Acellular Dermal Matrix Versus Pedicled Tongue Flap in Closure of Oro-nasal Fistula in Patients with Cleft Palate

Abstract

Oronasal fistula is a complication of palatoplasty that is an extremely difficult problem, particularly if recurrent or persistent. Large, persistent, or recurrent ONF mandates the use of regional flaps or grafts. The tongue flap is a regional flap that has an excellent blood supply and is safe, robust, and successful, thus is indicated for closure of a large and persistent ONF, in heavily scarred palates and on failure of previous attempts. The main drawbacks with it are spontaneous detachment from the palate, feeding and speech problems till depedicling, donor site surgery, and haemorrhage. AlloDerm is an acellular dermal matrix that is safe, resistant to infection and rejection, and permits a good healing. Acellular dermal matrix is a versatile successful reconstruction material for intra- and extraoral defects including the treatment of ONF especially if recurrent or refractory. Its main disadvantage is the associated cost. This study was conducted on 12 patients with ONF secondary to cleft palatoplasty that is large, persistent or recurrent. Patients were randomly and equally divided into two groups: study and control. Acellular dermal matrix was utilized for fistula closure in the study group while tongue flap was used for the control group. There was no significant difference between both groups regarding sex, age, time lag before developing ONF and its size, and site and number of previous recurrences; in addition to the preoperative hypernasality. There was no significant difference between both groups regarding ONF recurrence, presence of contracture, and success rate. However the difference between both groups on considering contour deformity was highly significant in advantage of the study group. No cases of ADM rejection were reported, despite one case of recurrence. For hypernasality, the difference between both groups was not significant postoperatively; nevertheless pre- and postoperative difference for each group was significant regarding the overall nasal and oral passages and almost all sounds displaying the improvement in hypernasality within both groups and assures the perfect closure of ONF. Acellular dermal matrix is an easier and shorter technique, obviates the need for donor site surgery, does not necessitate second surgery, does not lead to contour deformity, have a by far smoother postoperative period without tongue fixation or limitations of jaw movements, is associated with much lesser apprehension, and have a relatively unlimited availability. It might be considered as an alternative for the tongue flap in some cases.

Key words: Fistula, Palate, Cleft, Tongue, Flap, Alloderm.