Palatal Fistula

Palatal Fistula

Gregory D. Pearson


  • The Pittsburgh fistula classification system classifies fistulas as I to VII, from a posterior to anterior location on the palate4 (FIG 1).

    • Type I involves only the uvula (consisting of a bifid uvula).

    • Type II involves the soft palate.

    • Type III occurs at the junction of the hard/soft palate.

    • Type IV arises within the hard palate.

      FIG 1 • Pittsburgh fistula classification system.

    • Type V is located at the incisive foramen (reserved for Veau IV clefts).

    • Type VI is a lingual alveolar communication on the alveolus.

    • Type VII is located on the labial side of the alveolus.


  • Occurrence rates of palatal fistula vary from 0% to 60% in reported literature.1,2,3

  • Several factors have been associated with the prevention of palatal fistula:

    • Tension-free and watertight closure

      • Relaxing incisions advocated by von Langenbeck for tension-free closure.

      • Jackson et al. proposed “CHOP modification” of Furlow palatoplasty for soft palate repair.2

    • Complete two-layer closure of nasal and oral flaps

      • LaRossa promoted liberal use of vomer flaps for closure of the nasal floor.5

    • Infection prevention

      • The use of perioperative antibiotics is debated in the literature.


  • Palatal fistula will remain patent until the time of closure.

  • A fistula can be symptomatic or asymptomatic


  • Palatal fistula can occur after cleft palate repair, oncologic resection, trauma, or illicit drug use.

  • Patients may report that the fistula is symptomatic.

    • Nasal escape of food or liquids

      • May be intermittent

      • Typically, viscous liquids like yogurt

    • Nasal escape of air

      • May be noted by patient as change in voice

  • May be noted by speech pathologist as nasal turbulence or hypernasality

  • Physical examination will demonstrate a hole or communication from the oral to nasal cavity.

    • Fistulas can range from small to large and vary in location on the palate.

    • Small fistulas can be difficult to see, but the patient can typically state/point to the location.

      • An examination under anesthesia with a lacrimal probe can be useful to determine the location, size, and orientation of a fistula.

    • A dental mirror can be useful in evaluating anterior fistulas.

    • Deep crevasses or folds of mucoperiosteal tissue can simulate a fistula.

    • Palatal expansion may open an occult fistula that was already present.


  • Radiographic fistulograms (such as those performed for an enterocutaneous fistula evaluation) are not necessary.

  • Physical examination should determine whether a fistula is present.

  • Nasopharyngoscopy or video fluoroscopy should be employed to determine velopharyngeal gap size in patients with fistula and velopharyngeal dysfunction.


  • Obturators/dental retainers can be fabricated by dentists or orthodontists to provide symptomatic relief (FIG 2).

    • Obtaining patient compliance for wearing the retainer can be difficult.

    • The dental brackets on the retainer may loosen and require retightening or fabrication of a new splint.

    • The patient must have enough teeth to properly support a retainer.


  • Surgical management and operative options are largely dictated by the location of the palatal fistula based upon the Pittsburgh classification system.

  • When determining whether to repair a fistula, the surgeon should strongly consider and assess whether the fistula is symptomatic.

    • Nasal escape of fluids or foods, hypernasality, and preventing further surgical or orthodontic interventions (eg, bone grafting or orthognathic surgery) are all reasons for attempted fistula repair.

  • Pittsburgh type I

    • Bifid uvula rate ranges from 1.34% to 19% of selected populations, but the true fistula rate is probably underestimated in the literature.

    • Because these fistulas tend to be asymptomatic as well as concerns about anesthesia on pediatric brain development, these fistulas are the least likely to be repaired as a primary objective for an operation.

      FIG 2 • Palatal fistula (A) covered with an obturator (B).

  • Pittsburgh type II

    • When determining the type of reconstruction choice for a soft palatal fistula repair, a surgeon should also make a determination related to a child’s resonance (specifically if VPD is present) and the type of previous repair performed.

      • If the child has VPD, the fistula may be fixed but hypernasality will likely persist unless addressed with the repair.

    • If a child has normal resonance regardless of the type of primary palatoplasty performed, augmentation/reinforcement with acellular dermal matrix (ADM) can be used.6

    • For patients with a fistula after straight-line repair and concurrent VPD, addressing the VPD with either a palatal lengthening procedure or VPD surgery should be strongly considered.

      • A conversion to a Furlow double opposing Z-plasty typically allows repair of a type II fistula while addressing VPD in children with small velopharyngeal gaps on imaging.7

      • The CHOP modification with bilateral relaxing incisions can facilitate tension-free closure.

    • For larger velopharyngeal gaps and fistula or very large fistula (dehiscence), a superiorly based posterior pharyngeal flap may be necessary as conversion to Furlow may not lengthen the palatal sufficiently.

  • Pittsburgh type III

    • Traditional teaching reports that the junction of the hard palate and soft palate remains the most common site of fistula, particularly when employing a Furlow palatoplasty.

    • As for type II fistula, the patient’s resonance and type of previous repair should influence the operation considered for fistula repair.

  • Pittsburgh type IV

    • There is significant overlap for techniques used to repair type III and IV palatal fistulas.

    • The mucoperiosteal flaps tend to scar, become stiffer, and have less mobility compared to flaps used in a primary palatoplasty, thus limiting their advancement or rotation potential.

  • Pittsburgh type V

    • This is the second most common location of fistula as well as the most challenging to repair given the relative lack of palatal tissue in this area.

    • These fistulas are often the result of either poor inset of the lateral palatal mucoperiosteal flaps into the premaxillary segment or more commonly a premaxillary segment that is so anteriorly displaced out of the arch (a “locked out” premaxilla and intentional fistula) that closure at the time of initial palatoplasty is not possible.

  • Pittsburgh type VI and VII fistulas pertain to the alveolar arch and labial sulcus and are addressed in the chapter on alveolar cleft repair.

Preoperative Planning

  • The surgeon must discuss the possibility of palatal fistula recurrence after attempted closure with the patient and family.

  • Assuring proper patient compliance with postoperative instructions prior to embarking upon repair is imperative.

  • Depending on the type of repair technique used, a surgeon may consider having orthodontist fashion of a postsurgical retainer to protect repair while healing, particularly for type IV and V fistulas.

    • It is important to ensure the retainer does not put pressure on flaps or area of repair while still protecting the surgical site from tongue and food particulate.

  • As previously stated, in rare instances, an examination under anesthesia with a lacrimal probe can be useful to determine the location, size, and orientation of a fistula.

  • If a local flap is used, it must be protected from masticatory trauma during healing.


  • The patient should be orally intubated.

    • May use a regular endotracheal tube or oral RAE endotracheal tube depending upon surgeon and anesthesiologist’s preferences.

    • The endotracheal tube may be positioned in the midline or laterally depending on the repair technique chosen.

  • Typically, the patient should be placed in a horseshoe headrest with a shoulder roll and slight extension of the neck.

  • A Dingman mouth prop or dental bite blocks (in which use depends on surgical technique to be employed) can be extremely useful for proper exposure of the intraoral cavity.


  • Although multiple strategies can be performed for each site, the most common/useful approaches will be addressed according to the Pittsburgh classification system.

  • Pittsburgh type I: Excision and reapproximation

  • Pittsburgh type II:

    • Lateral relaxing incisions and rerepair

      • May consider augmentation with ADM

    • Conversion by Furlow palatoplasty

    • Posterior pharyngeal flap

  • Pittsburgh type III:

    • Lateral relaxing incisions and rerepair

      • May consider augmentation with ADM

    • Posterior pharyngeal flap (if VPD present)

    • Buccal myomucosal flap

    • Facial artery musculomucosal (FAMM) flap

  • Pittsburgh type IV:

    • Lateral relaxing incisions and rerepair with pushback technique

      • May consider augmentation with ADM

    • Elevation of mucoperiosteal flaps and pushback technique

    • Labial mucosal flap

      • If space in dental arch to pass through or if bite blocks employed

    • Buccal myomucosal flap

    • FAMM flap

    • Tongue flap

    • Free tissue transfer

  • Pittsburgh type V:

    • Labial mucosal flap

    • FAMM flap

    • Tongue flap

    • Premaxillary turnover flap

      • Primarily used as nasal lining flap for fistula at anterior incisive foramen in Veau IV cleft

    • Free tissue transfer