Reinoso Quezada, Santiago José¹; Maurat Argudo, Andrea Karina²; Heredia-Veloz, David³

Language: English/Spanish [Versión en español]
References: 11
Page: 337-344
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ABSTRACT

Palatal fistulas are the most common sequelae after performing a primary palatoplasty, allowing the passage of fluids and food from the oral cavity to the nasal cavity. Commonly the closure of a fistula sometimes requires the use of local flaps (palatal), but according to the location and size of the fistula, the use of other techniques such as lingual flap rotation is required. The purpose of this study is to present clinical cases in which the lingual flap rotation technique has been used as an alternative in the closure of palatal fistulas, because this procedure provides excellent esthetic and functional results.

INTRODUCTION

One of the consequences after surgical procedures such as palatal plasty are palatal fissures. Due to the complications that these fissures can generate in the patient, it is necessary to look for surgical therapies to remedy this situation.¹ Among the surgical techniques used for the closure of palatal fissures, flap techniques are mentioned.^1,2 The reconstruction of oral tissues is a challenge for the surgeon because there are several important factors such as anatomy, location and size of the defect.²

The flaps can come from different areas of the jugal mucosa, temporalis muscle and fascia and tongue, the latter provides flaps without altering the function due to its high vascularization and mobility.^1,3

The technique based on lingual flaps has also been successfully described in the treatment of defects produced by trauma, neoplasms and infections.^1-4 This surgical procedure used as a therapy for the closure of palatal fistulas from lingual flaps has been used for at least 100 years showing good results, for this reason the present study aims to present clinical cases in which the technique of lingual flap rotation has been used as an alternative in the closure of palatal fistulas, because this procedure provides acceptable aesthetic and functional results.

Cleft lip and palate. Cleft lip and palate (CLP) are frequent congenital malformations, produced by an alteration in the fusion of the soft and hard tissues of the upper lip, alveolar ridge, hard and soft palate, which will give origin to the facial structure, during the sixth to tenth week of embryofetal life.^4,5 Cleft palate can be unilateral (left or right) or bilateral. Cleft palate can have two forms: a distinguishable V-shape (primary cleft) or a U-shape (secondary cleft).⁵ The integral treatment of this malformation should be conducted by a multidisciplinary team formed by surgeons, otolaryngologists, dentists, psychologists and speech therapists.⁵

Despite the existence of new trends in the management of patients with cleft lip and palate, palatal fistula continues to be a very frequent complication, considered the most common sequel after primary palatoplasty, a surgical procedure whose main objective is to allow the development of speech, the separation of the oral and nasal cavities in order to avoid nasal regurgitation.⁶

Palatal fistula. Palatal fistula is an abnormal communication between the oral and nasal cavity, which occurs more frequently in the hard palate, its etiology is associated to a complication to the primary treatment of palatal closure (palatoplasty). It is estimated that between 12 to 45% of the patients submitted to a primary palatoplasty will develop this sequel, being more frequent its location in the junction of the hard and soft palate.^1,6

The success of a primary palatoplasty is to achieve the separation between the oral and nasal cavity, however, different causes such as: tension of the flap, necrosis, failure in the healing, defects in the technique, can cause the dehiscence of the palatoplasty resulting in the presence of a fistula.¹

Classification of fistulas. Cohen and Posnick classified fistulas: based on the size of the defect:

• 1. Simple cleft: this is a minimal midline defect caused by a small dehiscence over the hard palate.^3,4
• 2. Small fistulas: they measure less than 1.5 cm in diameter, they are frequently located in the midline, they are produced by a small dehiscence on the junction of the hard and soft palate or necrosis on the edges of the flaps.^3,4
• 3. Large fistulas: larger than 1.5 cm in diameter and usually caused by necrosis of the anterior third of the flaps, due to a probable lesion of the palatine artery, which communicates with the alveolar cleft.^3,4

Conservative treatments such as the use of vestibular, palatal and combined flaps and even bone grafts are indicated for the closure of intraoral defects. The lingual flap is indicated in cases of recurrent fistulas, palates with excess of scars, palates with low quality and quantity of residual palatal tissue that do not allow an adequate closure and in defects larger than 1 cm in diameter.^1,6,7

However, some transoperative and postoperative inconveniences can be immediate: bleeding, hematoma, epistaxis, temporary loss of sensitivity and taste, and mediate: infection, dehiscence, necrosis. No alterations have been reported in the mobility of the tongue, in the diction and articulation of words, the only reported sequel is a thinning of the tongue.⁷

An important consideration for patients who undergo pedicled dorsum of tongue flaps is to maintain a liquid diet for at least 14 days until the pedicle is detached.^1,7

There are two methods for obtaining a tongue flap: anterior and posterior based. Anterior-based flaps are indicated for defects of the hard palate, anterior buccal mucosa, anterior floor of the mouth and lips. Posterior-based flaps are indicated for defects of the soft palate, retromolar area and posterior buccal mucosa.¹

CASES REPORT

Clinical case 1. Nine year old male patient with a diagnosis of sequelae of CLP, with no family pathological history, refers that after the attempt of several surgical procedures he still presents oral and nasal communication. In the intraoral examination presents: a nasopalatine fistula (Figures 1A-D and 2A-E).

Clinical case 2. A 14 year old male patient, with a diagnosis of bilateral CLP sequelae, with no family pathological history, refers that after the attempt of several surgical procedures presents an oral and nasal communication, in the intraoral examination presents: an anterior nasopalatine fistula (Figure 3). Surgical procedure for the closure of palatine fistula.

For this procedure the multidisciplinary team should be formed by specialists who know the particularities of this technique including: an anesthesiologist specialist who handles fiberscope since the patient after the first procedure will be extubated and it will be impossible to perform a laryngoscopy after extubation.

Step 1: creation of lingual pedicled flap. This procedure should be performed under general anesthesia (nasotracheal intubation, which will allow adequate handling of the surgical area without interruptions), and lidocaine infiltration with 2% epinephrine. The palatal reception flaps will be performed initially, for this purpose the bed that will receive the pedicle must be adapted, which must be done using nasal floor flaps that will allow closure in two planes, and the oral mucosa surrounding the fistula is prepared to receive the flap. The fistula should be measured in length, thickness, and depth, this measurement should be transferred to the tongue, and should be increased by 2 to 3 mm since, by the use of electrocautery or measures to avoid bleeding, the size of the flap may decrease. The pedicle should remain for a minimum of 14 days in this position so that the vascularity of the receptor site has sufficient flow since at the moment of releasing the flap, ischemia will be avoided.

Step 2: pedicle release. The procedure for flap release is complicated, since the patient has a limited oral opening, with a high risk of suffering any airway complication at the time of intubation. This intubation must be performed by specialists who handle nasofibroscopy since the patient must be intubated through the nose and with a nasofibroscope. The release of the pedicle is a simple cut that can be done with a scalpel or electroscalpel, an important consideration to be taken into account is to leave in the palate a redundant tissue that allows for correcting any future defect (Figure 2A-C). After suturing the pedicle to the recipient site, the tension of these sutures should be avoided as much as possible, so primary tension stitches have been proposed to hold the lateral edges and the tip of the tongue, which will prevent possible dehiscence of the tongue. The patient should be evaluated in the following days to control the adequate blood perfusion of the transplanted area.

Evolution. There were no complications during the surgery, bleeding was minimal. At 15 days the patient was taken to the operating room to perform the flap release, at 30 days the patient was evaluated but did not present any complications (Figure 1E-F).

DISCUSSION

Palatal fistulas are an important problem in the treatment of patients with CLP, due to the high incidence of recurrent palatal fistulas and the multiple failures and attempts to achieve closure of a fistula, several authors have reported success in the use of a lingual flap in 100% of cases, taking into account important aspects such as the existence of a sufficiently wide base that provides adequate blood supply since this can be affected by the intrinsic tension and torsion of the procedure. These results reported in the literature coincide with those found in this study since the cases described presented success in functionality and esthetics.^1,8 Similar results were found in the research of Guerrero Santos et al,^1,3 in their study they showed a 70% success rate of the therapy by using anteriorly based lingual flaps, similar data was observed in the study of Pigott with a success rate of 85% using the anteriorly based lingual flap surgical technique.^1,3

Due to the multiple failures and attempts to achieve the closure of a palatal fistula, Guerrero-Santos and Altamirano et al^7,9 1966, were the first to report the use of a lingual flap for the closure of palatal fistulas, due to its good vascularization and excellent esthetic and functional results, in this research a similar success to the one described in the mentioned study was obtained.^7,9 Nawfal et al⁷ in their research in 2014 referred in their therapies a correct closure of palatal fistula using the lingual flap technique.⁷ Alsalman et al^8,10 2016 demonstrated success in the surgical procedure based on lingual flap because the acceptance of the therapy was 100% in the cases that were submitted to this surgical intervention; similar results showed this research where 100% success was obtained in the cases submitted to the lingual flap rotation technique.

González-Sánchez, and Jiménez-Barragán¹¹ used local mucoperiosteal flaps, placement of autologous bone graft mixed with plasma rich in growth factors and showed complete closure of fistulas in 90.9%, decreasing the recurrence rate described with other techniques by other authors, which is why this technique can be considered as an alternative in the therapy of fistula closure.¹¹ López-Sánchez et al⁶ used a musculomucosal flap of the facial artery, the results were excellent in the reconstruction of fistulas with FAMM flap, in a primary form and without complications in five patients (62.5%), in two patients (25%) the flaps had to be revised due to necrosis,⁶ this technique did not show a total success in the treated patients, unlike the technique of rotation of lingual flap presented in this study where 100% of success in the surgical procedure was evidenced.⁶

CONCLUSIONS

• 1. The use of the lingual rotation technique is an excellent alternative when there is a failure in a primary palatoplasty.
• 2. This type of procedure will be used depending on the location and size of the fistula.
• 3. It is important to consider the existence of a wide enough base to provide adequate blood supply, since blood flow may be affected by the intrinsic tension and torsion of the procedure.
• 4. This surgical technique is indicated when there is a wide fistula larger than 1 cm and surgical treatments have already been tried without success.

REFERENCES

1. Galicia Partida A, Ramírez Lugo R. Reconstrucción de fístula palatina anterior con colgajo lingual de base anterior. Reporte de un caso. Rev Odont Mex. 2016; 20 (1): 50-56. doi: 10.1016/j.rodmex.2016.02.008.

2. Sendota Hincapié JC, López-Noriega JC, Ruiz Rodríguez R, Sámano Osuna I. Cierre de fístulas palatinas amplias mediante colgajos de lengua en pacientes con secuelas de paladar hendido. Rev Odont Mex. 2006; 10 (3): 131-137. doi: 10.22201/fo.1870199xp.2006.10.3.15901.

3. De la Riva Parra V, Martínez Miranda J, Campos Molina A. Colgajo lingual de base anterior para cierre de fístula palatina en secuelas de labio y paladar hendido. Presentación de un caso. Rev Mex Cir Bucal Maxilofac. 2011; 7 (3): 109-112.

4. Corbo Rodríguez M, Marimon Torres M. Labio y paladar fisurados. Aspectos generales que se deben conocer en la atención primaria de salud. Rev Cubana Med Gen Integral. 2001; 17 (4): 379-385.

5. Bedón Rodríguez M. Villota González LG. Labio y paladar hendido: tendencias actuales en el manejo exitoso. Archivos de Medicina. 2012; 12 (1): 107-119.

6. López-Sánchez R, Berenguer-Fröhner B, González-Meli B, Rodríguez-Urcelay P, Marín-Molina C, De Tomás-Palacios E et al. Colgajo FAMM para reconstrucción de fístulas de paladar en pacientes con fisura palatina congénita: experiencia y resultados. Cir Plast Iberolatinoam. 2014; 40 (3): 261-270.

7. Nawfal F, Hicham B, Achraf B, Rachid B. Repair of large palatal fistula using tongue flap. Afr J Paediatr Surg. 2014; 11 (1): 82-83. doi: 10.4103/0189-6725.129247.

8. Mahajan RK, Chhajlani R, Ghildiyal HC. Role of tongue flap in palatal fistula repair: a series of 41 cases. Indian J Plast Surg. 2014; 47 (2): 210-215.

9. Mohan V, Nair RU, Usha AM. Versatility of tongue flaps for closure of palatal defects-case report. J Clin Diagn Res. 2017; 11 (1): ZD31-ZD33. doi: 10.7860/JCDR/2017/23978.9219.

10. Alsalman AK, Algadiem EA, Alwabari MS, Almugarrab FJ. Single-layer closure with tongue flap for palatal fistula in cleft palate patients. Plast Reconstr Surg Glob Open. 2016; 4 (8): e852. doi: 10.1097/GOX.0000000000000841.

11. Jiménez-Barragán K, González-Sánchez JG. Uso de plasma rico en factores de crecimiento para disminuir la recurrencia de fístulas nasopalatinas en pacientes con antecedente de paladar hendido. Otorrinolaringología. 2011; 56 (2): 63-75.

AFFILIATIONS

¹ Odontólogo Especialista en Cirugía Maxilofacial y Craneofacial, Universidad Nacional Autónoma de México. Subdecano de la Unidad Académica de Salud y Bienestar.

² Odontóloga. Magíster en Bioética, Universidad del Azuay de Cuenca. Docente en la Carrera de Odontología.

³ Odontólogo, Universidad de Cuenca. Máster Universitario en Educación Universitaria, Universidad Europea de Madrid, España.

Research support: the present research project was funded by the authors for its execution and completion.

CORRESPONDENCE

Santiago José Reinoso Quezada. E-mail: sreinoso@ucacue.edu.ec

Received: Noviembre 2017. Accepted: Febrero 2018.