Oral Maxillofacial Surg Clin N Am 14 (2002) 553 562

The management of oronasal fistulas in the cleft palate patient

Orrett E. Ogle, DDS
Department of Dentistry, Oral and Maxillofacial Surgery, Room 2B-320, Woodhull Medical and Mental Health Center, 760 Broadway, Brooklyn, NY 11206, USA

An oronasal fistula is an abnormal communication between the oral cavity and the nose that occurs after surgical repair of a cleft palate. After the primary repair of a cleft palate, oronasal fistulas develop in a certain number of patients; this is the most common defect in the hard palate after the primary surgical repair [1]. These fistulas are sometimes located in the soft palate but occur more frequently in the hard palate. They typically occur at the junction of the primary and secondary palate or at the junction of the hard and soft palate. It is difficult to determine the true incidence of fistula formation after primary repair of a cleft palate because the reports in the literature vary widely, and the centers that generate the reports seem to have a significant influence on the rate of fistula development. The severity (width) of the original cleft, however, shows a direct correlation with the risk of fistula formation [2], and the incidence of fistulas is higher after palatoplasty for complete clefts of the primary and secondary palates than after closure of an isolated secondary palatal cleft [3]. The technique used to close the palate and the experience and skill of the surgeon affect the occurrence rate [4]. Reported incidences over the years have ranged from a low of 5% [5] to between 9% and 50% with one-stage closures in a review article by Shultz [6]. In 1960, Musgrave and Bremner [5] reported the incidence of fistula formation in the palate to be 12.5% for bilateral clefts, 7.7% for unilateral clefts, and 4.6% for isolated clefts of the secondary palate. These numbers seem to be low compared to rates published

E-mail address: ogle-me@worldnet.att.net.

more recently in which the mean for isolated cleft palate was reported at 15% [6]. Lilja et al [7] reported an 8% fistula formation rate with their older use of the Wardill-Killner technique, and in the authors experience this technique produces fewer fistulas in the hard palate than other techniques that close the hard and soft palate in a one-stage procedure. The defect (often referred to as a fistula) in the anterior alveolar palate (Fig. 1) must be considered a residual cleft rather than a fistula, because this area is usually not repaired as a part of the primary closure of the cleft palate defect in cleft lip and cleft palate patients but is intentionally left opened. The management of this defect is presented elsewhere in this issue and is not discussed in this article. Some of the causes of oronasal fistulas include excessive tension on the primary repair site because of inadequate medial mobilization of the flaps, excessive trauma to the margins of the palatal flaps by instruments during surgery, faulty suturing, traumatic disruption of the healing wound, infections, inadequate attachment of the palatal tissue to the nasal mucosa, hematoma formation between the oral and nasal layers, and flap necrosis. The development of the fistula may be noted in the immediate postoperative period or may not become evident for a few weeks. Surgery to close the fistula should not be attempted too early, and the surgeon should wait until the area is fully healed and the inflammation has subsided completely (4 6 months). Attempting to close the defect in the presence of inflammation only makes the fistula worse because sutures do not hold in the inflamed palate and walk through the tissue in a few days. The presence of excess foreign body material de-

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Fig. 1. Unrepaired alveolar cleft.

creases hygiene at the repaired site, further increases the inflammation, and causes more tissue trauma and increased necrosis, with a resultant loss of additional tissue. An inadequate blood supply also negatively affects the healing process. In most attempts at early closure, only a one-layer closure is achieved, and secondary-breakdown is frequent. Adequate healing and subsequent scar contraction lead to a decrease in the size of the fistula and, in some cases, the fistula might even close spontaneously [8] or decrease to a size at which it causes minimal problems because the patient adapts completely to the larger problems that result from the fistula. Poor blood supply is one of the major contributing factors for the failure of fistula closure. Six to 12 months is the average time for the blood supply to reestablish itself satisfactorily after primary repair of the cleft palate. A wait of longer than 6 months is reasonable before closure of a palatal fistula is attempted.

into the mouth. Food particles that become impacted into a small fistula or crevice produce malodorous breath. Leakage from the nose also can be problematic and embarrassing. As nasal secretion seeps into the mouth, it produces a bad taste, poor oral hygiene, and bad breath. Larger fistulas permit a free flow of fluid into the nasal cavity in a volume large enough that it may exit through the naris. When attempting to drink, fluid may embarrassingly escape through the nose and run down on the upper lip. Similarly, mucus from the nasal cavity freely enters the mouth. The oronasal communication also may result in air loss through the nose during speech, which distorts articulation and produces hypernasal speech. Henningsson and Isberg [9] found that a palatal fistula as small as 4.5 mm2 can affect speech and resonance and result in hypernasality, audible nasal escape, and weakness of pressure consonants.

Closure of fistula The repair of a palatal fistula in the cleft palate patient is much more difficult than it seems, and most fistulas present a problem in which an extensive operation is needed to resolve a small defect. In some cases the financial cost may be high because a short stay in the hospital may be required for young children (teenagers can be treated on an ambulatory basis), and dietary restrictions are necessary for 7 to 14 days. Because of sometimes limited surgical access and scar tissue from previous surgery, successful closure is not always achieved. Large fistulas that permit the passage of liquid and food particles into the nose or affect speech should be closed as early as possible. When the fistula is small and presents minimal problems to the patient, closure can be delayed for several years. Small fistulas may be left untreated if they present no significant problem. It is the authors belief, however, that most of these defects should be closed at some point to provide a healthy oral and nasal environment. Most of these openings can be closed by using local tissue from the roof of the mouth without having to resort to distal flaps. The local blood supply is usually good enough to allow safe mobilization of mucoperiosteal flaps from the hard palate despite the presence of scarring. When additional tissue is needed, a flap may be developed from the tongue. In the case of the posterior fistulas addressed in this article, the tongue flap is posteriorly based. Closure of a communication between the oral and nasal cavities should be two layered because it

Problems of oronasal fistulas The problems caused by oronasal fistulas depend on the size of the fistulas and a patients ability to accommodate the smaller ones. Some of these fistulas are so small that they may not cause any obvious problems and the patient may be unaware of their existence. On the other hand, some children learn to control the problems caused by the fistula as they get older, despite the persistence of a moderately sized defect, and their complaints are minimal. A fistula is often a nuisance that permits liquids and occasionally solid food to go through into the nose. This is true regardless of the size of the hole. Small fistulas can be bothersome to the patient if popcorn kernels, nuts, or grains become lodged in the opening. Removing the particle can be uncomfortable and embarrassing as the patient noisily tries to suck the particle back

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provides greater support and stability of the repair and reduces the risk of failure. A two-layered closure can be obtained by turning medial and lateral flaps from the cleft margin (turnover flaps) to form the nasal floor. This area can be covered with a palatal flap based on the greater palatine artery [10]. When a palatal rotational flap is used, the suture line ideally should be over bone. The design of this palatal flap is similar to the one used to close a chronic oro-antral fistula, which results from perforation into the maxillary sinus as a complication of exodontia [11]. When designing the flaps on the palate for closure of the fistula, the flaps must be larger than the actual defect. This rule applies to the turnover flap and the rotation flap. The palatal mucoperiosteum is stiff, particularly when scarred by previous surgery. It does not transpose easily, nor is it elastic enough to stretch. The design also must permit adequate mobilization of the flaps to allow complete coverage of the defect without tension. To avoid failure, the flaps should be freed up sufficiently to allow them to come together in a tension-free manner. Oronasal fistulas in the soft palate do not require early treatment unless speech is affected. If there is adequate movement in the soft palate and speech is grossly unaffected, these fistulas may be closed at the same time that the bone graft for the alveolar cleft is performed [3]. The soft palate fistula can be closed easily by excising the fistula and closing the defect in two layers. Although it is tempting to close a narrow defect that follows the line of the palatal cleft in the hard palate by performing a modified von Langenbeck procedure (advancement flaps) and suturing the edges of the fistula medially in one layer, the surgeon must be aware that this technique has a high failure rate. Closure of the oronasal fistula in patients younger than age 5 is controversial. Before that age the maxilla has not matured adequately, and a secondary surgical intervention would disrupt the overlying periosteum, which further compromises the existing blood supply, increases the scarring with greater scar contraction on the alveolus, and worsens the malocclusion by the time of the full permanent dentition. Multiple procedures to achieve complete palatal closure were believed by some surgeons to cause inhibition in maxillary growth [12], which is still the belief of some cleft surgeons. Disruption of the overlying palatal periosteum at an early age also has been believed to cause midface growth restriction [13]. Contrary to this concept, other authors have stated that no hard evidence supports the theory that delaying surgery improves growth [14,15]. Many surgeons believe, however, that scar tissue produced by leaving

denuded area on the palate leads to subsequent dental malocclusion [16]. Because of this, some cleft centers with strong orthodontic input wait until the patient is at least 10 years old before attempting fistula repair. (Readers also should refer to the article by Bishara elsewhere in this issue for further discussion of this topic.) The quality of the speech always should be the guiding factor. For cases in which speech is severely affected, the surgeon, in consultation with the speech pathologist, may consider closing the fistula early. A speech distortion acquired at an early age is not necessarily permanent, however, and may be corrected through vigorous speech therapy after closure of the fistula and orthodontic or orthodontic/surgical treatment is completed [17]. As an alternative to early surgery, an obturator may be used to manage the oronasal fistula. DAntonio et al [18] found a significant improvement in the perceptual and aerodynamic characteristics of speech with temporary occlusion of hard palate fistulas. Early speech problems may be managed successfully on a temporary basis with a palatal prosthesis if compliance can be maintained [19], although it should be noted that 35% of patients studied were noncompliant with the prostheses. Isberg and Hennigsson [20] reported that obturation of the fistula consistently improved velopharyngeal activity regardless of its size and recommended that preoperative velopharyngeal videofluoroscopy be performed with an obturator in place. A palatal prosthesis, however, never should be considered as definitive treatment, and surgical repair of the defect always should be the final goal. If a palatal prosthesis is used, the child should be monitored carefully by a speech pathologist and surgery should be considered if adequate speech does not develop. Another use of the palatal prosthesis may be diagnostic, because it may be used to cover the defect preoperatively to give the surgeon the ability to predict surgical outcomes before secondary repair if the decision was made to repair the fistula before age 5. A maxillary denture with an attached speech bulb may be used to obturate the fistula in older individuals if requested by the patient (Fig. 2). The palatal prosthesis also can be used to obturate the fistula while the maxillary arch is expanded orthodontically [21].

Surgical techniques Longitudinal fistulas along the line of the palatal cleft If the fistula is long ( > 15 mm) and narrow (3 7 mm), closure may be attempted with a modification

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Fig. 2. Denture with an attached speech bulb that was used to obturate an oronasal fistula in an elderly edentulous cleft patient.

of the von Langenbeck procedure. With small fistulas it is difficult to obtain adequate closure of the nasal mucosa because of a lack of working access, and often it is not possible to bring the bleeding edges together because they tend to roll upward into the nasal cavity. A secure two-layered closure must be obtained and there should be minimal tension on the closure of the nasal mucosa. The cross-section of the fistula is measured and divided into two. The incision near the edges of the fistula must provide the additional tissue that is needed to bridge the defect. The distance obtained by halving the width of the fistula is noted, and an additional 2 to 4 mm is added, which provides the distance from the edge of the fistula where the medial incisions are placed. An adequate nasal flap is important to provide a tension-free closure. In addition to providing tissue to lengthen the nasal mucosa and bridge the defect, the additional border of oral mucosa is away from the edge of the fistula, which may be inflamed, and is better able to hold sutures. The two medial incisions are placed adjacent to the fistula. The length of these incisions should extend approximately 5 to 7 mm beyond the end of the fistula anteriorly and posteriorly. Lateral releasing incisions are then made. The surgeon is able to see a scar line between where the flap for the primary closure meets with the area that was left denuded to heal by secondary intention. The lateral releasing incisions should be placed on this scar line and should be long, which gives an adequate flap and

good lateral release and maintains the arterial blood supply. The incision is made to bone. Starting at the lateral incisions, a full-thickness mucoperiosteal flap is lifted widely off the bone. The surgeon should be careful to maintain the periosteal elevator on the bone while lifting the entire periosteum. (Fig. 3). The dissection is continued medially to end at the previously made incision at the margins of the fistula. The surgeon should see the periosteal elevator exiting this incision. The lateral flap is mobilized completely. The surgeon should grasp the flap with a 1 2 delicate Adson forcep (12 cm) or any other long, fine tooth forceps and check to see if the flap can be advanced to approximately 3 mm beyond the midline without tension. This test should be conducted at several points. Once the surgeon is certain that the lateral flaps can reach the midline in a tensionfree manner, attention is directed to the nasal mucosa. Using a combination of straight and curved Freer elevators, the mucosa is elevated carefully toward the fistula. Small nicks may have to be placed at the ends of the incision to obtain adequate release to be able to turn over the flap. At the bony margin, the nasal mucosa is freed carefully from the superior aspect of the palatal shelve. The dissection of the nasal mucosa is complete when it is able to reach 2 to 3 mm beyond the midline at least at three points in a tension-free manner. Once the four flaps have been developed and adequately mobilized, they are sutured in the midline.

Fig. 3. Developing an oral mucosal flap for closure of fistula using a modified von Langenbeck technique.

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The nasal mucosa is closed with 4-0 Vicryl on a P3 or RB1 needle. When closing the nasal mucosa, the knots are placed into the nasal cavity so as to minimize dead space between the nasal and oral mucosal layers. The palatal mucosa is advanced and closed in the midline with 4-0 Vicryl (Fig. 4). Mattress sutures are used to evert the wound margin; inversion of the margins of the palatal mucosa would cause a recurrence of the fistula.

Large round fistulas (Fig. 5A) This type of fistula is best closed by using a lining turnover flap hinged on the edge of the defect and a covering flap of palatal tissue mobilized from the side of the cleft. The turnover flaps form the floor of the nose, which permits epithelium to be placed into the nasal cavity and the bleeding side facing toward the mouth. The bleeding tissue is covered by the rotational flap. An incision is placed around the fistula (Fig. 5B,C). The distance of the incision from the edge of the defect is determined as described in the previous section. The flap must be long enough to reach beyond the midline of the defect because the closure must be tension free. The flap is elevated carefully and is turned over 180 to form the lining of the nasal cavity

Fig. 4. Complete closure of the nasal mucosa and partial closure of the oral mucosa using the modifiedvon Langenbeck technique.

(Fig. 6A,B). These flaps are closed with 5-0 Vicryl on a RB1 or P3 needle. A template is fabricated from the packaging paper of the surgical glove. The paper is cut to shape to cover the defect completely. Holding the paper over the defect, an ideal base of the rotational flap is determined. A hemostat or blunt periosteal elevator is used to secure the paper template at the proposed base of the rotational flap, and the anterior edge is transposed over the palate to give the length and size of the palatal flap. It is wise to add a few extra millimeters to the tip and to one of the borders to ensure adequate tissue for closure. The palatal flap is outlined and cut (Fig. 7). The flap is mobilized fully all the way to the greater palatine foramen, which is located approximately opposite to the third molar at the junction of the vertical alveolus and the horizontal shelf of the palate. As the surgeon approaches the foramen, a small bony projection is noted. The flap must be mobilized fully and rotated freely. As the flap is rotated medially, some bunching of the tissue is noted at the medial turn. A triangular wedge may be excised to permit the flap to lay flat. The palatal mucoperiosteal flap is rotated and sutured in place with 4-0 Vicryl sutures to cover all cut margins. It is best to place the first suture at the tip of the rotational flap and take it to the deepest portion of the defect left by the turnover flap. Once this is secured, the posterior areas are closed followed by the anterior area closest to the surgeon (Fig. 8A,B). The re-mucosalization of the hard palate is by secondary intention. The coverage of the denuded area on the hard palate with new mucosa occurs rapidly, is usually complete by postoperative week 4, and results in a near normal appearing hard palate surface. Because this process takes place over bone, contracture and donor site deformity are minimal if performed in the secondary dentition stage. If done in the primary dentition stage, however, the resulting scar may have an adverse effect on dental development. Postoperative discomfort is minimal. The author does not advise the use of a prefabricated prosthesis to attempt coverage of the donor site defect because the prosthesis may cause pressure on the inflamed flap and compromise its blood supply. An area of dead space between the bone and the rotational flap that results in the anterior portion of the wound, can be obliterated by placing Gelfoam or strips of absorbable collagen hemostatic sponges between the flap and the bone. The surgeon should be sure that hemostasis is complete before discharging the patient from the operating suite. Bleeding points may be controlled with low power electrocautery.

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Fig. 5. (A) Large, round oronasal fistula in the posterior portion of the hard palate. (B) Outline of the incision for the turnover flaps for creating the nasal floor. The epithelial portion of the hinged flap is in the nasal passage. (C) One side of the hinged flap developed and being turned into the nasal floor.

Fig. 6. (A,B) Turnover flaps sutured to create the nasal floor.

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Soft palate fistulas A #12 or #15 Bard Parker blade is used to split the tissues in the middle of the fistula. Using a combination of the Jeter cleft palate scissors (a pair of angled scissors) and the Dean scissors, the oral mucosa is separated from the underling layer of muscle and nasal mucosa. A fairly wide dissection is made until it is possible to bring both layers to the midline without tension. The tissue should be grasped with fine tooth forceps with minimal force. Care must be taken not to handle the palatal mucosa excessively with these forceps because it traumatizes the wound margin and produces inflammation, which makes it difficult to hold the sutures in the immediate postoperative phase. The layer of muscle and nasal mucosa is closed with 4-0 Vicryl, as is the palatal mucosa. At least two mattress sutures should be placed in the oral mucosa to evert the margins. Tongue flap The tongue flap is indicated for closure of a palatal fistula in cleft palate patients with a persistent large palatal defect, in heavily scarred palates, and in cases in which previous attempts at fistula closure have been unsuccessful. It should not be the first method of choice and should be used only when other methods are not feasible. The tongue is undoubtedly the most important organ in the oral cavity with respect to sensation and function. Taking tissue from it may cause some sensory deficits and deformity that may otherwise be avoided by using local flaps to this

Fig. 7. Outline of rotation flap to form the outer layer of the closure.

Small round/oval fistulas (Fig. 9) The technique for closing these smaller fistulas is identical to that described for the large, round fistulas except that only one turnover flap is made (Fig. 10A,B). The turnover flap should be big enough to cover the defect completely. It is sutured beyond the clinical defect. When cutting the rotational flap, it should not be cut exactly at the edge of the defect; rather, a small margin of tissue should be left to hold sutures from the turnover flap. The rotational flap is measured, cut, elevated, and sutured into place with 4-0 Vicryl.

Fig. 8. (A,B) Postoperative view of immediate closure.

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Fig. 9. Small oval fistula in the middle zone of the hard palate.

more complex technique. It must be noted, however, that no reports have shown that removing sizeable segments from the tongue causes any impairment of speech or movement and that loss of tongue sensation and taste is temporary [22]. The tongue flap offers the advantages of an abundance of tissue for palatal reconstruction, an excellent blood supply, and ease of rotation. The posteriorly based midline tongue flap gives the greatest blood supply [23,24] and, consequently, a high success rate [22]. There is also low donor morbidity with tongue flaps [22,25]. Where possible, a two-layered closure also should be achieved with the tongue flap [26], but because of the cases in which the tongue flap is used for posterior fistulas this is often not possible. The surgery is performed under general anesthesia with a nasotracheal tube. The margins of the fistula

are deepithelialized by beveling the periphery of the defect to increase the area of contact. The bevel is placed away from the defect so as to increase the bleeding surfaces on the palatal mucosa adjacent to the defect. The bevel should be fairly large to expose a widely bleeding surface onto which the tongue flap is sutured. The tongue flap is designed so that the base of the flap lies slightly behind the posterior border of the fistula with the tongue in the neutral position. The width of the flap should be sufficient to fill the crosssectional defect, and the length should be long enough (Fig. 11) to allow for the turnover with some freedom of tongue movement. The creation of a long pedicle permits slack in the flap, which allows greater freedom of movement of the tongue [27]. The base of the flap should be at least half the width of the tongue or two thirds the width of the fistula to ensure a rich blood supply. The base should be as wide as anatomically possible. The tongue is dried and the flap design is marked on the dorsum of the tongue with a surgical marking pen. The flap is raised with either a #15 scalpel blade or electrocautery with an even thickness. The thickness of the flap should be between 7 and 10 mm and includes the underlying muscle, which ensures a rich vascularity. After full mobilization of the flap, complete hemostasis is obtained at the donor site, which is then closed with resorbable sutures. In attaching the tongue flap, 4-0 Vicryl is first placed in the posterior portion of the defect. Approximately six sutures are preplaced. The needles are left attached to the sutures, and they are left long. The

Fig. 10. (A) Outline of incisions for one turnover flap and a rotational flap to close the defect and form the outer layer. (B) Immediate postoperative closure.

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Fig. 11. Posteriorly based tongue flap with long pedicle.

alignment of the tongue flap is determined and the position where each suture will be placed is ascertained. At least three sutures from the margins of the fistula are placed into the tongue flap and left untied originally. The knots may be tied after the third suture is in place. The remaining preplaced sutures are passed through the tongue flap and secured. The remainder of the unclosed margins, which are accessible, is closed completely with interrupted sutures. In most cases the flap is usually left with a raw surface, but it may be tubed. Maxillo-mandibular fixation (MMF) can be used to decrease movement and tension on the sutures and ensure the security of the flap insertion [28,29]. At the end of the procedure the surgeon should evaluate the adequacy of the airway. A bite block may be left in the mouth for the first 12 hours and the patient kept in a beach chair position. Patients who have had previous velopharyngeal flaps should be intubated for 1 or 2 days after tongue flap surgery and MMF should not be performed. After 21 days, the pedicle is divided close to the palate and any defects noted in the anterior are closed. The surgeon should attempt to contour this final inset portion of the tongue flap so that it matches the contour of the palatal vault as much as possible, because protruding tissue from the palate may cause speech defects [30]. Final contouring of the tongue flap on the palate should not be done before 4 to 6 months after the original pedicle has been separated because the blood supply to the graft may not be established fully before 3 months [29]. The remaining portion of the tongue pedicle is reinserted into the donor site of the tongue. Postoperative scars and minor changes in shape are noted on the tongue, but it does not interfere with speech or movement. In badly scarred palates there is always the possibility that a flap may not establish a good blood supply with the surrounding palatal tissue because of the excessive scarring. If necrosis at the margins of

the flap is noted after division of the pedicle, it is most likely caused by an inadequate blood supply from the random-pattern flap. Unfortunately, there is no sure way to test for a lack of adequate blood supply before taking the flap down. One method of testing the adequacy of the blood supply to the distal portion of the flap is by cross-clamping the pedicle with a bulldog clamp before dividing it and observing the color of the flap at the transferred end. If the tongue flap does not turn bluish or blanches and then returns to a near pink color, it can be considered to have enough blood supply to be able to divide it from its base. (Placing the bulldog clamp should be done using a small volume of local anesthesia without a vasoconstrictor.) Sometimes, however, the bulldog clamp may not compress the flap adequately to affect the donor blood source. The anesthesia for the takedown of the flap is a hazardous procedure and is usually a challenge to the anesthesiologist. The surgeon and the anesthesiologist may be faced with a child who cannot open his or her mouth widely, and the view and access to the pharyngeal area are obstructed. For general anesthesia, a sedated awake fiberoptic nasotracheal intubation is required, but if the patient is unable or unwilling to cooperate, it is a technically difficult and frustrating experience. The surgeon should seek a pediatric anesthesiologist who is experienced with fiberoptic intubation and has a good disposition. In older children, local anesthesia by infiltration may decrease the challenge, because after the area is numb the flap simply may be separated close to the palate to allow for the intubation. Adequate hemostasis should be obtained by the surgeon before turning the patient over to the anesthesiologist for intubation. Once induced, the surgeon may then perform the procedure under ideal control.

Summary This article presented surgical techniques that may be used to close oronasal fistulas. The author believes that the oral and maxillofacial surgeon can adapt these techniques easily to his or her practice and they are most frequently successful. Although these techniques have been presented to manage defects seen in the cleft palate patient, they are not solely limited to cleft surgery but may be adapted for other fistulas on the palate. A detailed description of the tongue flap was presented because this flap is versatile and may be used for other intraoral reconstructive procedures.

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O.E. Ogle / Oral Maxillofacial Surg Clin N Am 14 (2002) 553562 [15] Witzel MA, Salyer K, Ross RB. Delayed hard palate closure: the philosophy revisited. Cleft Palate J 1984; 21:263. [16] Ross RB. Facial growth in cleft lip and palate. In: McCarthy JG, editor. Plastic surgery. Philadelphia: WB Saunders; 1990. p. 2437. [17] Peter-Falzone SJ. Speech outcome after closure of oronasal fistulas with bone graft: discussion. J Oral Maxillofac Surg 2001;59:1413 4. [18] DAntonio LL, Barlow SM, Warren DW. Studies of oronasal fistulae: implications of speech motor control. Presented at the Annual Meeting of the AmericanSpeech-Language-Hearing Association. San Antonio, TX, November 20 23, 1992. [19] Marsh JL, Wray RC. Speech prosthesis versus pharyngeal flap: a randomized evaluation of the management of velopharyngeal incompetency. Plast Reconstr Surg 1980;65:592 4. [20] Isberg A, Hennigsson G. Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study. Plast Reconstr Surg 1987;79:525. [21] Clasper R. A combined obturator and expansion appliance for use in patients with patent oral-nasal fistula. Br J Orthod 1995;22:357. [22] Kim M, Lee J, Choi J, et al. Two stage reconstruction of bilateral alveolar cleft using a Y-shaped anterior based tongue flap and iliac bone graft. Cleft Palate Craniofac J 2001;38:432 7. [23] Johnson PA, Banks P, Brown AE. Use of the posteriorly based lateral tongue flap in the repair of palatal fistula. Int J Oral Maxillofac Surg 1992;21:6 9. [24] Kinnebrew MC, Malloy RB. Posteriorly based, lateral lingual flaps for alveolar cleft bone graft coverage. J Oral Maxillofac Surg 1983;41:555 61. [25] Thind MS, Singh A, Thind RS. Repair of anterior secondary palate fistula using tongue flaps. Acta Chir Plast 1992;34:79 91. [26] Jackson IT. Cleft lip and palate. In: Kelly V, editor. Practice of pediatrics. Philadelphia: JB Lippincot Co.; 1985. [27] Carreirao S, Lessa S. Tongue flaps and the closing of large fistulas of the hard palate. Ann Plast Surg 1980; 4:182 90. [28] Kim YK, Yeo HH, Kim SG. Use of the tongue flap for intraoral reconstruction: a report of 16 cases. J Oral Maxillofac Surg 1998;56:716 9. [29] Steinhauser EW. Experience with dorsal tongue flaps for closure of defects of the hard palate. J Oral Maxillofac Surg 1982;40:787 9. [30] Kummer AW, Neal HW. Changes in articulation and resonance after tongue flap closure of palatal fistulas: case reports. Cleft Palate J 1989;26:51 5.

Acknowledgment The author wishes to thank Dr. Hope Wettan for the drawings and Dr. Steven Wettan for technical advice with the illustrations used in this article.

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[1] Stal S, Spira M. Secondary reconstructive procedures for patients with clefts. In: Serafin D, Georgiade NG, editors. Pediatric plastic surgery. St. Louis: CV Mosby Co.; 1984. p. 352. [2] Biavati MJ, Bassichis B. Cleft palate. Available at: http://www.emedicine.com/ent/topic136.htm. Accessed October 18, 2001. [3] Jackson IT, Fasching MC. Secondary deformities of cleft lip, nose and cleft palate. In: McCarthy JG, editor. Plastic surgery. Philadelphia: WB Saunders; 1990. p. 2814. [4] Rintala AE, Haapanen M. The correlation between training and skill of the surgeon and reoperation rate for persistent cleft palate speech. Br J Oral Maxillofac Surg 1995;33:295 6. [5] Musgrave RH, Bremner JC. Complications of cleft palate surgery. Plast Reconstr Surg 1960;26:180 9. [6] Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986;78:739 45. [7] Lilja J, Elander A, Lohmander A, et al. Isolated cleft palate and submucous cleft palate. Oral Maxillofac Surg Clin N Am 2000;12:455 68. [8] Rintala AE, Ranta R. Spontaneous narrowing of the palatal cleft during the first year of life: a quantitative study. Scand J Plast Reconstr Surg Hand Surg 1987; 21:35 8. [9] Henningsson G, Isberg A. Influence of palatal fistula on speech and resonance. Folia Phoniatr 1987;39:183. [10] Bardach J, Slayer KE. Cleft palate repair. In: Bardach J, Slayer KE, editors. Surgical techniques in cleft lip and palate. Chicago: Year Book Medical Publishers; 1987. [11] Baker PR. Closure of oral antral communications and treatment of sinus infections. In: Dym H, Ogle OE, editors. Atlas of minor oral surgery. Philadelphia: WB Saunders; 2001. p. 131 2. [12] Chapman JH, Birch DA. An orthodontic and otolaryngological review of thirty four cleft lip and cleft palate patients. Br J Surg 1965;52:646. [13] Millard Jr DR. Wide and or short cleft palate. Plast Reconstr Surg 1962;29:40. [14] Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Part 5: Timing of cleft palate repair. Cleft Palate J 1987;24:54.