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How To: Multilayered Closure of Oronasal and Oroantral Fistula Using Intranasal and Intraoral Flaps

by Isaac P. Obermeyer, MD, Naya Sterritt, Yarah M. Haidar, MD, Tjoson Tjoa, MD, and Edward C. Kuan, MD, MBA •

INTRODUCTION

Oroantral fistula (OAF) and oronasal fistula (ONF) are related conditions that describe an abnormal, epithelialized communication between the oral cavity and the maxillary sinus or nasal cavity, respectively. Patients present with bothersome reflux of oral contents (e.g., saliva, food) into the nasal cavity during deglutition. There are numerous factors that can lead to the development of a fistula, such as dental extractions, tumor resection, osteonecrosis secondary to radiation and medications, and trauma, among others. Small fistulas may close spontaneously, but the persistent fistula may be a difficult problem to address surgically. Commonly employed techniques for fistula closure include local intraoral flaps (e.g., palatal island flaps, buccal fat and mucosal advancement, facial artery musculomucosal flaps) (J Korean Assoc Oral Maxillofac Surg. 2020;46:58–65).

An alternative, or adjunct, to OAF–ONF repair is using a vascularized, pedicled intranasal flap, such as the nasoseptal flap (Laryngoscope. 2006;116:1882–1886) (NSF) or lateral nasal wall flap (Int Forum Allergy Rhinol. 2020;10:673–678) (LNWF). The NSF and LNWF are pedicled flaps of the posterior septal artery and inferior turbinate tributaries, which are both terminal branches of the sphenopalatine artery and are frequently used in skull base reconstruction. In the current study, we describe a multilayered repair technique for OAF–ONF involving an intraoral local tissue flap combined with a pedicled intranasal flap, with excellent outcomes (see supporting video).

METHOD

Case Series 

The first patient is an 85-year-old male with a one-year history of regurgitation of fluids into the right nasal cavity. He was found to have a 1.0-cm right ONF. This was believed to be due to bisphosphonate-related osteochemonecrosis of the maxilla. The patient underwent successful surgical closure of the fistula via a multilayered approach, including right NSF and a left palatal rotational flap.

The second patient is a 64-year-old male with an eight-year history of a right OAF after extraction of right maxillary molars. Shortly after, he developed nasal regurgitation and recurrent right-sided sinus infections. Exam demonstrated a 1.1-cm right OAF adjacent to the location of the first right maxillary molar, and thick mucus emanating from the right middle meatus suggestive of odontogenic sinusitis. He underwent surgical closure, which entailed a right endoscopic medial maxillectomy to treat the sinus inflammation, remove diseased mucosa surrounding the defect, and gain access to the fistula along the maxillary sinus floor. Using a right LNWF to cover the defect from above and a right buccal fat pad flap for intraoral coverage, successful closure, and resolution of symptoms (including sinus infections) were accomplished.