Soft palatal fistulas are difficult precisely because the obvious options run out. Transoral local flaps fail or have already been used, and what remains - regional or free tissue transfer - carries morbidity out of proportion to a defect that may be under a centimetre across.
This technique report describes a different route for an 8 by 6 mm soft palatal fistula. A vascularised nasoseptal flap was harvested from the septum and nasal floor, rotated through the nasopharynx to cover the fistula from above, and suture-fixated transorally to the mobile soft palate so that it stayed apposed while it healed. Closure was achieved. Nasal regurgitation resolved, velopharyngeal function improved partially, and Eustachian tube dysfunction - the obvious concern when a flap is rotated across the nasopharynx - did not follow.
This is one patient, and it should be read as an option to remember rather than a technique with evidence behind it. The nasoseptal flap is already familiar to anyone doing endoscopic skull base work, which is what makes it interesting here: the harvest and the vascular anatomy are known quantities, and the novelty is the destination. For a unit facing a recurrent palatal fistula after failed transoral repair, it is worth knowing this has been done before the conversation turns to free tissue transfer.
- Consider the nasoseptal flap when transoral repair has failed and before offering free tissue transfer
- Transoral suture fixation to the mobile palate was the step that kept the flap apposed
- Counsel about Eustachian tube function; it was preserved here but this is a single case
- The harvest is the same one used in endoscopic skull base surgery, so the skill often already exists in the unit
- Velopharyngeal function improved only partially - closure of the fistula is not restoration of speech
Why it matters
It puts a low-morbidity option between failed transoral repair and free tissue transfer, where there was previously nothing.
Don't overread it
A single-patient technique report - it establishes feasibility, not success rates.
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