Cleft oronasal fistula: A review of treatment results and a surgical management algorithm proposal

Background: Oronasal fistulas (ONF) following cleft palate repair are commonly encountered and remain a challenging problem. With reported recurrence rates between 33% and 37%, this urges us to critically evaluate the current treatment and propose a surgical management protocol. Methods: A retrospective study of patients treated for ONF by a single surgeon between 1995 and 2005 was performed. Data regarding cleft type, age at palate repair, complications, location and size of fistula, tissue condition, surgical technique employed, and success rate were gathered. Results: There were 64 patients (33 male and 31 female), and 44% of them had bilateral cleft lip and palate. Hypernasality and regurgitation were the major presenting symptoms of these patients with ONF. Fistulas mostly occurred in the hard palate area (53.1%). Severe scarring surrounding the ONF was reported in 31.2% of patients. Local flap and two-flap palatoplasty were the most common techniques (62.5%) used for closure of the ONF. Twenty-five percent of patients needed more than one repair to close the fistula. However, the overall success rate of closure was high (90.5%). Velopharyngeal (VP) function was significantly improved: only 26.8% of patients had adequate VP function before ONF closure and 64.3% patients had adequate VP function after ONF closure. However, the VP function of twenty patients remained inadequate or marginal. Conclusions: A high success rate was achieved for closure of cleft ONF, although a certain percentage of patients required re-operation. Multiple fistulas and severely scarred palates made closure difficult. Successful closure of a fistula improved VP function but VP surgery was still indicated in certain patients. Based on the findings, an algorithm for management of cleft ONF was proposed.