How reliable is the vomer flap in early hard palate repair?

Hard palate closure with a vomer flap at the time of lip repair has been widely adopted. A recent study by Deshpande et al. showed a high rate of failure of the vomer flap and led the authors to abandon the technique. We conducted a retrospective study of vomer flap healing in a consecutive series of cases performed by the senior author (D.O.). The case records of 71 patients who underwent repair of unilateral cleft lip and palate with a vomer flap at the time of lip repair were studied. Vomer flap healing was assessed and documented by the senior author at the time of definitive palate closure, and this was recorded. Adequate records were available for 66 cases. Twelve patients (18%) had associated syndromes and were included in the analysis. The median age at the time of lip and vomer flap repair was 3.5 months, and that at the time of palate repair was 8 months. At definitive palatoplasty, the vomer flap was intact in 62 patients (94%). Four patients (6%) had partial or complete failure of the vomer flap. All failures occurred in cases where the vomer flap was sutured directly to the nasal mucosa, a technique since abandoned in favour of double-breasting the flap to the raw surface of the oral mucosa. Five patients had incomplete healing of the palate following definitive palatoplasty, two of whom had a previous vomer flap failure. Contrary to Deshpande et al., we found the vomer flap to be highly reliable in closing the hard palate at the time of primary lip repair.

Repair of anterior cleft palate fistulae with cancellous bone graft: a simple technique that facilitates dental reconstruction.

BACKGROUND: Cleft palate fistulas of the anterior hard palate following previous repair are a challenging surgical problem. In addition to nasal regurgitation and potential adverse effects on speech, these fistulas may necessitate obturation with a removable dental prosthesis and can mitigate a fixed prosthodontic dental reconstruction. The authors present a method of repair using cancellous bone graft and only native palatal mucosa. METHODS: The authors carried out a retrospective review of 27 consecutive patients who underwent anterior palate fistula repair performed by a single surgeon over an 8-year period. RESULTS: The authors performed 29 fistula closure procedures using cancellous bone on 27 consecutive patients. Twenty-three (85 percent) of the initial 27 palatal fistula repairs in this study resulted in complete closure of the fistula. Two of the four patients who had incomplete closure went on to have a second operation using exactly the same technique, and complete closure was achieved. The remaining two patients in whom only partial closure was achieved were asymptomatic and no further treatment was necessary. All patients had an improvement in fistula symptoms after surgery. All patients who were using removable dentures/obturators were restored with fixed dental restorations supported by osseointegrated implants or fixed conventional bridges. CONCLUSIONS: This relatively simple method achieves reliable closure of most anterior hard palate fistulas and can be repeated if necessary. This technique removes the necessity of obturation of the defect with a removable prosthesis and in some cases facilitates the placement of dental implants.

Do helmets worn for hurling fail to protect the ear? Identification of an emerging injury pattern.

Hurling is an Irish national game of stick and ball known for its ferocity, played by 190 000 players. Facial injuries were common but have been significantly reduced by legislation enforcing compulsory helmet wearing. Current standard helmets worn by hurlers do not offer protection to the external ear. Here we describe an emerging pattern of ear injuries and demonstrate the risk of external ear injuries in hurlers complying with current helmet safety standards. A 6-month retrospective analysis was carried out of patients attending Cork University Hospital (CUH) with ear lacerations sustained while hurling. Patient notes were reviewed and helmet manufacturers were interviewed. Seven patients were identified, all of whom sustained complex through ear lacerations while wearing helmets complying with current safety standards. Current helmet design fails to protect the external ear placing it at an increased risk of injury, a potential solution is to include ear protection in the helmet design.

Management of gastro-bronchial fistula complicating a subtotal esophagectomy: a case report.

BACKGROUND: The development of a fistula between the tracheobronchial tree and the gastric conduit post esophagectomy is a rare and often fatal complication. CASE PRESENTATION: A 68 year old man underwent radical esophagectomy for esophageal adenocarcinoma. On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis. A fiberoptic bronchoscopy was performed which demonstrated a gastro-bronchial fistula in the posterior aspect of the left main bronchus. He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support. A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistula CONCLUSIONS: This is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy. Our experience would suggest that in very carefully selected cases where bronchopulmonary contamination from the fistula is minimal or absent, there is no associated inflammation of the tracheobronchial tree and the patient is stable from a respiratory point of view without evidence of sepsis, there may be a role for a trial of conservative management.