One of the known complications of cleft palate surgery is development of fistula. This study highlights our experience with cleft palate surgery in relation to fistula occurrence at our center. This is one of the first studies of this kind in Oman. We retrospectively reviewed 362 records of cleft palate patients. The most common technique used for cleft palate repair at our center was Veau-Wardill-Kilner technique. In our series we have noticed palatal fistulae in 32% of cases. This high rate is partially due to inclusion of very anterior fistulas in patients with complete cleft lips and palates, which actually represent part of the alveolar cleft rather than breakdown of the palatal repair. This will be closed during time of alveolar bone grafting at a later stage. We recommend a future prospective controlled study to study the factors that lower the incidence of fistula in our population.
The management of Cleft Palate needs involvement of a multidisciplinary team which includes Plastic surgeons, otolaryngologists, orthodontists and speech language therapists. Surgical repair of cleft palate is important for feeding, normal speech mechanism and hearing. The recommended age for palate repair is between 6 - 12 months [
The development of a fistula is one of the well-known complications that might develop after a surgical repair [
Patients with cleft lip and/or palate operated at Khoula Hospital between the period of January, 2008 and July, 2015 were included in the study. Patients with cleft lip only were excluded from the study.
Veau classification was used to classify cleft palate cases (
Fistula cases were diagnosed upon follow-up clinically on examination or based on history of nasal regurgitation when drinking. Our fistula cases included very anterior fistulas which are close to alveolar clefts since we depend on the patients’ record files. There was no distinction and no clear differentiation made in the exam note between alveolar clefts and fistula.
Patient’s data was extracted from the hospital “Al Shifa 2” system (Khoula
Veau classification | Description |
---|---|
Veau I | Defects of the soft palate only |
Veau II | Defects involving the hard and soft palate |
Veau III | Defects involving the soft palate to the alveolus usually involving the lip |
Veau IV | Complete Bilateral Clefts |
Hospital). The data was analyzed using the “Statistical Package for Social Sciences” (SPSS) version 19 for Windows.
Cases were reviewed twice independently by the first two authors to extract fistula cases.
Total of 362 cases were included in the study 182 (50.3%) male and 180 (49.7%) female patients. Mean age of those patients at time of surgery was 28.27 months (range 2.0 - 432.0 months old; Standard Deviation (SD) 53.74 months).
Distribution of cleft palate cases was as follows: 88 cases (24.3%) were Veau I, 156 (43.1%) of cases were Veau II, 83 (22.9%) cases Veau III and 35 (9.7%) of cases were Veau IV (
Veau-Wardill-Kliner technique was used to repair 270 (74.6%) of the cases. In 84 (23.2%) cases, Von Langenback technique was used. While Bardach Salyer technique was used in only 5 (1.4%) cases and Furlow repair in 3 (0.8%) cleft palate cases.
Palatal fistula has developed in 118 (32.6%) of operated cases noting that 40 (11%) of cases has failed to follow up. Mean time frame between surgery and fistula appearance was 8.77 months with a range of 1 to 78 months post-opera- tion and SD of 13.51 months.
Chi square was used to investigate any relation between surgical technique used and appearance of fistula. It showed a p-value of 0.77%, which meant that there was no significant association between surgical technique used and appearance of fistula.
Of the cases that developed fistula, 59.3% (70 out of 118 cases) were males. The increase in male cases was statistically significant with a p-value of 0.041%. Odds ratio for male to female risk of developing a fistula was 1.641 (
Gender | Total | ||||||
---|---|---|---|---|---|---|---|
Male | Female | ||||||
Mean Age at time of surgical repair (months) | 26.962 | 29.583 | 28.265 | ||||
Standard deviation of the age at time of surgery | 54.8440 | 52.7121 | 53.7360 | ||||
Extent of clefting (Veau Clessification) | Defects of the soft palate only | 35 | 53 | 88 | |||
Defects involving the hard and soft palate | 81 | 75 | 156 | ||||
Defects involving the soft palate to the alveolus usually involving the lip | 49 | 34 | 83 | ||||
Complete Bilateral Clefts | 17 | 18 | 35 | ||||
Total | 182 | 180 | 362 | ||||
Surgical technique | Total | |||||
---|---|---|---|---|---|---|
Veau-Wardill-Kilner Technique | Von Langenback Technique | Bardach Salyer Technique | Furlow repair (Double oppsing Z-plasties) | |||
Extent of clefting (Veau Clessification) | Veau I: Defects of the soft palate only | 61 | 24 | 1 | 2 | 88 |
Veau II: Defects involving the hard and soft palate | 95 | 60 | 0 | 1 | 156 | |
Veau III: Defects involving the soft palate to the alveolus usually involving the lip | 80 | 0 | 3 | 0 | 83 | |
Veau IV: Complete Bilateral Clefts | 34 | 0 | 1 | 0 | 35 | |
Total | 270 | 84 | 5 | 3 | 362 |
Gender | Total | ||||
---|---|---|---|---|---|
Male | Female | ||||
Fistula Development (Yes, No, Lost follow up) | Yes | Number of cases | 70 | 48 | 118 |
% within Fistula cases | 59.3% | 40.7% | 100.0% | ||
% within Gender | 38.5% | 26.7% | 32.6% | ||
No | Number of cases | 96 | 108 | 204 | |
% within Fistula cases | 47.1% | 52.9% | 100.0% | ||
% within Gender | 52.7% | 60.0% | 56.4% | ||
Lost follow up | Number of cases | 16 | 24 | 40 | |
% within Fistula cases | 40.0% | 60.0% | 100.0% | ||
% within Gender | 8.8% | 13.3% | 11.0% | ||
Total | Number of cases | 182 | 180 | 362 | |
% within Fistula cases | 50.3% | 49.7% | 100.0% | ||
% within Gender | 100.0% | 100.0% | 100.0% |
Fistula Development | Total | ||||
---|---|---|---|---|---|
Yes | No | Lost follow up | |||
Surgical technique | Veau-Wardill-Kilner Technique | 88 | 142 | 28 | 258 |
34.1% | 55.0% | 10.9% | 100.0% | ||
Von Langenback Technique | 28 | 57 | 11 | 96 | |
29.2% | 59.4% | 11.5% | 100.0% | ||
Bardach Salyer Technique | 1 | 3 | 1 | 5 | |
20.0% | 60.0% | 20.0% | 100.0% | ||
Furlow repair (Double opposing Z-plasties) | 1 | 2 | 0 | 3 | |
33.3% | 66.7% | .0% | 100.0% | ||
Total | 118 | 204 | 40 | 362 | |
32.6% | 56.4% | 11.0% | 100.0% |
Correction of palatal fistula was planned in 43 (35.6%) of fistula cases. Repair using local flaps was done in 24 (20.3%) of total fistula cases. Veau-Wardill- Kliner technique was used to repair 4 (3.4%) fistula cases. Only one case (0.8%) repaired primarily. While 2 fistula cases (1.7%) has failed to follow up, no repair was done in 87 (73.7%) of fistula cases within the study period and were advised to continue follow up (
The main goals of the surgical repair are to restore the normal anatomic alignment evidenced by no nasal regurgitation during food intake and to achieve a good functional outcome evidenced by good speech production.
Many centers have reported their cleft palate surgery outcomes in the literature. The cases of distribution between males and females was equal [
Our study demonstrated a mean age of patients at time of operation of 28.27 months of age with a wide SD. Our current practice at Khoula hospital is age of approximately 12 months at time of operation. The obtained result can be due to late presentation of some cases.
Distribution of cases favored Veau II, followed by Veau I, Veau III and Veau IV.
Our study demonstrated that there was no significant association between surgical technique used and appearance of fistula. The distribution of cases on different surgical repair types might have an effect on the result. Veau-Wardill- Kliner technique is the most commonly used technique at our institution. This might be a possible limitation of our study that is attributed to the nature of the study as it is a retrospective study.
Fistula developed | Total | ||||
---|---|---|---|---|---|
Yes | No fistula | Lost follow up | |||
Fistula Surgical repair | Yes, operation planned and/or done | 42 | 1 | 0 | 43 |
No, operation not planned | 74 | 203 | 2 | 279 | |
Lost follow up | 2 | 0 | 38 | 40 | |
Total | 118 | 204 | 40 | 362 |
Fistula Developed | Total | ||||
---|---|---|---|---|---|
Yes | No fistula | Lost follow up | |||
Surgical technique of fistula correction | Local Flap | 24 | 0 | 0 | 24 |
20.3% | 0.0% | 0.0% | 6.6% | ||
No repair done | 87 | 204 | 4 | 295 | |
73.7% | 100.0% | 10.0% | 81.5% | ||
Lost Follow up | 2 | 0 | 36 | 38 | |
1.7% | 0.0% | 90.0% | 10.5% | ||
Primary repair | 1 | 0 | 0 | 1 | |
0.8% | 0.0% | 0.0% | 0.3% | ||
Veau-Wardill-Kliner Technique | 4 | 0 | 0 | 4 | |
3.4% | 0.0% | 0.0% | 1.1% | ||
Total | 118 | 204 | 40 | 362 | |
100.0% | 100.0% | 100.0% | 100.0% |
In comparison with a study that compared association of fistula with rotation palatoplasty and conventional palatoplasty a statistically significant difference between the two groups. The conventional palatoplasty group included Furlow palatoplasty and Veau Wardill Kliner techniques. Overall fistula appearance was 17.7%, in which 6% (4/67) was in the rotation palatoplasty group and 18% (18/100) was in the conventional palatoplasty group [
A study done in university of Texas Southwestern Medical center compared patients with and patients without palatal fistula. They reported no significant difference between the two groups in regard to gender, age at palatoplasty and type of palate repair [
Palatal fistula rate excluding international unrepaired anterior palatal fistula at the alveolus in a retrospective study of cases repaired by one surgeon using Von Langenback Technique was 8 patients out of 177. Surgical repair was required in 2 cases out of those fistulae.
Higher incidence of fistulae was demonstrated in cases of bilateral cleft lip and palate [
Our study demonstrated a high rate of fistula development. There was no significant association between surgical technique used and development of fistula. However, there was significant increase in cases of fistula in males.
A meta-analysis done by Bykowski and others showed a significant association between Veau classification and fistula development. Fistula cases were more among Veau IV cases [
At Khoula hospital we follow a strict post-op cleft palate feeding protocol. The protocol states liquid diet feeding for 5 days followed by 2 weeks of soft diet.
A contributing factor to the failure of cases to follow up is the fact that Khoula hospital is a tertiary plastic center that deals with cases from all across the country. Problems of transport and the distance between area of residence and our hospital might limit the ability of patients to continue to follow up. Another factor is that appointments are around 6 months to a year apart. Some parents might simply forget about the appointment. Some parents might be satisfied with their results and will stop following up.
Knowing the factors associated with palatal fistula post-operatively will help us reduce its incidence or even prevent it. Hence reduce the number of operations need to repair the fistula, decrease follow-up appointments and improve overall patient’s satisfaction.
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Our study faced a number of limitations beginning with the fact that the palate repair was done my multiple surgeons with different techniques and different level of experience. Since it is a retrospective study, we depended on the documentation and records of patient’s files. The extraction of data was difficult in some cases as the exams findings and detection of fistulae differs with different surgeons especially if the fistula is very small and does not pose any clinical symptoms. Our study had an overestimated number of fistulae due to the fact that we included anterior palatal fistulae in continuity with alveolar clefts. The reason for that is that our exam notes did not clearly distinct between alveolar clefts and fistulae. Some of the most anterior fistulae which are in continuity with alveolar cleft can be corrected at the time of alveolar bone grafting. We did not study the palatal width as it was not measured and could not be traced from the records although it was found as non contributing factor to fistula appearance in some studies [
Closure of fistula located at any part of human body is a surgical challenge so as Palatal fistula. No such study was conducted in Oman to show the incidence of Palatal fistula after primary palate repair. The aim of this study was not only to know the incidence but also the contributing factors which leads to this complication which is very difficult to treat. By knowing and evaluating the factors associated with development of palatal fistula, help us to standardize the surgical techniques to prevent/reduce the incidence of fistula formation. This helps to improve the overall results by avoiding the need for another anaesthesia, hospital stay , number of operations need to repair the fistula, decrease follow-up appointments and improve overall patient’s satisfaction. By keeping this retrospective study as a baseline we can proceed with prospective studies after making the appropriate strategies and protocols for the repair of cleft palate to obtain better results.
Al Balushi, A., Sahib, M.M. and Al Balushi, T. (2017) Palatal Fistula Post-Cleft Palate Repair: A Tertiary Center Experience in Oman. Modern Plastic Surgery, 7, 21-30. https://doi.org/10.4236/mps.2017.73003