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An unusual presentation of oro-naso-palatal fistula

From Volume 46, Issue 9, October 2019 | Pages 825-826

Authors

Ammar Hamid

BDS(Hons)

Department of Oral and Maxillofacial Surgery, Whipps Cross University Hospital, London, UK

Articles by Ammar Hamid

Email Ammar Hamid

Priyanka Patel

BDS(Hons), MFDS RCS(Glasg)

Department of Oral and Maxillofacial Surgery, Whipps Cross University Hospital, London, UK

Articles by Priyanka Patel

Abstract

This case report is of a 29-year-old male who complained of nasal escape of food and fluids through his nose for 6 months. Further questioning revealed a previous cocaine habit which has now ceased. Examination revealed a septal perforation and CT scanning revealed a 16 mm wide sagittal bone defect involving most of the hard palate as well as absence of the inferior half of the nasal septum. A diagnosis of septal perforation leading to an oro-naso-palatal fistula was made. This rather unusual presentation and clinical findings are discussed within this article.

CPD/Clinical Relevance: The effects of cocaine misuse on the oral mucosa are presented.

Article

Ammar Hamid

Case report

A 29-year-old Caucasian male presented with a 6-month history of nasal escape of food and fluids. He reported constant pain over the bridge of his nose and frontal bone region. He also reported blockage of his nasal airway. There was no history of nasal bleeding or discharge.

Examination

The examination was undertaken by a Consultant in Oral and Maxillofacial Surgery. The patient's nose demonstrated good dorsal height and projection. The nasal tip was well supported. On intra-oral examination he was fully dentate with a well maintained, minimally restored dentition. There was a defect within the midline of the hard palate approximately 1.5 cm in width, which was temporarily occluded with ‘igloo gel’ (Figure 1).

Figure 1. Intra-oral view: palatal defect occluded using ‘igloo gel’.

Intra-nasal examination under good light and a nasal speculum (Figure 2) revealed a large septal defect which extended from the columella posteriorly to include the entire cartilaginous and bony septum. In effect both nasal cavities were in continuity.

Figure 2. Examination with nasal speculum: swab used to illustrate defect within the nasal cavity.

The margins of the perforation showed no evidence of crusting or ulceration.

Past medical and social history

A full medical history was undertaken and nothing significant was found. He had no history of nasal trauma or facial/oral operations. He did not have a family history of developmental defects or cleft lip and palate.

On direct questioning into his social history, the patient reported habitual misuse of cocaine for 2–3 years. We were unable to confirm if he had abstained from this habit or whether he was undergoing rehabilitation.

Diagnosis

Extensive septal perforation which involved the nasal floor and hard palate leading to an oro-naso-palatal fistula. CT imaging was carried out in three different planes to establish the anatomical boundaries of the defect (Figures 3, 4 and 5).

Figure 3. Coronal view showing defect centrally.
Figure 4. Sagittal view of the defect.
Figure 5. Transverse view of the defect.

Plan of treatment

The main concern of the patient at presentation was the problem of nasal escape which the patient found both socially and functionally unacceptable. We discussed provision of a hard acrylic cover plate which would help obturate the palatal defect and allow for normal swallowing.

Despite such a large defect, it was surprising to note that dorsal support to the nose had not been compromised and nasal tip support was maintained. Frequently, cocaine misuse results in collapse of the nasal bridge with resultant saddle nose deformity.1

Outcome and follow-up

The patient was referred to a tertiary ENT department owing to the size of the defect and involvement of the hard palate. The maxillofacial consultant hypothesized that reconstruction of the defect would require a multidisciplinary approach from colleagues in both ENT and plastic surgery.

Discussion

It was not possible to establish complete abstinence from cocaine misuse and therefore it is paramount to communicate with, and illicit support from, the patient's general medical practitioner (GMP), who may consider referral to a rehabilitation service or support group. Alternative treatment modalities also include referral to an ENT clinic for assessment and possible surgical management. This may include repair of the defect with vascularized free flap transfer to the defect.2,3

The history of drug misuse for 2–3 years would seem inconsistent with the size of the defect. It is our opinion that this habit might have extended for a longer period of time. The sheer size of the defect indicates chronic cocaine misuse over an extended period. Moreover, rather surprisingly, the external nose maintained good support and projection, despite the enormity of the defect which extends almost all the way back to the choanae. In this case, the entire shelf of palatal bone was destroyed with necrosis of nasal septum extending onto the hard palate, causing an oral-nasal fistula.

Learning points

Other than described above, the causes of oro-nasal fistula include:

  • Unrepaired clefts;
  • Syphilis (in underdeveloped countries);
  • Granulomatous disease; and
  • Post-surgery for malignant tumours in the hard palate.4

    • It is important to take a full medical and social history; patients will often not disclose drug misuse and the clinician must be aware that patients often under report the length of time and extent of drug misuse. This is also seen commonly in patients with alcohol misuse and excessive smoking habits.

    Referral to the appropriate specialty is advised and the patient must be made aware of the complexity of definitive treatment. However, the clinician should also try to facilitate appropriate short-term solutions to help alleviate the patient's symptoms and, in this case, a simple acrylic plate can be made by a general dental practitioner (GDP) to provide palatal coverage.