Do oral flora colonize the nasal floor of patients with oronasal fistulae?

OBJECTIVE: To determine if oral bacteria colonize the cleft nasal floor in patients with unilateral oronasal fistula when compared with the unaffected nasal floor and whether the results obtained would be of benefit in assessing oronasal fistulae in the clinic. DESIGN: Prospective study of 26 patients with cleft palate and unilateral oronasal fistula. Microbiological culture swabs were taken from the mouth and nasal floors of patients. The unaffected nasal floor was used as a control. Bacterial isolates were identified and compared in the laboratory by a senior microbiologist. MAIN OUTCOMES MEASURE: A significant growth of oral bacteria from the cleft nasal floor when compared with the unaffected nasal floor. RESULTS: Four patients were excluded because no growth was found on any culture plate. In the remaining 22 cases, a light growth of oral flora was found in the cleft nasal floor in only 3 patients. No statistical correlation between culture of oral bacteria and the cleft nasal floor could be found (p =.12). CONCLUSIONS: The relative lack of colonization of the cleft nasal floor by oral bacteria may reflect poor transmission of bacteria through the fistula, competition with commensal nasal flora, or an inability of oral bacteria to survive in a saliva-depleted area. The investigation is not helpful in the assessment of oronasal fistulae in the clinic.     

Meeting Report

Abstract

A combined obturator and expansion appliance design is described for use in patients with patent oronasal fistulae. This is helpful in cleft palate cases, where small fistulae may increase in size during orthodontic expansion of the upper arch, resulting in increased hypernasality of speech and nasal escape.     

Staphylococcus aureus transmission through oronasal fistula in children with cleft lip and palate

Objective: To determine the presence of Staphylococcus aureus in a nasal flora and oral environment, the correlation between frequency of transmission of S. aureus and oronasal fistula size, and the pattern of methicillin resistance on S. aureus strains in children with cleft lip and palate (CLP). Design: Thirty-two CLP children with and without oronasal fistulas, ranging in age from 5 to 13 years were examined for oronasal fistula presence and size. Stimulated saliva samples and nasal swab samples were taken and investigated for S. aureus presence. S. aureus presence and counts were correlated with fistula presence and size. Results: Saliva samples showed statistical differences between the groups with and without oronasal fistulas with an area ranging from 0.80 to 28.26 mm(2). The S. aureus counts were significantly higher (r = .535, p = .002) in saliva samples from children with larger oronasal fistula. The S. aureus count was not significantly different (r = -.013, p = .942) in nasal samples compared with oronasal fistula size. Methicillin resistance with disk-diffusion method was recorded as sensitive (>/=13 mm) in all S. aureus strains. Conclusions: The results of this study indicate a positive correlation between fistula size and S. aureus transmission to one oral environment through oronasal fistulae, and a positive correlation between frequency of S. aureus transmission and fistula size. All S. aureus strains were sensitive to methicillin. These results may have implications for preventive treatment of CLP children.     

Two-flap palatoplasty for treatment of oronasal fistula by trauma sequel

The oronasal fistula is a chronic communication between the oral and nasal cavity that often affects patients with cleft palate. However, others uncommon causes of oronasal fistula are associated with facial traumas, infections and neoplasias. In this report we present a case of oronasal fistula as consequence of facial trauma that was treated by two flaps technique for palatoplasty. In this sense, we discussed treatment indications, surgical technique and patient prognostic of a relatively simple option that can provide a definitive repair with minimal morbidity.     

Isolated soft tissue cleft lip: the influence on the nasal cavity and supernumerary laterals.

OBJECTIVE: The purpose of this investigation was to estimate the vertical deviation of the nasal floor and to register dental disturbances (i.e., hypo- and hyperdontia) in patients with an isolated soft tissue cleft lip. DESIGN: Thirty patients with isolated cleft lips were randomly selected from the files of the Department of Maxillo-Facial Surgery and Jaw Orthopedics. As a matched control group, 30 patients were selected from the files of the Department of Orthodontics. Panoramic radiographs were analyzed and the lowest point of the floor of the left and right nasal cavity was measured to the nearest 0.5 mm. The presence of supernumerary (deciduous or permanent) or missing lateral incisors was recorded from the patient's journals. RESULTS: The vertical position of the nasal floor differed significantly between the cleft and the non-cleft side (p < 0.001). Supernumerary, deciduous, and permanent laterals were recorded in 73% of the subjects in the cleft lip group (22 patients). In the control group, no differences were found between the position of the nasal floor on the left and right side and no supernumerary laterals were recorded. Missing laterals were not noted in any of the individuals investigated. CONCLUSIONS: Isolated cleft lips were in most cases associated with: (1) lowering of the nasal floor on the cleft side and (2) supernumerary primary or permanent lateral incisors on the cleft side. Panoramic radiographs can be used to detect differences in the vertical position of the floor of the nasal cavity in patients with isolated cleft lips and to diagnose supernumerary laterals.     

Microsurgical tissue transfer for rehabilitation of the patient with cleft lip and palate.

OBJECTIVE: Three case reports of microsurgically revascularized tissue transfer for secondary closure of complex oronasal fistulae in cleft lip and palate patients are reported. One scapular and two radial forearm flaps were used in that respect; the scapular flap was transferred without a skin paddle and was left for secondary epithelialization whereas iliac crest bone was transplanted in the two patients with the forearm flaps in a further surgical step. CONCLUSIONS: These microsurgical flaps represent solutions in selected cases of oronasal fistulae in patients with cleft lip and palate with extensive scarring, large defects, or both. Alternative free flaps of the vast spectrum available today, however, also deserve consideration.     

口腔黏膜瓣用于非综合征型单侧完全性唇裂鼻底修复的效果评价

目的: 探讨非综合征型单侧完全性唇裂患儿一期手术中采用口腔黏膜瓣进行鼻底修复的效果,并对鼻底、鼻翼外形对称性等指标进行评价。方法: 对2014年9月—2016年9月采用口腔黏膜瓣进行鼻底修复的16例非综合征型单侧完全性唇裂患儿的临床资料进行回顾分析,根据患儿术前、术后1周、术后1年恢复情况,拍摄正面、仰视照片,测量健、患侧鼻底宽度,鼻小柱高度,鼻孔高度及宽度,鼻的长度及宽度。采用SPSS19.0软件包对数据进行统计学分析。结果: 16例患儿术后均未出现口腔-鼻腔瘘及鼻底凹陷,鼻翼塌陷得到明显改善,术后1年鼻底宽度对称比0.79±0.15,鼻孔宽度对称比0.856±0.17,鼻孔高度对称比1.44±0.17,鼻小柱高度对称比1.62±0.48。结论: 非综合征型单侧完全性唇裂患儿一期修复手术中采用口腔黏膜瓣,进行鼻底修复,不仅能减少口腔-鼻腔瘘的发生,还能严密封闭鼻底裂隙,恢复鼻底形态,并保持良好的鼻翼外形及鼻孔对称性。     

Management of alveolar clefts

The management of alveolar clefts has changed through the years as medical knowledge has improved. An alveolar cleft is the result of abnormal primary palate formation during weeks 4 to 12 of gestation. The rationale for its closure includes 1) stabilizing the maxillary arch, 2) permitting support for tooth eruption, 3) eliminating oronasal fistulae, and 4) providing improved esthetic results. Methods for closure of the alveolar cleft have been solidified during the last century with the use of bone grafting. Secondary bone grafting is now the preferred method of treatment, because early grafting has proven detrimental to midfacial growth. Various materials for bone grafting have been proposed, including iliac crest, cranium, tibia, rib, and mandibular symphysis. Regardless of the timing and materials used, the main principles in approaching alveolar clefts have been well described. They include 1) appropriate flap design, 2) wide exposure, 3) nasal floor reconstruction, 4) closure of oronasal fistula, 5) packing bony defect with cancellous bone, and 6) coverage of bone graft with gingival mucoperiosteal flaps. Certain alveolar clefts are difficult to manage by grafting alone, and orthodontic preparation may be required. Complications of alveolar bone grafts include donor site morbidity as well as graft exposure and loss.     

Oxygen and the sugar metabolism in oral streptococci.

Streptococci have several ways of adapting themselves to the constantly changing environment of the human oral cavity. This paper discusses the adaptation of sugar metabolism to variations in oxygen levels. In all streptococci the Embden-Meyerhof pathway of glycolysis works under aerobic as well as anaerobic conditions, but pyruvate is converted into different metabolic end products depending on the oxygen levels. Under anaerobic conditions all streptococci form formate, acetate, and ethanol by a pyruvate formate-lyase pathway. If sugar is in excess, they also form lactate using a lactate dehydrogenase. Under aerobic conditions pyruvate formate-lyase is inactivated. This enzyme is then replaced by a pyruvate oxidase in some streptococci and by a pyruvate dehydrogenase in others. The characteristics of these enzymes help streptococci like S. sanguis, S. oralis, S. gordonii, and S. mitis to compete successfully with other bacteria in those sites of the oral cavity that are freely exposed to saliva, while mutans streptococci have to colonize anaerobic sites such as those in-between the teeth and in the occlusal fissures of the teeth.     

Bacterial contamination of filtered intraoral bone chips

Intraoral bony defects can be filled with bony particles that are collected in a titanium filter. The aim of this study was to determine quantitatively and qualitatively the degree of this contamination. Over a period of 3 months, bony particles were collected from 50 patients undergoing oral surgery. The bony particles were scraped off the filter, resuspended, and incubated aerobically and anaerobically on human blood agar media. Colony forming units (CFU) were determined as well as the most common species of bacteria. All samples showed anaerobic and aerobic growth. After anaerobic incubation in 44 samples the number of bacteria was higher (38) or equal (six) to that after aerobic incubation. On average, 435,000 CFU (aerobic) and 1,013,000 CFU (anaerobic) per sample were found. The most frequently identified bacteria belonged to Veillonella spp. in the anaerobic and to Streptococcus oralis in the aerobic cultures. In 43 samples black-pigmented colonies were detected. Only bacteria common in the oral cavity were identified. Prophylactic antibiotic therapy may be indicated when using filtered bony particles for intraoral augmentation procedures.     

Bone grafting with platelet-rich plasma in alveolar cleft. Case report

Bone grafting of the alveolus has become an essential part of the contemporary surgical management of oral clefts. The benefits of this procedure are the stabilization of the maxillary arch, elimination of oronasal fistulae, the reconstruction of the soft tissue nasal base support, creation of bony support for subsequent tooth eruption or, when they are not present or not preserved, for implants application. The authors show a case of bone grafting with the aid of platelet-rich plasma (PRP). Because of the difficulties due to the oral cleft and to its surgical reparation (big size of bone defect, hard scars and sclerotic soft tissue) the authors decided to add PRP to a bone graft taken from the chin. PRP contains a high concentration of growth factors and is able to stimulate both wound and bone regeneration. Infact, the authors have observed very good results both in bone integration and in soft tissue reparation.     

Speech outcome after closure of oronasal fistulas with bone grafts.

PURPOSE: The purpose of this prospective study was to evaluate the outcome of speech after complete closure of oronasal fistulas with bone grafts and to determine the possible relationship between outcome of speech and the size and location of the oronasal fistulas. PATIENTS AND METHODS: Ten unilateral cleft lip and palate patients with postoperative oronasal fistulas, ranging in age from 7 to 14 years, underwent secondary alveolar cleft repair and closure of the oronasal fistulas with an iliac bone graft. All patients underwent videofluoroscopic evaluation of the velopharyngeal valve, audiologic assessment, and speech evaluation (resonance, nasal emission, articulation, intelligibility, and nasalance) preoperatively. The examinations were repeated 3 months postoperatively. RESULTS: Six patients had preoperative velopharyngeal competency (60%). Of the 4 patients with slight to mild velopharyngeal incompetency preoperatively, 2 developed velopharyngeal competency postoperatively. All patients had satisfactory audiologic function preoperatively. Every patient also was intelligible before and after surgery. Eight patients (80%) showed nasal emission before surgery and 7 of these patients improved postoperatively (P <.01). Nine patients had articulation errors before surgery, with no significant improvement postoperatively. Nasalance was significantly improved in selected sequences. All patients had variable levels of nasality preoperatively; 8 showed a significant decrease of nasality postoperatively (P <.002). The results were not related to location or size of the oronasal fistulas. CONCLUSION: A significant improvement in speech is noticeable after closure of oronasal fistulas. Early oronasal fistula closure might prevent permanent speech distortions acquired by the cleft palate patients at an early age.     

Aerobic and anaerobic microbiology of periapical abscess

Aspirates of pus from periapical abscesses in 39 patients were studied for aerobic and anaerobic bacteria. Bacterial growth was present in 32 specimens. A total of 78 bacterial isolates (55 anaerobic and 23 aerobic and facultative) were recovered, accounting for 2.4 isolates per specimen (1.7 anaerobic and 0.7 aerobic and facultatives). Anaerobic bacteria only were present in 16 (50%) patients, aerobic and facultatives in 2 (6%), and mixed aerobic and anaerobic flora in 14 (44%). The predominant isolates were Bacteroides spp. (23 isolates, including 13 Bacteroides melaninogenicus group), Streptococcus spp. (20), anaerobic cocci (18), and Fusobacterium spp. (9). Beta-lactamase-producing organisms were recovered from 7 of the 21 (33%) specimens that were tested. This study highlights the polymicrobial nature and importance of anaerobic bacteria in periapical abscess.     

The tongue flap: placement and fixation for closure of postpalatoplasty fistulae

A tongue flap is frequently used for closure of fistulae following cleft palate repair. Early tongue flap dehiscence is a troublesome complication. While the tongue flap is a very effective means of functionally obliterating the transpalatal oronasal opening, the final appearance of the repair leaves much to be desired. More often than not, the tongue tissue appears bulky and unnatural in the roof of the mouth. A method is described that overcomes the problem of flap detachment during the early postoperative period by suspending and supporting the tongue pedicle with a palatal sling. On peroral view, the repaired area has a better appearance when the tongue flap lines the nasal side rather than the oral side as in conventional procedures.     

Characteristic forms of the upper part of the oral cavity in newborns with isolated cleft palate.

OBJECTIVE: To determine the functional and morphological compensation of the lack of integrity in the upper part of the oral cavity in newborns with isolated cleft palate. Integrity of the upper part of the oral cavity is required for the effective pumping of amniotic fluid, the essential mode of nutrition in intrauterine life. The adaptation could be seen immediately after birth. MATERIALS: Plaster casts of the upper part of the oral cavity in 60 newborns with isolated cleft palate of various extent and plaster casts of the upper part of the oral cavity in 27 newborns without cleft were used. A number of surface points were identified and used for a trigonometric morphological analysis. RESULTS: The parameters of the upper part of the oral cavity in four groups of newborns with various extent of isolated cleft palate were compared with newborns without cleft palate. The results indicate a shift of the functional oral cavity into the nasal cavity and the pharynx, depending on the extent of the cleft. CONCLUSION: The pumping activity of the tongue forms the upper part of the oral cavity and consequently the tongue moves into the nasal cavity and pharynx, depending on the extent of the cleft. In this way, effective pumping of amniotic fluid is possible despite the cleft. This is of vital importance for the fetus during intrauterine life. A poorly passable or even unpassable respiratory way is only of secondary importance during that time.     

The buccal flap--a useful technique in cleft palate repair?

OBJECTIVE: To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. DESIGN: Retrospective study cohort of patients with cleft palate. SETTING: Primary care center for treatment of craniofacial congenital anomalies. PATIENTS AND METHODS: One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. RESULTS: The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. CONCLUSIONS: The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.     

Is alveolar cleft reconstruction still controversial? (Review of literature)

Cleft lip and palate (CL/P) is a frequent congenital malformation that manifests in several varieties including unilateral or bilateral and complete or incomplete. Alveolar cleft reconstruction remains controversial with regard to timing, graft materials, surgical techniques, and methods of evaluation. Many studies have been conducted addressing these points to develop an acceptable universal protocol for managing CL/P. The primary goal of alveolar cleft reconstruction in CL/P patients is to provide a bony bridge at the cleft site that allows maxillary arch continuity, oronasal fistula repair, eruption of the permanent dentition into the newly formed bone, enhances nasal symmetry through providing alar base support, orthodontic movement and placement of osseointegrated implants when indicated. Other goals include improving speech, improvement of periodontal conditions, establishing better oral hygiene, and limiting growth disturbances. In order to rehabilitate oral function in CL/P patients alveolar bone grafting is necessary. Secondary bone grafting is the most widely accepted method for treating alveolar clefts. Autogenous bone graft is the primary source for reconstructing alveolar cleft defects and is currently the preferred grafting material.     

Relationship between oral bacteria and hemodialysis access infection

OBJECTIVE: Controversy exists concerning the association between oral bacteria and infection of hemodialysis (HD) shunts. The purpose of this study was to determine the extent to which oral bacteria are associated with vascular access site infections in a group of HD patients. STUDY DESIGN: Microbial blood culture data for 87 HD patients were collected: 53 via chart review (retrospective), and 34 with newly suspected vascular access infections (prospective). The primary outcome was the nature (i.e., species) of the bacteria recovered from blood cultures of subjects with vascular access infection, specifically those bacteria considered to be oral flora. RESULTS: The predominant bacteria reported to cause HD vascular access infections were Staphylococcus (48.6%) and Enterococcus (17.6%) species. Most infections occurred in hemodialysis catheters (89%) compared with AV grafts (11%) and AV fistulas (0%). The subclavian venous access (41%) and the internal jugular venous access (38.9%) were more commonly infected than other sites. None of the bacteria identified by blood cultures were considered to be oral flora. CONCLUSION: The results suggest that oral bacteria rarely, if ever, cause vascular access infections in hemodialysis patients.     

Canine eruption into grafted alveolar clefts: a retrospective study

BACKGROUND: The contemporary treatment of cleft lip and palate involves a sequence of surgical procedures and orthodontic management. Alveolar bone grafting (ABG) is usually undertaken after orthodontic expansion of the maxillary segments between the ages of eight and 12 years. Two of the important goals of alveolar bone grafting are the provision of bony support for the eruption of the canine and the closure of residual oro-nasal fistulae. The purpose of this study was to retrospectively evaluate the root development and eruption of the canine following ABG. METHODS: Group 1: radiographic and clinical records of a sample of 19 cleft patients who underwent alveolar bone grafting procedures, performed between 1996 and 1999 were reviewed. Group 2: a random sample of 15 cleft patients attending for routine dental review were clinically examined. The age of patient, degree of root development and eruption status of the canine, and presence of oronasal fistulae pre and post alveolar bone grafting were evaluated. RESULTS: Most cleft canines had continued root development and descended in the alveolus towards eruption following ABG. Four canine teeth (8 per cent) were impacted and required surgical exposure and orthodontic treatment following failure of eruption. Closure of anterior oro-nasal fistulae at the time of grafting was maintained post-operatively. CONCLUSIONS: This study demonstrated that canine root development and eruption continued satisfactorily through grafted alveolar clefts in most cases and closure of anterior oro-nasal fistulae was achieved in all cases.     

Isolation of bacteria from cervical lymph nodes in patients with oral cancer.

Thirty patients with oral mucosal cancer were studied in relation to oral mucosal damage and bacterial translocation to the regional lymph nodes in the neck. All 30 patients (gingiva 11, tongue 13, cheek mucosa four, oral floor two) underwent extensive, clean-contaminated, head-and-neck surgery (including neck dissection) with free flap reconstruction. A total of 153 lymph nodes was harvested for microbial and histological examination. Viable bacteria were isolated from 70 lymph nodes (45.8%) from 25 patients (83.3%). Bacterial cells in the nodes were detected by scanning electron microscopy. Bacterial translocation was found more often in metastatic nodes (75.0%) than in uninvolved nodes (40.3%) (p = 0.015; chi2 test). Gingival carcinoma yielded 56.4% of bacterial growth in the regional lymph nodes compared to tongue (40.3%), oral floor (40.0%) and cheek mucosa (37.5%). As the gingival carcinoma group includes more T4 cases (11/11; 100%) than the other three groups (7/19; 36.8%), bacterial translocation in uninvolved nodes could be caused by the size and invasion of the primary oral tumor. Oral streptococci (Streptococcus intermedius, Strep. constellatus, Strep. oralis, Strep. mitis, Strep. sanguis, Strep. salivarius) were the most common isolates. Aerobic enteric bacteria (Enterococcus, Escherichia, Klebsiella etc.) were also found in the lymph nodes. Among the anaerobic bacteria, Peptostreptococcus spp. were isolated from 12 patients. Damaged oral mucosa in patients with oral cancer might allow the new bacterial colonization on the surface and subsequently drain the bacteria into the regional lymph nodes as well as the general circulation.