound-curved needle can be used. No attempt is made at formal closure of either the nasal or the palatal mucosa.
Speech assessment Pre- and postoperative speech assessments were available for nine of the patients. These assessments were carried out by a Speech and Language Therapist experienced in
551
552 Table 1
British Journal of Plastic Surgery Patient details
Patient no.
Age
Size of fistula
1 2 3 4 5 6 7 8 9 10 11 12 13 14
5 7 16 2 12 4 8 6 2 5 7 5 3 12
Small Small Small Small Small Small Large (2 cm) Small Small Small Small Medium Small Small
No. of previous palatal operations
2 1 4 1 3 1 1 1 1 2 3 1 2 2
Additional procedures
Dental clearance Palate re-repair Dermofat graft to separate fistula Laryngoscopy Cleft nose revision Lop ear correction Palate re-repair and grommets Cleft lip revision Palate re-repair
Fistula closure
No Yes No, but fistula smaller Yes Yes No, but fistula smaller Yes Yes Yes Yes Yes Yes Yes Yes
cleft work, using the Cleft Audit Protocol for Speech (CAPS). 13,t4 A u d i o and video recordings made at the time of assessment were used to verify live transcription and nasality rating. In other cases the family impression of speech before and after fistula closure may be relevant.
Results Figure 1--Angle-bladed knife used to create the pocket (Visitec, Warwickshire,UK).
f
Figure 2---Showing the pocket being created in the palatal mucoperiosteum, with subsequent insertion of the cartilage graft, held in position with an absorbable suture.
Complete closure of the palatal fistula was achieved in 11 of the 14 patients (79%), with resolution of nasal regurgitation being noted in all of these patients. In all nine patients with pre- and postoperative speech assessments, resonance was hypernasal before fistula repair. In five patients resonance was less hypernasal on postoperative assessment and in the remaining four there was no change. In five patients audible nasal emission was present preoperatively. In three of these patients this feature was reduced post fistula repair and in two cases it remained mild and intermittent. In four patients nasal turbulence occurred preoperatively and in three of these it was not present on postoperative assessment. Findings regarding nasality are complicated by other factors such as the presence of velopharyngeal insufficiency (VPI), other procedures carded out at the same operation, nasal congestion at pre- or postoperative assessment and, in one case, increased use of oral articulations at postoperative assessment. In this patient increased use of plosives resulted in more perceived nasal emission. However, it is possible that fistula repair facilitated oral plosive production and use. In addition to changes in nasality there were improvements in strength of consonant production in three cases and in place o f articulation in one case. In this case a pattern of replacing anterior sounds with those made posterior to the fistula had resolved on postoperative assessment. One patient with successful closure of the fistula for whom speech assessment was not available was described by his parents to have 'less nasal speech'. In another patient concerns about speech remain and may be related to VPI. The three patients in whom complete closure o f the palatal fistula was not successful (including the patient with the 2 c m long fistula) all had their fistula made
Cartilage grafts for closure of cleft palate fistulae noticeably smaller by this procedure. Speech assessment was incomplete pre- or postoperatively or both in these three patients but none reported any improvement in their speech. The mean number of previous palatal operations for these three patients was 2.3 compared with 1.6 for those patients who had successful closure of the fistula with this technique. This was not statistically significant due to the small numbers of patients. Mean follow-up was 8.6 months, range 2-22 months. Determining the average time taken to perform this procedure was complicated by the fact that 9 of the 14 patients had additional procedures whilst under the same anaesthetic, e.g. cleft lip revision. The average operating time in those patients who only had closure of the palatal fistula was 27 min. Patients stayed for between 0 and 3 nights (mean 0.9 nights), but those patients only having closure of the palatal fistula stayed for a mean of 0.6 nights.
Discussion The plethora of techniques that have been described for closure of palatal fistulae attests to the fact that no single procedure is consistently satisfactory. Attempts at closure of palatal fistulae have been associated with failure rates as high as 65%, 7 increasing with the second, third or further attempts. Poor blood supply, limited available tissue, scarred adjacent mucosa and early wound contraction often lead to the re-establishment of a fistulous track. Temporary and surgical fistula closure has been found to contribute to improvements in speech. 8'9 In this series improvements in resonance, audible nasal emission, nasal turbulence, strength of consonant production and place of articulation have been noted. Repair of fistula may facilitate improvement in speech when carried out at the same time as surgery for VPI. Combined procedures may reduce the number of operations required for the patient, but complicate evaluation of results. The choice of procedure will be governed by the location and size of the fistula, presence or absence of symptoms, age of the patient, previous operations on the palate and the preference of the surgeon. Certain principles, however, should guide the surgical approach: epithelial continuity between mouth and nose should be avoided, as should overlapping suture lines and the use of flaps containing devascularised tissue. The operation should ideally re-establish normal anatomy with a partition between the two cavities lined by epithelium on either side. Closure with one sound epithelial layer (oral or nasal) may be better than two poorly vascularised layers, however, with or without the addition of an interposing layer. Local flaps have been described for closure of palatal fistulae, t'tS-2~ but the rigidity of the palatal mucosa, especially if it is already scarred, presents a problem for all but the smallest of fistulae. Tongue flaps have been described 2t-23 for closure of palatal fistulae, but this is a two stage procedure and causes a degree of airway obstruction with some anaesthetic difficulties. It would seem reasonable to reserve this procedure for those extremely large and relatively uncommon fistulae where other manoeuvres will not suffice. Other surgical techniques that have been described include free flaps, 24-29 tissue expansion 3~ and the now historical tube pedicle. Interpositional grafts of bone, 31
553 free periosteum, 32 or dermis-fat33 to separate the oral and nasal layers have also been described with good success rates. Matsuo et al reported the successful use of conchal cartilage in a single patient in 1990.12 We obtained complete closure of the palatal fistula in 11 of our 14 patients using this technique. Vandeput et a133 reported their experience of using dermis-fat grafts in 17 patients in 1994. An ellipse of dermis-fat a little larger than the defect and 8 mm thick was harvested from a gluteal fold and used to fill up the defect after dissection of the nasal-oral fistula. The nasal layer was not closed, but the oral mucosa was closed as much as possible. All fistulae remained closed over 3 years of follow-up. They claimed that because fat tissue has a low metabolism, a small free fragment survived well. The reported success rate of fistula surgery in terms of complete closure of the fistula, as already mentioned, is generally disappointing. However, a reduction in the size of the fistula may be adequate in many cases to eliminate symptoms or reduce them to an acceptable level. 34 Reoperation is therefore not always necessary, 3 but in this series, the speech did not improve in the three patients with persistent, albeit smaller, fistulae. In general, one should avoid wide undermining and palate denuding in growing children. With this technique there is minimal dissection of the hard palate mucoperiosteum, which should help to minimise tissue loss through ischaemia and, in the long term, growth disturbances. This technique is simple, can be performed as a daycase procedure, involves little tissue dissection, and is reasonably successful. We consider it the treatment of choice for small palatal fistulae.
References 1. Reid DAC. Fistulae in the hard palate following cleft palate surgery. Br J Plast Surg 1962; 15: 377-84. 2. Amaratunga NAS. Occurrence of oronasal fistulas in operated cleft palate patients. J Oral Maxillofac Surg 1988; 46: 834-7. 3. /~byholm FE, Borchgrevink HHC, Eskeland G. Palatal fistulae following cleft palate surgery. Scand J Plast Reconstr Surg 1979; 13: 295-300. 4. Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991 ; 87:1041-7. 5. Karling J, Larson O, Henningsson G. Oronasal fistulas in cleft palate patients and their influence on speech. Scand J Plast Reconstr Hand Surg 1993; 27: 193-201. 6. Lehman JA Jr, Curtin P, Haas DG. Closure of anterior palate fistulae. Cleft Palate J 1978; 15: 33-8. 7. Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986; 78: 739-45. 8. Isberg A, Henningsson G. Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study. Plast Reconstr Surg 1987; 79: 525-30. 9. Jackson MS, Jackson IT, Christie FB. Improvement in speech following closure of anterior palatal fistulas with bone grafts. Br J Plast Surg 1976; 29: 295-6. 10. Harding A, Grunwell E Relationship between speech and timing of hard palate repair. In Grunwell R e d . Analysing Cleft Palate Speech. London: Whurr, 1993: 48-82. 11. Henningsson G, Isberg A. Influence of palatal fistulae on speech and resonance. Folia Phoniat 1987; 39: 183-91. 12. Matsuo K, Kiyono M, Hirose T. A simple technique for closure of a palatal fistula using a conchal cartilage graft. Ptast Reconstr Snrg 1991; 88: 334-7.
554 13. Sell D, Harding A, Grunwell P, Razzell R, Harland K. Cleft Audit Protocol for Speech. Thameside Community Healthcare NHS Trust, 1996. 14. Sell D, Harding A, Gmnwell R GOS.SRASS.98: an assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised). Int J Lang Commun Disord 1999; 34: 17-33. 15. Rintala A. A double, overlapping hinge flap to close palatal fistula. Scand J Hast Reconstr Surg 1971; 5: 91-5. i6. Henderson HR The 'tadpole flap': an advancement island flap for the closure of anterior palatal fistulae. Br J Hast Surg 1982; 35: 163-6. 17. Millard DR Jr, Seider HA. The versatile palatal island flap: its use in soft palate reconstruction and nasopharyngeal and choanal atresia. Br J Hast Surg 1977; 30: 300-5. 18. Stenstrtm SJ, Thilander BL. Bone grafting in secondary cases of cleft lip and palate. Hast Reconstr Surg 1963; 32: 353-60. 19. Jackson IT. Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. Br J Hast Surg 1972; 25: 93-105. 20. Rintala A. Labiobuccal mncosal island flap for closure of anterior palatal fistulae: case report. Scand J Hast Reconstr Surg 1979; 13: 480.2. 21. Klopp CT, Schurter M. The surgical treatment of cancer of the soft palate and tonsil. Cancer 1956; 9: 1239-43. 22. Guerrero-Santos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Hast Reconstr Surg 1966; 38: 123-8. 23. Posnick JC, Getz SB Jr. Surgical closure of end-stage palatal fistulas using anteriorly based dorsal tongue flaps. J Oral Maxillofac Surg 1987; 45: 907-12. 24. Batchelor AG, Palmer JH. A novel method of closing a palatal fistula: the free fascial flap. Br J Plast Surg 1990; 43: 359-61. 25. Chem RC, Franciosi LFN. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery 1983; 4: 35-9. 26. Chen H, Ganos DL, Coessens BC, Kyutoku S, Noordhoff MS. Free forearm flap for closure of difficult oronasal fistulas in cleft palate patients. Hast Reconstr Surg 1992; 90: 757-62. 27. MacLeod AM, Morrison WA, McCann JJ, Thistlethwaite S, Vanderkolk CA, Ryan AD. The free radial forearm flap with and
British Journal o f Plastic Surgery
28.
29.
30. 31.
32. 33. 34.
without bone for closure of large palatal fistulae. Br J Plast Surg 1987; 40: 391-5. Inoue T, Harashina T, Asanami S, Fujino T. Reconstruction of the hard palate using free iliac bone covered with a jejunal flap. Br J Hast Surg 1988; 41: 143-6. Soutar DS, Scheker LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983; 36: 1-8. De Mey A, Malevez C, Lejour M. Treatment of palatal fistula by expansion. Br J Plast Surg 1990; 43: 362-4. Stal S, Spira M. Secondary reconstructive procedures for patients with clefts. In Serafin D, Georgiade NG, ed. Paediatric Plastic Surgery, Vol 1. St. Louis, MO: CV Mosby Company, 1984: 352. Schultz RC. Free periosteal graft repair of maxillary clefts in adolescents. Hast Reconstr Surg 1984; 73: 556-65. Vandeput JJ, Droogmans B, Tanner JC. Closure of palatal fistulas using a detxnis-fat graft. Hast Reconstr Surg 1995; 95:1105~. Rintala AE. Surgical closure of palatal fistulae: follow-up of 84 personally treated cases. Scand J Hast Reconstr Surg 1980; 14: 235-8.
The Authors Steven L. A. Jeffery FRCS, Specialist Registrar John G. Boorman FRCS (Hast), Consultant/Plastic Surgeon Denise C. Dive MRCSLT, Specialist Speech and Language Therapist Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK. Correspondence to Mr S. L. A. Jeffery, Department of Plastic Surgery Royal Victoria Infirmary, Queen Victoria Road Newcastle upon Tyne NE1 4LP, UK Paper received 12 October 1999. Accepted 12 June 2000, after revision.
PLASTIC
SURGERY
Use of cartilage grafts for closure of cleft palate fistulae S. L. A. Jeffery, J. G. Boorman and D. C. Dive
Queen Victoria Hospital, East Grinstead, West Sussex, UK SUMMARY. We describe the results of using a free cartilage graft in the closure of cleft palate fistulae in 14 patients with a mean follow-up of 8.6 months. Complete closure of the fistula was achieved in 11 patients (79%), with partial closure in the remaining three patients. This technique is simple, causes relatively little discomfort, involves little tissue dissection and can be performed as a day-case procedure. The success rate is comparable with or better than other methods, and we consider it the treatment of choice for small cleft palate fistulae. 9 2000 The British Association of Plastic Surgeons
Keywords: cleft palate, fistula, cartilage graft. A fistula between the oral and nasal cavities following primary repair of the cleft palate can occur at any site along the line of the repaired cleft. The incidence of palatal fistulae following primary repair varies widely with figures quoted ranging from 18% to 34%. 1-5 Several factors are known to influence occurrence of fistulae. In general, the more severe the cleft, the more likely it is that a postoperative palatal fistula will occur. Tension at the site of closure, haemorrhage or infection can cause wound breakdown after cleft palate repair. Oronasal fistulae are not necessarily symptomatic. The most common complaint is regurgitation of fluid into the nasal cavity. Other reported symptoms include packing of food into the fistulous track, causing mucosal inflammation, malodour, 3 nasal catarrh 6 and hearing loss. 7 Reported speech symptoms are hypernasal resonance, audible nasal escape, weakness of pressure consonants 8'9 and retracted tongue placement in the articulation of speech sounds, l~ Speech and resonance have been shown to improve with temporary cover of the fistula. 11 Improvement in resonance, nasal emission and strength of consonants has been reported following surgical closure of fistulae. 9 Cinefluoroscopic studies have shown that the activity of the lateral pharyngeal walls and the soft palate increased during temporary cover of palatal fistulae. 8 A small asymptomatic fistula may become symptomatic when it enlarges after orthodontic treatment to expand the alveolar arch. 7 Fistulae have been classified according to size (small 1-2mm, medium 3-5mm, large > 5 m m ) 1 and Schultz has described them as pinpoint, slit, oval and total dehiscence. 7 Most fistulae are small and slit-like. Some symptomatic fistulae can be managed by obturators, but there are inherent problems with this approach, such as a sharp increase in the oral bacteria count, with a resultant increase in the incidence of dental caries. Because these dentures must fit closely around the necks of the teeth in order to be retained, chronic gingivitis also occurs with the use of these obturators. 6 Ideally fistulae should be closed if speech or social problems arise. Matsuo et a112 reported the use of conchal cartilage for the successful closure of a palatal fistula in a single patient
in 1990, and we have found no further papers describing the use of this technique. The senior author has been using this method since 1997, and we describe the early experience with this technique.
Patients Fourteen patients underwent closure of palatal fistula using cartilage grafting. The mean age was 7 years range 2-16 years). Patients had had one to four (mean 1.8) previous palatal operations, including the initial cleft palate closure (Table 1). Two fistulae were located in the postalveolar area, three at the incisive foramen, eight in the hard palate and one at the hard-soft palate junction. Twelve fistulae were classified as small (1-2mm), one was medium (2-5 mm) and one was large (2cm long). We have excluded from this study fistulae or unclosed clefts in the alveolar region, which we normally close at the time of alveolar bone grafting.
Surgical technique Patients are normally admitted as a day case, unless additional procedures are to be carried out. The palatal mucoperiosteum is dissected for 2-3 mm from the fistula margin, creating a pocket for the cartilage graft. An angled blade such as that made by Visitec (Warwickshire, UK) (Fig. 1) is of great help to make this pocket. An incision is then made in the crease behind one of the ears and a conchal cartilage graft a little larger than the fistula is harvested. This is then sutured into the pocket with absorbable sutures (Fig. 2). As access is inevitably limited, we find the small P-2 needle on 5-0 PDS most useful for this, alternatively a compound-curved needle can be used. No attempt is made at formal closure of either the nasal or the palatal mucosa.
Speech assessment Pre- and postoperative speech assessments were available for nine of the patients. These assessments were carried out by a Speech and Language Therapist experienced in
551
552 Table 1
British Journal of Plastic Surgery Patient details
Patient no.
Age
Size of fistula
1 2 3 4 5 6 7 8 9 10 11 12 13 14
5 7 16 2 12 4 8 6 2 5 7 5 3 12
Small Small Small Small Small Small Large (2 cm) Small Small Small Small Medium Small Small
No. of previous palatal operations
2 1 4 1 3 1 1 1 1 2 3 1 2 2
Additional procedures
Dental clearance Palate re-repair Dermofat graft to separate fistula Laryngoscopy Cleft nose revision Lop ear correction Palate re-repair and grommets Cleft lip revision Palate re-repair
Fistula closure
No Yes No, but fistula smaller Yes Yes No, but fistula smaller Yes Yes Yes Yes Yes Yes Yes Yes
cleft work, using the Cleft Audit Protocol for Speech (CAPS). 13,t4 A u d i o and video recordings made at the time of assessment were used to verify live transcription and nasality rating. In other cases the family impression of speech before and after fistula closure may be relevant.
Results Figure 1--Angle-bladed knife used to create the pocket (Visitec, Warwickshire,UK).
f
Figure 2---Showing the pocket being created in the palatal mucoperiosteum, with subsequent insertion of the cartilage graft, held in position with an absorbable suture.
Complete closure of the palatal fistula was achieved in 11 of the 14 patients (79%), with resolution of nasal regurgitation being noted in all of these patients. In all nine patients with pre- and postoperative speech assessments, resonance was hypernasal before fistula repair. In five patients resonance was less hypernasal on postoperative assessment and in the remaining four there was no change. In five patients audible nasal emission was present preoperatively. In three of these patients this feature was reduced post fistula repair and in two cases it remained mild and intermittent. In four patients nasal turbulence occurred preoperatively and in three of these it was not present on postoperative assessment. Findings regarding nasality are complicated by other factors such as the presence of velopharyngeal insufficiency (VPI), other procedures carded out at the same operation, nasal congestion at pre- or postoperative assessment and, in one case, increased use of oral articulations at postoperative assessment. In this patient increased use of plosives resulted in more perceived nasal emission. However, it is possible that fistula repair facilitated oral plosive production and use. In addition to changes in nasality there were improvements in strength of consonant production in three cases and in place o f articulation in one case. In this case a pattern of replacing anterior sounds with those made posterior to the fistula had resolved on postoperative assessment. One patient with successful closure of the fistula for whom speech assessment was not available was described by his parents to have 'less nasal speech'. In another patient concerns about speech remain and may be related to VPI. The three patients in whom complete closure o f the palatal fistula was not successful (including the patient with the 2 c m long fistula) all had their fistula made
Cartilage grafts for closure of cleft palate fistulae noticeably smaller by this procedure. Speech assessment was incomplete pre- or postoperatively or both in these three patients but none reported any improvement in their speech. The mean number of previous palatal operations for these three patients was 2.3 compared with 1.6 for those patients who had successful closure of the fistula with this technique. This was not statistically significant due to the small numbers of patients. Mean follow-up was 8.6 months, range 2-22 months. Determining the average time taken to perform this procedure was complicated by the fact that 9 of the 14 patients had additional procedures whilst under the same anaesthetic, e.g. cleft lip revision. The average operating time in those patients who only had closure of the palatal fistula was 27 min. Patients stayed for between 0 and 3 nights (mean 0.9 nights), but those patients only having closure of the palatal fistula stayed for a mean of 0.6 nights.
Discussion The plethora of techniques that have been described for closure of palatal fistulae attests to the fact that no single procedure is consistently satisfactory. Attempts at closure of palatal fistulae have been associated with failure rates as high as 65%, 7 increasing with the second, third or further attempts. Poor blood supply, limited available tissue, scarred adjacent mucosa and early wound contraction often lead to the re-establishment of a fistulous track. Temporary and surgical fistula closure has been found to contribute to improvements in speech. 8'9 In this series improvements in resonance, audible nasal emission, nasal turbulence, strength of consonant production and place of articulation have been noted. Repair of fistula may facilitate improvement in speech when carried out at the same time as surgery for VPI. Combined procedures may reduce the number of operations required for the patient, but complicate evaluation of results. The choice of procedure will be governed by the location and size of the fistula, presence or absence of symptoms, age of the patient, previous operations on the palate and the preference of the surgeon. Certain principles, however, should guide the surgical approach: epithelial continuity between mouth and nose should be avoided, as should overlapping suture lines and the use of flaps containing devascularised tissue. The operation should ideally re-establish normal anatomy with a partition between the two cavities lined by epithelium on either side. Closure with one sound epithelial layer (oral or nasal) may be better than two poorly vascularised layers, however, with or without the addition of an interposing layer. Local flaps have been described for closure of palatal fistulae, t'tS-2~ but the rigidity of the palatal mucosa, especially if it is already scarred, presents a problem for all but the smallest of fistulae. Tongue flaps have been described 2t-23 for closure of palatal fistulae, but this is a two stage procedure and causes a degree of airway obstruction with some anaesthetic difficulties. It would seem reasonable to reserve this procedure for those extremely large and relatively uncommon fistulae where other manoeuvres will not suffice. Other surgical techniques that have been described include free flaps, 24-29 tissue expansion 3~ and the now historical tube pedicle. Interpositional grafts of bone, 31
553 free periosteum, 32 or dermis-fat33 to separate the oral and nasal layers have also been described with good success rates. Matsuo et al reported the successful use of conchal cartilage in a single patient in 1990.12 We obtained complete closure of the palatal fistula in 11 of our 14 patients using this technique. Vandeput et a133 reported their experience of using dermis-fat grafts in 17 patients in 1994. An ellipse of dermis-fat a little larger than the defect and 8 mm thick was harvested from a gluteal fold and used to fill up the defect after dissection of the nasal-oral fistula. The nasal layer was not closed, but the oral mucosa was closed as much as possible. All fistulae remained closed over 3 years of follow-up. They claimed that because fat tissue has a low metabolism, a small free fragment survived well. The reported success rate of fistula surgery in terms of complete closure of the fistula, as already mentioned, is generally disappointing. However, a reduction in the size of the fistula may be adequate in many cases to eliminate symptoms or reduce them to an acceptable level. 34 Reoperation is therefore not always necessary, 3 but in this series, the speech did not improve in the three patients with persistent, albeit smaller, fistulae. In general, one should avoid wide undermining and palate denuding in growing children. With this technique there is minimal dissection of the hard palate mucoperiosteum, which should help to minimise tissue loss through ischaemia and, in the long term, growth disturbances. This technique is simple, can be performed as a daycase procedure, involves little tissue dissection, and is reasonably successful. We consider it the treatment of choice for small palatal fistulae.
References 1. Reid DAC. Fistulae in the hard palate following cleft palate surgery. Br J Plast Surg 1962; 15: 377-84. 2. Amaratunga NAS. Occurrence of oronasal fistulas in operated cleft palate patients. J Oral Maxillofac Surg 1988; 46: 834-7. 3. /~byholm FE, Borchgrevink HHC, Eskeland G. Palatal fistulae following cleft palate surgery. Scand J Plast Reconstr Surg 1979; 13: 295-300. 4. Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991 ; 87:1041-7. 5. Karling J, Larson O, Henningsson G. Oronasal fistulas in cleft palate patients and their influence on speech. Scand J Plast Reconstr Hand Surg 1993; 27: 193-201. 6. Lehman JA Jr, Curtin P, Haas DG. Closure of anterior palate fistulae. Cleft Palate J 1978; 15: 33-8. 7. Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986; 78: 739-45. 8. Isberg A, Henningsson G. Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study. Plast Reconstr Surg 1987; 79: 525-30. 9. Jackson MS, Jackson IT, Christie FB. Improvement in speech following closure of anterior palatal fistulas with bone grafts. Br J Plast Surg 1976; 29: 295-6. 10. Harding A, Grunwell E Relationship between speech and timing of hard palate repair. In Grunwell R e d . Analysing Cleft Palate Speech. London: Whurr, 1993: 48-82. 11. Henningsson G, Isberg A. Influence of palatal fistulae on speech and resonance. Folia Phoniat 1987; 39: 183-91. 12. Matsuo K, Kiyono M, Hirose T. A simple technique for closure of a palatal fistula using a conchal cartilage graft. Ptast Reconstr Snrg 1991; 88: 334-7.
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The Authors Steven L. A. Jeffery FRCS, Specialist Registrar John G. Boorman FRCS (Hast), Consultant/Plastic Surgeon Denise C. Dive MRCSLT, Specialist Speech and Language Therapist Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK. Correspondence to Mr S. L. A. Jeffery, Department of Plastic Surgery Royal Victoria Infirmary, Queen Victoria Road Newcastle upon Tyne NE1 4LP, UK Paper received 12 October 1999. Accepted 12 June 2000, after revision.