Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence

Abstract

Background: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. Methods: Over the past 15 years, the authors’ team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. Results: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. Conclusion: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.

Prevention and management of oronasal fistulas

“…Recently, the Pakistan Comprehensive Classification was devised based on three main characteristics: location, size, and velopharyngeal competence [27 ▪▪ ]. Dehiscence was included as a fourth component if present.…”

“…Until recently, a compendium of the different oronasal repair techniques was not available. Fayyaz et al [27 ▪▪ ] described an algorithm for palatal fistula management based on their proposed classification system. Rothermel et al recently published a ‘toolbox’ of the available options for the different types of ONF.…”

“…Several studies have shown that for small-to-medium sized hard and soft palate fistulas, a two-layered closure using local advancement flaps was effective [17,27 ▪▪ ,32]. Velopharyngeal competence should be determined prior to the repair of the soft palate fistula.…”

Cephalometric predictors of hypernasality and nasal air emission

“…Not all cleft palate team worldwide, however, have access to imaging assessment of velopharyngeal function, such as videofluoroscopy or nasoendoscopy. 1 Fayyaz, et al 1 (2019), for example, proposed assessing velopharyngeal competency as part of a "system of classification for defining and describing palatal fistulae". According to the authors 1 , conducting a videofluoroscopic or nasoendoscopic evaluation "would have been a better approach", but it is not always available, leading the authors to Using cephalometric radiographs to study the relationship between the velum and the pharynx is not a novel idea, 5,6,7,8,9,10…”

“…Knowledge about anatomical aspects of the structures of the velopharynx are rapidly expanding, involving the use of precise imaging of human body. The use of more advanced imaging methods, like Magnetic Resonance Imaging and Cone-Beam Computed Tomography Imaging, optimize the understanding of velopharyngeal dynamics and relationships between anatomical structures.17,18,19,20 However, many CLP teams around the world have no resources to perform even a nasoendoscopic or a videofluoroscopic assessment 1. While the use of 2-dimensional images with the velopharynx at rest -obtained with a cephalometric radiograph -may provide important information regarding the anatomical possibility of velopharyngeal closure, data obtained with 2D imaging may never substitute information derived from dynamic assessment of velopharyngeal function for speech.During the treatment decision process for management of velopharyngeal dysfunction (VPD), however, information obtainable with nasoendoscopic or videofluoroscopic assessments may be limited by the child's compliance to the endoscope insertion and to exposure to larger amounts radiation, respectively.…”