Cleft Palate and Palatal Fistulas: Severity Predicts Occurrence

Surgeons have traditionally repaired cleft palate using relaxing incision to close the palate, but this surgery has been linked to palatal fistulas and other complications. A recent study in JAMA Facial Plastic Surgery described predictive associations of persistent palatal fistulas in patients with a previously repaired cleft palate.

Cleft palate is the 4th most common birth defect in the United States, and is frequently associated with a craniofacial syndrome or anomaly. Approximately 7500 children are born with cleft palate every year, and approximately 5% to 15% of them have related craniofacial problems. Surgeons have traditionally repaired cleft palate using relaxing incision to close the palate, but this surgery has been linked to palatal fistulas, velopharyngeal insufficiency, deficient anterior-posterior maxillary growth, and deficient vertical mid-facial development. JAMA Facial Plastic Surgery has published a study in its online issue that describes predictive associations of persistent palatal fistulas in patients with a previously repaired cleft palate.

This case-control study included patients who underwent cleft palate repairs between January 1, 1986, and December 31, 2000, at a major tertiary care hospital center in New York City. All study cases had their primary surgery before the age of 3 years and had their cleft-related care at the same hospital. The researchers defined palatal fistula as a breakdown of the primary surgical palate repair resulting in persistent oral-nasal cavity patency.

The researchers identified 130 repairs, including 12 girls and 11 boys with palatal fistula and 56 girls and 51 boys as controls who had cleft palate repair but did not develop fistulas. The mean patient age at the time of palatoplasty was 12.6 months and 14.5 months in the palatal fistula and control groups, respectively.

As the severity of cleft palate increased, so did postoperative complication rates. This finding was expected. The researchers classified cleft palate using the Veau classification system. They found that with each Veau class increase, the odds of a palatal fistula increased by 2.64. This is the first study to quantify risk by Veau class.

Orthodontic treatments were not associated with increased risk of fistula formation. Patient sex, age at palatoplasty, type of palatoplasty, ear infection, clefts associated with syndromes, and the surgeon did not appear to increase risk either.

The researchers conclude that using the Veau classification system can help healthcare professionals predict risk of postoperative palatal fistula in the cleft palate population.