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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 80-83

Width of cleft palate and postoperative palatal fistula – Do they really correlate?


Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Gurgaon, India

Date of Submission28-Feb-2020
Date of Acceptance02-Jun-2020
Date of Web Publication31-Jul-2020

Correspondence Address:
Dr. Hardeep Singh
Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Sector 38, Gurgaon, NCR, 122001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_5_20

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  Abstract 


Background: Palatal Fistula according to previous studies is directly proportional to width of the clefts. The fallacies with these studies were presence of multiple confounding factors such as multiple surgeons using different techniques of repair. Aim: This study attempted to assess the correlation between the actual width of cleft (W) and ratio of cleft width to sum of width of palatal shelves (R) with the incidence of palatal fistula done by single surgeon using same standardized repair thus eliminating bias due to multiple variables. Methods: This study includes consecutive cases of palatoplasty over 18 months. Bardachs 2 flap palatoplasty with radical Muscle dissection was performed. Palatal fistula was assessed at 3 weeks and at 2months. Results were analyzed with Wilcoxon signed rank test. Results: The values of W and R were analyzed in 45 patients. At 3 weeks 4 patients had fistula (8.9%) while at 2 months follow up only one patient (2.2%) had it. In patients without a fistula (n=41), the mean W was 1.22+0.31 cms SD (range 0.4 to 1.9cm) and R was 0.47+0.14 SD (range 0.15 to 0.83). In 4 patients with fistula at 3 weeks, the mean W was 1.28+0.39 cm SD (range 0.90 tp 1.8 cm) and R was 0.60+0.37 SD (range 0.35 to 1.13). This difference was not statistically significant (P value- 1.000 and 0.968 respectively). Conclusion: This study shows correlation between the width of the cleft or the width of palatal shelves have no significant influence on palatal fistula. The high incidence in previous studies may be related to surgical techniques.

Keywords: Palatal fistula, palatal shelves, width of cleft palate


How to cite this article:
Khazanchi RK, Singh H. Width of cleft palate and postoperative palatal fistula – Do they really correlate?. J Cleft Lip Palate Craniofac Anomal 2020;7:80-3

How to cite this URL:
Khazanchi RK, Singh H. Width of cleft palate and postoperative palatal fistula – Do they really correlate?. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Dec 3];7:80-3. Available from: https://www.jclpca.org/text.asp?2020/7/2/80/291145




  Introduction Top


Cleft lip (CL) and cleft palate (CP) are the most common congenital anomalies of the craniofacial region, with an average worldwide incidence of 1 in 700.[1] Palatal fistula is one of the common complications of the CP repair, with an incidence ranging from 2% to 63%.[2],[3],[4] Previous studies have shown that the incidence is high in patients with wide clefts, complete CL and CP, and when the ratio from the width of the cleft to the sum of palatal shelves is high.[5] The fallacies with these studies were the presence of multiple confounding factors such as multiple surgeons using different techniques of palate repair.

This prospective observational study attempted to assess the correlation between the actual width of CP (W) and the ratio of CP width to sum of width of palatal shelves at the widest portion of the cleft (R) with the incidence of palatal fistula in surgeries done by a single surgeon using the same standardized repair and with a standard perioperative plan of care at a single center, eliminating bias due to multiple variables.


  Materials and Methods Top


It is a prospective study done in a tertiary care hospital over a period of 18 months including all consecutive cases of palatal repair.

Inclusion criteria

All patients with CL and CP or CP undergoing palate repair of previously unoperated palate were included in the study.

Exclusion criteria

Redo palate repair, submucous CP, and syndromic CP patients were excluded from the study.

Every patient in the study underwent measurements W and R after administration of anesthesia. All measurements were done by a malleable plastic scale by the operating surgeon (senior author). These were measured at the widest portion of the cleft. Veau classification of CL and CP was used for grouping [Table 1].
Table 1: Veau classification of the patients in the study

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Bardach's two-flap palatoplasty with radical muscle dissection technique was performed in all patients. Steps of the same are as follows: (1) local infiltration in palatal shelves, (2) incision over cleft margin and lateral incisions, (3) raising mucoperiosteal flaps, (4) separating nasal layer, (5) nasal layer repair, (6) radical muscle dissection, (7) double-breasting muscle repair keeping muscle in the posterior one-third of the soft palate, and (8) mucoperiosteal layer repair. If the repair was assessed to be under tension, a tensor tenotomy and division of the periosteal sleeve over the pedicle was done sequentially to achieve a tension-free repair. Postoperatively, patients were kept on thin semisolid feeds for 2 weeks. They were discharged once the feeding was established, mostly on the first postoperative day.

Documentation of palatal fistula was done at 3-week and at 2-month postoperative follow-up visits. A fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate, excluding intentionally unrepaired fistulas. Patients with palatal fistula noted in early follow-up visit were advised to maintain proper mouth hygiene and reassessed at 60 days. Cleft width and the ratio of cleft width to sum of palatal shelves in patients with fistula were compared with those without fistula using Wilcoxon signed-rank test for statistical significance.


  Results Top


Forty-five patients who underwent palatoplasty by a single operating surgeon and a single operating technique were included in the study, of which 25 were female (56%) and 20 were male (44%). The mean age at operation was 14.24 months (range: 7–36 months). The values of W and R were analyzed [Table 2] and [Table 3]. The cleft was usually widest at the posterior border of the maxillary tuberosity.
Table 2: Details of the patients

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Table 3: Details of the patients

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At 3-week follow-up, four patients had fistula (8.9%), whereas at 2-month follow-up, only one patient (2.2%) had it. Three of the four fistulae had healed spontaneously. All the three fistulae which healed were present at the junction of hard and soft palates, whereas the fistula which persisted was present 4 mm posterior to this junction.

In patients without a fistula (n = 41), the mean W was 1.22 + 0.31 cm standard deviation (SD) (range: 0.4–1.9 cm). In four patients with fistula at 3 weeks, the mean W was 1.28 + 0.39 cm SD (range: 0.90–1.8 cm). Although it was slightly higher, this difference was not statistically significant (P = 1.000).

The mean R was 0.47 + 0.14 SD (range: 0.15–0.83) in patients without a fistula (n = 41). This was 0.60 + 0.37 SD (range: 0.35–1.13) in patients who had palatal fistula at 3-week follow-up (n = 4). Again, the difference was of no statistical significance (P = 0.968).

On follow-up at 60 days, three of four fistulae healed spontaneously, whereas one fistula just behind the junction of hard and soft palates was persisting giving an overall incidence of 2.22%. In this patient, the cleft width was 1.3 cm and the ratio was 0.54. The widest CP in the series has a width of 1.9 cm and its ratio was 0.68. This healed without a fistula. Among two patients with cleft width 1.8 cm each, one showed palatal fistula at early follow-up visit which healed spontaneously.


  Discussion Top


CP repair is one of the common procedures done for craniofacial clefts. The first trial of repair was done by Johann Friedrich Dieffenbach in 1816 when he elevated soft-tissue flaps instead of paring the edges.[6] This was followed by contibutions by von Langenbeck, Veau, Wardill, and Kilner. Bardach's two-flap palatoplasty showed promising result for closure of wider clefts leading to lesser fistula rates.[7],[8],[9] Sommerland and cutting introduced radical muscle mobilization for better speech.[10],[11]

Palatoplasty is associated with various complications – hemorrhage, respiratory obstruction, hanging palate, dehiscence of the repair, oronasal fistula formation, bifid uvula, velopharyngeal incompetence, abnormal speech, maxillary hypoplasia, dental malpositioning and malalignment, and otitis media. Palatal fistula is probably the most common complication associated with CP surgery.[11] Factors that have been proposed to influence the fistula rate are Veau class, width of cleft, surgeon's experience, age at repair, gender, ethnicity, and whether the cleft is part of a syndrome or a range of other malformations.[3],[4] Muzaffar et al. defined a fistula as a failure of healing or a breakdown in the primary surgical repair of the palate, excluding intentionally unrepaired fistulas.[3] Early dehiscence and fistulas are primarily caused by errors in technique such as inadequate mobilization, closure under tension, injury at reintubation, poor handling of tissues, failure to achieve a layered closure, postoperative bleeding, or infection.

A study by Parwaz et al. showed that palate and cleft measurements were related to fistula rate. They concluded that a preoperative cleft width of ≥15 mm and a ratio of cleft width to the sum of the palatal shelves ≥0.48 have a statistically significant risk of fistulization.[5] However, in this study, von Langenbeck procedure and modified Veau–Wardill–Kilner repair were done by different surgeons. The minimal follow-up of 4 weeks was done for all, and it showed a 35% fistula rate, with a high dropout rate of 28%.

Another study by Landheer et al. showed a positive correlation between cleft width ≥13 mm and incidence of palatal fistula.[12] The overall fistula rate was 21% (27% in two-stage repair and 14% in one-stage repair). The outcome of this study was that the risk for the development of fistulas was significantly increased in patients with a cleft width of ≥13 mm. Interpreting and comparing fistula incidences have been difficult in previous years. Many articles discussing fistula incidence did not mention a definition of fistula, thereby making comparison between incidence numbers unreliable.

Our study found no significant correlation between the cleft width and the ratio of CP width to the sum of palatal shelves with occurrence of palatal fistula. We believe that to reduce fistula rates after palatoplasty, the surgeon must concentrate on the technique to achieve a tension-free repair with minimum trauma rather than be intimidated by the cleft width. The following steps are executed sequentially in the order given, stopping once a tension-free closure is achieved.

  1. Lateral releasing incision
  2. Releasing the pedicle circumferentially
  3. Tensor palati tenotomy
  4. Separating the pedicle by dissecting in the flap
  5. Dividing the periosteal sleeve around the pedicle
  6. Deroofing of greater palatine canal to release greater palate pedicle
  7. Use of buccal mucosa flaps.



  Conclusion Top


This study shows that the correlation between the width of the cleft and the width of palatal shelves has no significant influence on palatal fistula. The high incidence in previous studies may be related to surgical techniques rather than these factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cobourne MT. The complex genetics of cleft lip and palate. Eur J Orthod 2004;26:7-16.  Back to cited text no. 1
    
2.
Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, et al. Timing of hard palatal closure: A critical long-term analysis. Plast Reconstr Surg 1996;98:236-46.  Back to cited text no. 2
    
3.
Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, et al. Incidence of cleft palate fistula: An institutional experience with two-stage palatal repair. Plast Reconstr Surg 2001;108:1515-8.  Back to cited text no. 3
    
4.
Emory RE Jr., Clay RP, Bite U, Jackson IT. Fistula formation and repair after palatal closure: An institutional perspective. Plast Reconstr Surg 1997;99:1535-8.  Back to cited text no. 4
    
5.
Parwaz MA, Sharma RK, Parashar A, Nanda V, Biswas G, Makkar S. Width of cleft palate and postoperative palatal fistula – Do they correlate? J Plast Reconstr Aesthet Surg 2009;62:1559-63.  Back to cited text no. 5
    
6.
Bishara SE, Tharp RM. Effect of von langenback palatoplasty on facial growth. Angle orthop 1977;47:34-41.  Back to cited text no. 6
    
7.
Veau V. Division Palatine. Paris: Masson; 1931.  Back to cited text no. 7
    
8.
Wardill WE. Technique of operation for cleft palate. Br J Surg 1937;25:117.  Back to cited text no. 8
    
9.
Schweckendiek W, Doz P. Primary veloplasty: Long-term results without maxillary deformity. a twenty-five year report. Cleft Palate J 1978;15:268-74.  Back to cited text no. 9
    
10.
Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 2003;112:1542-8.  Back to cited text no. 10
    
11.
Cutting CB, Rosenbaum J, Rowati L. The technique of muscle repair in cleft soft palate. Plast Reconstr Surg 1995;2:215-22.  Back to cited text no. 11
    
12.
Landheer JA, Breugem CC, van der Molen AB. Fistula Incidence and predictors of fistula occurrence after cleft palate repair: Two-stage closure versus one-stage closure. Cleft Palate Craniofac J 2010;47:623-30.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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