Surgical Repair of Palatal Fistulae in Adults-Outcomes, Challenges, and Determinants of Recurrence

Palatal fistulae remain one of the most challenging complications following cleft palate repair, with incidence rates reported between 2.4% and 35% in recent studies. They pose significant morbidity for patients, including oronasal regurgitation, speech impairment, and failure to thrive. Although extensively studied in pediatric populations, palatal fistula repair in adults remains poorly documented. Adult patients frequently present with more chronic defects, extensive fibrosis, and reduced tissue elasticity, necessitating a tailored surgical approach. This study aimed to evaluate the surgical management of adult palatal fistulas at a high-volume cleft center, highlighting the challenges and complexities associated with repair, as well as recurrence rates.

A retrospective cohort study was conducted at CLAPP Hospital, Lahore, Pakistan, including adult patients 18 years and older who presented with palatal fistulas between January 2015 and December 2023. Patient demographics, fistula size and location, surgical techniques utilized, recurrence rates, and associated risk factors were collected and analyzed. Surgical techniques included Bardach redo-palatoplasty, Langenbeck redo-palatoplasty, buccal sulcus flap, buccinator flap, and tongue flap, contralateral mucoperiosteal flap, among others. Statistical analysis was performed using R (Version 4.3.2).

A total of 231 patients (mean age, 24.7 ± 6.07 years) were included. Most fistulas were located in the anterior (29.9%) and posterior (10.4%) hard palate, with a significant proportion (32.5%) extending across multiple midline regions. Fistula sizes varied, with 18.6% classified as S3 (11-15 mm) and 21.6% as S4 (>15 mm). The most commonly utilized technique was Bardach redo-palatoplasty (60.6%), followed by buccal sulcus flap (11.7%). Overall, 21.2% of patients experienced fistula recurrence, with significantly higher recurrence rates in patients with previously repaired fistulas (P = 0.0209). Univariate and multivariate analyses identified fistulas exceeding more than 15 mm (P = 0.008) and lateral fistulas as having the highest risk of recurrence (P = 0.021).

Despite the inherent challenges, palatal fistula repair in adults yields significant improvements in functional outcomes and quality of life. A tailored surgical approach, meticulous planning, and adequate surgical expertise remain essential to achieving optimal outcomes.