Palatal Fistulae: Classification, Prevention, and Algorithmic Surgical Management

Palatal fistulae, defined as persistent epithelialized communications between the oral and nasal cavities, represent the most common complication following cleft palate repair. They significantly impair speech and feeding, contributing to psychosocial challenges and increased healthcare burden. Fistula formation is often multifactorial, influenced by surgical technique, closure under tension, cleft severity, and postoperative care. Comprehensive assessment includes clinical examination, speech evaluation, and nasopharyngoscopy to determine the anatomical extent and functional impact of the defect. Whereas small, asymptomatic fistulae may be monitored, symptomatic cases require surgical intervention following a healing period of 6 to 9 months. Existing classification systems, such as the Pittsburgh and various size-based classifications, offer limited guidance for complex cases. The Pakistan Comprehensive Fistula Classification system addresses these gaps by incorporating 4 key domains: location, size, velopharyngeal competence, and dehiscence. This multidimensional framework facilitates standardized communication and individualized surgical planning. Surgical repair follows key principles: multilayered, tension-free closure; preservation of tissue vascularity; functional reconstruction of the velopharyngeal port; and use of regional flaps. An algorithmic approach ensures appropriate flap selection and incorporation of adjunctive procedures, such as levator retropositioning or pharyngeal flaps, when velopharyngeal dysfunction is present. By following these principles, even recurrent or complex defects can be successfully managed to restore palatal integrity and improve speech outcomes. This chapter reviews the etiology, classification, and algorithmic surgical management of palatal fistulae, emphasizing functional restoration over mere defect closure.