CASE REPORT |
https://doi.org/10.5005/jp-journals-10077-3293 |
Use of Tongue Flap in Anterior Palatal Fistula Repair: A Case Report
1,4–6Department of Oral and Maxillofacial Surgery, GSL Dental College and Hospital, Rajamahendravaram, Andhra Pradesh, India
2,3Department of Pediatric and Preventive Dentistry, GSL Dental College and Hospital, Rajamahendravaram, Andhra Pradesh, India
Corresponding Author: Padma Praveena Mavuri, Department of Pediatric and Preventive Dentistry, GSL Dental College and Hospital, Rajamahendravaram, Andhra Pradesh, India, Phone: +91 9989709564, e-mail: praveenamavuri@gmail.com
Received: 13 December 2023; Accepted: 30 January 2024; Published on: 27 April 2024
Aims and background: Orofacial clefts are one of the most prevalent congenital anomalies worldwide and contribute significantly to the global burden. Cleft of the palate is widespread and negatively impacts health and child development, leading to social isolation, speech problems, malnutrition, and psychological effects. Case description: A 9-year-old child reported to the department with the chief complaint of regurgitation of liquids through the nose. The patient was diagnosed with an anterior palatal fistula. The present case report provides insight into the use of tongue flaps for palatal fistula closure and a brief review of other techniques. Conclusion: Though recurrent palatal fistula closure is a difficult condition, there are several treatments available, and the success of the treatment depends on the size and position of the fistula and clinical expertise. Clinical significance: Utilization of tongue flaps to close palatal abnormalities is associated with a low incidence of complications and a higher rate of success in both children and adults. When treating end-stage palatal anomalies, tongue flap closure is associated with a high success rate and a low rate of complications in both children and adults. How to cite this article: Pamidi VRCB, Mavuri PP, Javangula TP, et al. Use of Tongue Flap in Anterior Palatal Fistula Repair: A Case Report. J South Asian Assoc Pediatr Dent 2024;7(1):42–45. Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.ABSTRACT
Keywords: Case report, Cleft palate repair, Oronasal fistula, Palatal fistula, Tongue flap
INTRODUCTION
Oronasal fistula or anterior palatal fistula is the most frequent problem that results after cleft palate repair, accounting for 4% of cleft-treated cases.1 Based on the size, palatal fistulae can be categorized as small (<2 mm), medium (2–5 mm), and large (>5 mm).2 Large fistulas require early closure since they significantly impair speech and cause fluid and food particles to regurgitate through the nose. Fistulas develop as a result of tension produced during closure, which leads to dehiscence and infection of the wound, impairment of vascular supply, trauma to the tissue, hematoma formation, and airway compromise.3
Patients with oronasal fistulas can be treated by means of either surgical intervention or nonsurgical therapy. For the closure of symptomatic fistulae, a two-layer, tension-free closure is recommended. There are numerous surgical procedures available to close the fistulae. The various factors that play a role in the choice of closure method include the size, location, and quality of the surrounding tissue, the number of previous attempts of closure, the expertise of the operating surgeon, and others.
The different types of flaps used for the repair of the palatal fistula include local flaps, regional flaps, and free tissue flaps. The immediate area of resection serves as the source of local flaps, which are rotated into position and are provided with axial blood supply. Buccal mucosal flaps, facial artery myomucosal flaps, pharyngeal flaps, nasolabial flaps, and tongue flaps come under local flaps. Radial forearm flaps, fibula-free flaps, and free Iliac crest flaps are examples of free tissue flaps that undergo fibrosis and epithelialization over a period of time to provide mucosal lining for prosthetic rehabilitation. Use of regional flaps in the head/neck area includes the temporalis and pectoralis major myocutaneous flaps, which are reliable and adapt but have a poor esthetic result due to their bulk of the tissue.4
CASE DESCRIPTION
A 9-year-old child reported to the Department of Pediatric and Preventive Dentistry with the chief complaint of opening in the palate and regurgitation of liquids through the nose. On eliciting the history, at birth, the child had unilateral cleft lip and palate. He was operated for cleft lip at 9 months and cleft palate at 18 months of age. After 2 years of primary closure of the palate, the parents noted a small fistula in the anterior part of the hard palate, which increased to the present size. There was nasal regurgitation on taking fluids for 2 years. Extraoral examination showed scarring of the left upper lip, deviated columella and nasal tip with bulging of the upper lip toward the right (noncleft side), mismatched level of the lower lateral cartilages, and widening of the nostril due to inadequate support on the side of the cleft.
On clinical examination, 1 × 1.5 cm oval-shaped oronasal communication was noted in the anterior region of the hard palate, extending mediolaterally from 11, 12, and 21 and anteroposteriorly from the lateral incisor on either side to the first deciduous molar (Fig. 1). The residual palatal mucosa measured 2 mm on each side adjacent to the defect. A final diagnosis of the anterior palatal fistula was given, and treatment planning was done to close the defect by using a tongue flap.
Fig. 1: Fistula measuring 1.0 × 1.5 cm noted in the anterior hard palate crossing the midline
Treatment Procedure
Preparation of Palate
Routine blood investigations such as complete blood pictures, clotting and bleeding time, kidney and liver function tests, and chest X-rays were advised. After assuring all investigations to be normal, nasal intubation was done under aseptic conditions. Skin preparation was done using 5% betadine, and local infiltration was given with 2% lidocaine with 1:200000 epinephrine. A transverse incision was made around the margins of the fistula, and the palatal mucosa was elevated to expose the defect completely. The nasal mucosa was separated and approximated with 3–0 and 4–0 Vicryl sutures (Fig. 2).
Fig. 2: Transverse incision on the palatal flap proximal to the rim of the fistula
Management of Tongue Flap
A bite block was placed. The tip of the tongue was secured with a suture to allow for protrusion. After local anesthesia administration, a little wider flap than the width of the fistula containing mucosa, longitudinal muscle, and transverse muscle was raised with the anterior pedicle (Fig. 3). The raised flap was then approximated with the palatal mucosa and sutured to the nasal mucosa (Fig. 4). Postoperatively, the airway was secured using the nasopharyngeal tube. The patient was put on fluids for 1st week. Intermaxillary fixation was done for 3 weeks while feeding was provided using a ryles tube during the postoperative period. Periodically, intermaxillary fixation was released, followed by thorough irrigation to aid in better healing of the defect.
Fig. 3: Tongue flap containing mucosa, longitudinal muscle, and transverse muscle elevated from the dorsum of the tongue
Fig. 4: Tongue flap secured to the palate by Vicryl sutures
After 3 weeks, when there was uneventful healing of the flaps, a second surgery was planned to separate the pedicle. Nasal intubation was done. The donor area of the tongue, that is, the anterior-based tongue flap, was debrided with approximation to the hard palate was done using 3–0 Vicryl sutures. The recipient area of the palate was closed on all sides (Fig. 5).
Fig. 5: After 3 weeks, separation of tongue flap from dorsum and approximation to the soft palate
On follow-up after 3 weeks, there was complete healing of the donor site with slight narrowing of the tongue (Fig. 6) with normal movements and speech. There was uneventful healing and closure of the anterior palatal fistula at a recall of 3 months (Fig. 7). Class II composite restorations in relation to 54, 55, 64, and 65, and pit and fissure sealant applications were done in relation to 16 and 26 at 3 months follow-up period.
Fig. 6: Complete healing of the donor site after 3 weeks
Fig. 7: At 3 months recall, uneventful healing and closure of anterior palatal fistula
DISCUSSION
Guerrero-Santos and Altamirano were the first to report the use of tongue flaps to treat hard palate fistulae.
The better adaptability of the tongue flap was contributed by the abundant circulation provided by the lingual artery and its branches. The easy accessibility of the available tissue from the tongue provides effective closure of large palatal defects.6 There is no major donor morbidity associated with tongue flap no impairment to speech or movement, but a transient loss of taste sensation was noted.7 Vasishta et al., in their study, treated 40 (24 males and 16 females) patients with palatal fistulas by the use of tongue flaps and concluded that tongue flaps resulted in excellent vascularity and the least morbidity of the donor site.7 In their review of 20 patients with recurrent secondary palatal fistula treated with anteriorly and posteriorly based dorsal tongue flaps, Gupta et al.5 found it to be a successful procedure because it offers significant amounts of well-vascularized tissue for fistula closure with minimal functional and esthetic morbidity. A few other techniques described in the literature are discussed.
The free radial forearm flap described by Zemann et al. demonstrated that the radial forearm flap leaves only minor scarring when used to close palatal defects in children younger than 6 years.8
Kobayashi et al.9 suggested a buccal musculomucosal flap as a treatment alternative for the closure of large palatal defects after cleft palate repair. The advantages include no requirement for a second surgery to release the pedicle and no detrimental effects at the donor site; neither was there difficulty in speech nor disturbances in taste.
Choi et al.10 in his case report , described the use of buccinator myomucosal flap which was first introduced by Bozola et al. in 1989, as the surgical technique of choice in children due to its proximity to the palatal region and minimal donor-site morbidity.
Ashtiani et al.11 in his case report of 22 cases, described facial artery myomucosal flap, which was first introduced Pribaz et al. in 1992, to be a useful flap when surrounding tissue quality or availability is low and the fistula is large and resistant. It is a single-staged procedure with low donor site morbidity. Despite the availability of abundant vascularized tissue, there are chances of complications such as partial or complete failure of flap tissue due to venous congestion, thrombosis, and recurrent infection of the fistula.
Vomer flaps, which were introduced in the early 1900s, were used for primary hard palate closure. Several studies reported spontaneous narrowing of the residual hard palate cleft after primary closure of the soft palate with a vomer flap.12
Mastoid fascia graft is a three-layer technique for the closure of fistulas without tension. This procedure via postauricular sulcus incision helps minimize the formation of incision scars.13 Several other donor sites, such as the vast lateralis muscle, first dorsal metatarsal artery, and radial forearm, with or without prelamination, have been considered in the literature for the repair of palate abnormalities.14
CONCLUSION
Though there are several treatment options available in the literature, recurrent palatal fistula closure still remains a difficult condition. A customized approach should include the patient’s preferences, the size and position of the fistula, the symptoms present, any previous closure procedures, the quality and quantity of the surrounding tissue, and the size and location of the surrounding tissue. Reconstruction of oral deformities with the help of a tongue flap is the most reliable technique since it produces excellent results with a low risk of morbidity.
Clinical Significance
The tongue flap is the preferred tissue over the other available flaps owing to their location in the floor of the oral cavity, offering a wide range of motion and various options for positioning. Though it is a two-stage surgical procedure, the tongue flap continues to be the preferred flap for treating extremely severe and complex anterior palatal fistulae since it produces excellent results with a low risk of morbidity and a high percentage of success in both children and adults.
ORCID
Padma Praveena Mavuri https://orcid.org/0000-0002-4609-4976
Tripura Pavitra Javangula https://orcid.org/0000-0003-0448-5191
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