A novel approach for successful closure of sinonasal fistulae

Medial canthus sinonasal fistula is associated with troublesome aesthetic and functional issues. Corneal irritation and drying results from escape of both air and secretions from the nasal cavity across the ocular surface as well as misting of spectacles if worn. Reconstruction of such fistulae is associated with a high rate of recurrence and thus presents a difficult surgical challenge.

This paper describes the senior author's surgical approach to manage medial canthus sinonasal fistulae utilizing an interpolated forehead flap combined with extended galeafrontalis and pericranial flap for stepped closure. The technique of flap elevation and inset is discussed, with emphasis on key manoeuvres to prevent sinus recurrence. A retrospective review of consecutive cases is presented.

Four patients were treated using this technique over 12 months. In all cases, fistulae developed following adjuvant radiotherapy for tumour resection. Flap elevation was performed in combination with a bicoronal approach in 2 patients and via direct forehead approach in 2 patients. No post-operative complications or recurrence of fistula have occurred over 12 months follow-up.

The success of this technique is attributed to inclusion of a galeafrontalis and pericranial extension to the forehead flap. In addition, the fistula site must be prepared to accommodate the flap by dissection of a wide subcutaneous pocket. This stepped method of closure provides an effective barrier to air and nasal secretions and also achieves an excellent aesthetic outcome.