Repair of an oronasal fistula with a two-layer closure method involving an autogenous fascia lata graft and oral mucosal flap in a pony

Marcos Lores 1Sharjah Equine Hospital, Bridge No. 6, Al Dhaid Rd, Al Atain, Sharjah.

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Thomas Yarbrough 2Dubai Equine Hospital, 2 St No. 22A, Dubai, United Arab Emirates.

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Abstract

CASE DESCRIPTION

A 9–year-old pony gelding was evaluated because it was suspected that a persistent oronasal fistula had developed after a fractured right maxillary second premolar tooth had been extracted via repulsion 6 months earlier.

CLINICAL FINDINGS

Unilateral mucopurulent nasal discharge and malodorous breath were noted on clinical examination. Examination of the oral cavity revealed a 1 × 0.5-cm defect at the oral aspect of the right maxillary second premolar alveolus, from which feed material was extracted. Endoscopic examination revealed feed material in the rostral aspect of the right nasal cavity, confirming the diagnosis of oronasal fistula.

TREATMENT AND OUTCOME

The pony initially underwent a reconstructive surgical procedure that combined an alveolar bone flap with a sliding mucoperiosteal hard palate flap to repair the oronasal fistula. The fistula reoccurred 5 months later and was ultimately repaired by means of a novel 2–layer flap closure method involving an autogenous fascia lata graft and oral mucosa flap.

CLINICAL RELEVANCE

Fascia lata was effective as a scaffolding graft for repair of the oronasal fistula in this pony and may be useful for repair of oronasal fistulas in other equids as well.

Abstract

CASE DESCRIPTION

A 9–year-old pony gelding was evaluated because it was suspected that a persistent oronasal fistula had developed after a fractured right maxillary second premolar tooth had been extracted via repulsion 6 months earlier.

CLINICAL FINDINGS

Unilateral mucopurulent nasal discharge and malodorous breath were noted on clinical examination. Examination of the oral cavity revealed a 1 × 0.5-cm defect at the oral aspect of the right maxillary second premolar alveolus, from which feed material was extracted. Endoscopic examination revealed feed material in the rostral aspect of the right nasal cavity, confirming the diagnosis of oronasal fistula.

TREATMENT AND OUTCOME

The pony initially underwent a reconstructive surgical procedure that combined an alveolar bone flap with a sliding mucoperiosteal hard palate flap to repair the oronasal fistula. The fistula reoccurred 5 months later and was ultimately repaired by means of a novel 2–layer flap closure method involving an autogenous fascia lata graft and oral mucosa flap.

CLINICAL RELEVANCE

Fascia lata was effective as a scaffolding graft for repair of the oronasal fistula in this pony and may be useful for repair of oronasal fistulas in other equids as well.

A 310-kg (682-lb) 9-year-old Welsh Mountain Pony gelding was evaluated because it was suspected that a persistent oronasal fistula had developed after a fractured right maxillary second premolar tooth had been extracted by repulsion1 via the dorsorostral aspect of the maxilla 6 months earlier. The repulsion procedure, carried out at the same hospital on an outpatient basis with the pony standing, had been performed because attempts to extract the fractured tooth via the oral cavity had been unsuccessful owing to severe decay of the tooth crown. Five days after the tooth had been extracted, a communication between the oral and nasal cavities was noted on endoscopic examination and filled with a temporary alveolar plug of polyvinyl siloxane puttya (Figure 1) Afterward, repeated loosening of the plug had resulted in persistent communication between the oral and nasal cavities and the need for repeated replacement of the plug.

Figure 1—
Figure 1—

Endoscopic image of the oral cavity of a 9–year-old Welsh Mountain Pony obtained 5 days after dental repulsion of a fractured right maxillary second premolar tooth was performed via the dorsorostral aspect of the maxilla. Notice the communication (approx 1 × 0.5 cm; star) between the alveolus of the extracted tooth and the nasal cavity (ie, oronasal fistula). The proximal aspect of the alveolus (black arrowhead) and the distal alveolar border (blue arrowhead) are visible.

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

On clinical examination, unilateral (right-sided), mucopurulent, green-tinged nasal discharge and malodorous breath were noted, but the pony otherwise appeared healthy and in good condition. Examination of the oral cavity confirmed that the right maxillary second premolar tooth was absent, and a 1-cm-long (caudal to rostral) by 0.5-cm-wide (medial to lateral) defect was evident at the oral aspect of the alveolus, from which feed material was extracted. Endoscopic examination showed feed material and mucopurulent discharge in the rostral aspect of the right nasal cavity. Approximately 10 cm caudal to the right external naris, a defect was noted in the middle nasal meatus from which feed material was exuding (Figure 2) The alveolar cavity was lavaged orally with physiologic saline (0.9% NaCl) solution to remove all foreign matter. Radiography revealed no osseous or dental tissue within the alveolus associated with the fistula. The diagnosis of a persistent oronasal fistula was confirmed on the basis of clinical examination and diagnostic imaging findings, and surgical repair was recommended.

Figure 2—
Figure 2—

Endoscopic image of the right nasal cavity (approx 8 cm caudal to the external naris) of the pony in Figure 1 obtained 6 months after the dental repulsion procedure. Notice the defect (approx 10 cm caudal to the external naris; arrowhead) in the middle nasal meatus from which feed material is exuding. The nasal septum (arrow) is normal in appearance.

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

The pony was admitted to the hospital, and initial surgical repair of the oronasal fistula was completed over a 2-day period. On the first day, with the pony sedated and standing, the tissue lining the alveolar defect was debrided by curettage and the alveolar cavity was lavaged extensively with physiologic saline solution. A shallow alveolar plug of polyvinyl siloxane puttya was then used to fill the coronal aspect of the fistula, and food was withheld until surgery the next morning.

The next day, 2 surgical procedures were performed in series to repair the oronasal fistula. For the first procedure, an alveolar bone flap was created by use of the technique described by Easley and Freeman,2 except that the procedure was performed with the pony sedated and standing rather than anesthetized. Phenylbutazoneb (2.2 mg/kg [1 mg/lb], IV), procaine penicillinc (20 mg/kg [9 mg/lb], IM), and gentamicin sulfated (6.6 mg/kg [3 mg/lb], IV) were administered before surgery. A 14-gauge IV cathetere was placed, and sedation was achieved by administration of detomidine hydrochloridef (0.01 mg/kg [0.0045 mg/lb], IV) and butorphanol tartateg (0.01 mg/kg, IV), with additional doses administered as required. The pony was placed in stocks and fitted with earplugs. An equine mouth wedge speculumh was inserted to hold the mouth open during the procedure, and the temporary alveolar plug was removed. The face and neck area on the right side were clipped of hair and aseptically prepared. The surgical site was locally anesthetized by injection of 8 mL of 2% mepivacaine hydrochloridei within the infraorbital foramen,1,3 and 5 mL of mepivacaine was infiltrated SC at the planned incision site. In brief, a skin incision was made, and then the buccinator muscle was dissected from the right maxilla. Three osteotomies of the maxilla were performed dorsally, rostrally, and caudally; the ventral aspect of the alveolar bone flap was left intact where it was fractured manually so that it could be deflected axially and trimmed carefully to fit tightly against the medial wall of the alveolus (Figure 3)

Figure 3—
Figure 3—

Intraoperative photograph showing the creation of an alveolar bone flap in the pony in Figure 1. The buccinator muscle was dissected from the right maxilla. Three osteotomies of the maxilla (arrowheads) were performed dorsally, rostrally, and caudally, leaving the ventral aspect of the alveolar bone flap intact where it was fractured so that the flap could be deflected axially, across the medial wall of the alveolus.

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

At the end of the first procedure, anesthesia was induced with ketamine hydrochloride,j and the pony was positioned in left lateral recumbency for the second procedure. A sliding mucoperiosteal hard palate flap was created as described by Barakzai and Dixon4 (Figure 4) In brief, a mouth wedge speculum was inserted, the skin around the right commissure of the lips was clipped of hair and aseptically prepared, and the rostral portion of the oral cavity was irrigated with dilute povidone iodine solution. Starting at the commissure of the lips, a 5-cm-long full-thickness (skin to buccal mucosa) buccotomy was performed to allow better access to the surgical site. The oral aspect of the fistula was debrided, and then a mucoperiosteal hard palate flap was fashioned by making a 1.5-cm incision (caudal to rostral) down to the bone on the medial edge of the fistula along the palatal aspect of the alveolar defect. The hard palate mucoperiosteum was elevated, and two 3-cm transverse incisions at the rostral and caudal edges of the fistula permitted the creation of the flap. Once created, the flap was advanced laterally and sutured to the gingiva. The greater palatine artery was accidentally transected during the procedure, which required that transfixing ligatures be placed on the arterial ends rostral and caudal to the edges of the flap. The pony's recovery from anesthesia was unremarkable; procaine penicillin (20 mg/kg, IM, q 12 h) and phenylbutazonek (2.2 mg/kg, PO, q 12 h) were administered for 5 days after surgery. Food was withheld for 24 hours after surgery, and then a semiliquid mash of soaked alfalfa cubes was fed 6 times/d for 4 weeks to minimize pressure on the healing tissues. The pony was discharged from the hospital 7 days after surgery.

Figure 4—
Figure 4—

Intraoperative photograph showing the creation of a sliding mucoperiosteal hard palate flap in the pony in Figure 1. Through the buccotomy incision (arrowheads), the mucoperiosteal hard palate flap (arrows) is visible, having been advanced laterally and sutured to the gingiva.

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

One month after surgery to repair the oronasal fistula, the pony was returned to the hospital for a follow-up evaluation. Findings on clinical examination suggested that the oronasal fistula had healed, and endoscopic examination of the nasal cavity revealed no feed material or discharge. Following this examination, the owner was instructed to return the pony to its regular diet.

Five months after surgery, the owner returned to the hospital with the pony, reporting reoccurrence of the original clinical signs. Clinical and endoscopic examination confirmed that the oronasal fistula had reoccurred. Compared with its original size, the fistula appeared mildly reduced in size, but on the basis of the medical history and fistula location, surgical reconstruction was recommended. The pony was readmitted to the hospital at this time, and a plan was made to repair the fistula by use of an autogenous fascia lata graft.

Prior to the procedure, the pony received phenylbutazone (2.2 mg/kg, IV); xylazine hydrochloridel (0.8 mg/kg [0.35 mg/lb], IV) and diazepam hydrochloridem (0.2 mg/kg [0.1 mg/lb], IV) as premedicants. Anesthesia was induced with ketamine hydrochloride and maintained with isofluranen in oxygen. The pony was positioned in left lateral recumbency.

The skin over the lateral aspect of the right thigh and right maxillary region was clipped of hair and aseptically prepared. The rostral portion of the oral cavity was irrigated with dilute iodine solution. A 6-cm-long proximodistal incision was made through the skin in the craniolateral aspect of the middle portion of the thigh. The subcutaneous tissues were dissected bluntly away to reveal the fascial sheath. An elliptical 2 × 2.5-cm section of fascia lata was excised and wrapped in a blood-soaked gauze pad. The fascial defect was left open, and the incision was closed in 2 layers; subcutaneous tissues were closed with 2-0 polyglactin 910o in a simple continuous pattern, and the skin was closed with size-0 polydioxanonep in a simple interrupted pattern.

At the same time that the fascia lata graft was being harvested, a second surgeon made a 6-cm-long linear rostrocaudal skin incision over the alveolus of the right maxillary second premolar tooth. Blunt dissection through the buccinator muscle toward the oral cavity was performed, with special attention taken to avoid damaging the dorsal buccal branches of the facial and infraorbital nerves, parotid salivary duct, buccal salivary glands, and mandibular labial artery (Figure 5) Following buccotomy, thorough debridement of the oral aspect of the fistula was performed. The oral mucosa was then gently undermined approximately 3 mm around all edges of the fistula. The fascia lata graft was trimmed to size and used to reconstruct the buccal aspect of the fistula; the graft was sutured in place along the undermined edges of oral mucosa around the fistula with 3-0 polyglactin 910 in a simple interrupted pattern. After placement of the fascia lata graft, a 1-cm-diameter oral mucosal pedicle flap was created by making a circumferential incision over the adjacent oral mucosa on the lateral aspect of the fistula (Figure 6) After partial undermining of the oral mucosa, the flap was rotated while maintaining the pedicle; 3-0 polyglactin 910 was used to suture the flap in place over the previously placed fascia lata graft with simple interrupted sutures. Finally, the buccotomy incision was closed in 2 layers; 2-0 polyglactin 910 was used to close the mucosal, submucosal, and muscle layers in an inverting horizontal mattress pattern, and 2-0 polydioxanone was used to close the skin in a simple interrupted pattern.

Figure 5—
Figure 5—

Intraoperative photograph showing the buccotomy site for the pony in Figure 1. The buccotomy allowed direct access to the oral site of the oronasal fistula for placement of the fascia lata graft (arrowhead).

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

The pony's recovery from anesthesia was unremarkable, and administration of doxycyclineq (10 mg/kg [4.5 mg/lb], PO, q 12 h for 2 weeks) and phenylbutazone (2.2 mg/kg, PO, q 12 h for 5 days) was initiated. Food was withheld for 24 hours after surgery, and then a semiliquid mash of soaked alfalfa cubes was offered 6 times/d for 4 weeks to minimize pressure on the healing tissues. By 3 days after surgery, clinical signs (ie, nasal discharge and malodorous breath) of the fistula were no longer evident. The pony was discharged from the hospital 7 days after surgery.

Fourteen days after surgery, the pony was returned to the hospital for a follow-up evaluation. The owner reported that the pony remained free of the previous clinical signs. Clinical examination revealed that the buccotomy and thigh skin incisions had healed by first intention. A subsequent follow-up examination at 4 weeks after surgery revealed that the fistula had completely healed, and endoscopic examination of the nasal cavity revealed no feed material. Accordingly, the owner was instructed to resume feeding the pony its regular diet. Twelve months later, findings at a final follow-up examination confirmed that the fistula had healed and the clinical signs had completely resolved (Figure 6).

Figure 6—
Figure 6—

Photographs of the oral cavity of the pony in Figure 1. A—Schematic representations of the sites of the oronasal fistula (black oval), buccotomy (red line), fascia lata graft placement (green circle), and oral mucosa flap harvest (used to cover the fascial graft; blue dotted line). B—Same photograph without these representations, showing that the oronasal fistula was completely healed at 12 months after surgical repair of the oronasal fistula with a fascia lata graft.

Citation: Journal of the American Veterinary Medical Association 256, 4; 10.2460/javma.256.4.463

Discussion

Diseases of the cheek (ie, premolar and molar) teeth are an important cause of illness in horses, and in the absence of techniques with established long-term efficacy for dental preservation, extraction remains the treatment of choice.5 Common indications for cheek tooth exodontia include dental fracture, periodontal disease, severe decay or caries, mandibular fracture with alveolar or tooth involvement, and periapical abscess.6 Approaches for cheek tooth exodontia include extraction via the oral cavity, repulsion via a sinus, lateral buccotomy, transcortical buccotomy, and minimally invasive buccotomy with in-tradental screw extraction.1,5,7–9 The pony of the present report was originally treated for a sagittal fracture of the right maxillary second premolar tooth with associated decay. Because extraction of the tooth via the oral cavity was impossible given the severe decay of the tooth crown, repulsion via the dorsorostral aspect of the maxilla was performed with the pony sedated and standing.1

Previous reports6,10,11 indicate that the proportion of horses with complications resulting from exodontia of cheek teeth ranges from 0% to 70%. Regarding exodontia by repulsion of check teeth specifically, 20% to 47% of horses reportedly develop complications.4,9 Complications of exodontia include dental or alveolar sequestration, inadvertent disruption of adjacent structures, palatine artery laceration, and alveolar plug failure leading to fistula formation.1,4,6

Failure of a temporary alveolar plug, as a result of leakage or premature loss of the plug, is a frequent complication following exodontia, particularly when performed by repulsion. Alveolar plug failure is more likely to occur when > 1 tooth has been removed, leaving a large oral defect,4 or when a maxillary second premolar tooth is removed, leaving only 1 adjacent tooth (maxillary third premolar tooth) to support plug adherence. Premature loss of the plug may allow communication between the oral cavity and the maxillary sinus or nasal cavities via the alveolus, resulting in formation of a persistent oromaxillary or, less frequently, oronasal fistula, respectively.2,6 In the pony of the present report, failure of the alveolar plug resulted in formation of a rostrally located, persistent oronasal fistula, which required surgical intervention to achieve final resolution.

Most horses with an oromaxillary fistula can be treated with the horse standing and sedated by removing the infected tissue and feed material from the alveolus, placing a temporary alveolar plug on the coronal aspect of the alveolus until granulation tissue fills the remainder of the socket, and treating the sinusitis.2,4,6,12,13 The alveolar plug can be maintained in place for most oromaxillary fistulas because 2 teeth are present, 1 rostral and 1 caudal to the fistula, providing a gap in which to wedge the plug and solid surfaces for it to adhere to. For horses in which the plug approach fails to resolve the oromaxillary fistula, various muscle transposition techniques can be used to treat fistulas that occur caudal to the maxillary fourth premolar teeth.13,14

In general, oronasal fistulas constitute a formidable reconstruction challenge regardless of the species affected.4,12 Indeed, despite the more extensive range of surgical options available for humans than for horses, the reported rate of fistula reoccurrence in humans is as high as 65%.12,15 In horses, the range of surgical options to correct oronasal fistulas is particularly limited. Muscle transposition techniques used for repair of oromaxillary fistulas are not applicable to repair of oronasal fistulas because the muscle flap would not be long enough to reach the alveolar defect, which is located more rostrally for oronasal fistulas than for oromaxillary fistulas.2 Only 2 surgical techniques for oronasal fistula repair in horses have been described. One technique involves the use of a sliding mucoperiosteal hard palate flap,4 whereas the other technique uses an alveolar bone flap.2 Although the reports2,4 of these novel surgical techniques each indicate a successful outcome in a single horse with an oronasal fistula, there are risks associated with their use.12,16

The sliding mucoperiosteal hard palate flap technique is more invasive than the alveolar bone flap technique and requires that the horse undergo general anesthesia. Another concern with this technique is the risk of creating an avascular flap should the palatine artery be transected and require ligation.4 Moreover, in the case report4 concerning this technique, the horse developed partial dehiscence along the palatal-gingival suture line that likely resulted from tension along the line of repair.16 The alveolar bone flap technique can be safely performed with local anesthesia and the horse sedated and standing, as was done for the pony of the present report. However, the overall healing time for the horse that underwent the alveolar bone flap procedure2 was longer than that for the horse that underwent the sliding mucoperiosteal hard palate flap procedure,4 probably because the oral aspect of the rotated alveolar bone flap has minimal soft tissue coverage, which may cause partial or total loss of viability of the flap. Additionally, both surgical techniques2,4 involve only a 1-layer flap closure. In contrast, techniques used to treat oronasal fistulas in other species, including humans, involve use of a 2-layer flap closure method, which provides more resistance to motion and a lower risk of dehiscence.15

In the pony of the present report, a combination of the alveolar bone flap and sliding mucoperiosteal hard palate flap techniques was used for the initial repair attempt in an effort to address the limitations associated with the use of each of these techniques. However, the attempt to add structural support to the mucoperiosteal hard palate flap and soft tissue coverage to the alveolar bone flap by combining these 2 techniques failed to prevent reoccurrence of the oronasal fistula.

Ultimately, an alternative novel surgical technique that used a 2-layer flap closure method involving an autogenous fascia lata graft and oral mucosa flap resulted in successful repair of the oronasal fistula in the pony of the present report. Fascia lata, the fascial sheath surrounding the thigh muscles, becomes thicker at its distal aspect (ie, toward the stifle joint).17 To the authors' knowledge, the use of a facia lata graft for oronasal fistula repair in horses has not been previously reported. However, the use of fascia lata as a graft material in other species, including humans, has been well documented.17–20 Major advantages associated with the use of fascia lata as a graft material include the ease with which the tissue is harvested, its availability in large quantities, and its ability to integrate well in the graft site while providing excellent structural support.17

The fascia lata grafting technique was a safe and effective surgical option that provided adequate structural support for reconstruction of a persistent oronasal fistula in the pony of the present report. The use of this novel surgical technique resulted in rapid resolution of the pony's clinical signs and successfully sealed the oronasal fistula located at the level of a maxillary second premolar tooth. This technique may be useful for repair of oronasal fistulas in other equids as well.

Acknowledgments

The authors received no external funding and declare that there were no conflicts of interest.

Footnotes

a.

Take 1 Advanced putty, Kerr Corp, Romulus, Mich.

b.

Ilium Nabudone P IV, Troy Laboratories Pty Ltd, Smithfield, NSW, Australia.

c.

Ilium Propercillin, Troy Laboratories Pty Ltd, Smithfield, NSW, Australia.

d.

Aagent, Fatro SpA, Veterinary Pharmaceutical Industry, Bologna, Italy.

e.

Intraflon 2, Vygon Value Life, Ecouen, France.

f.

Eqdomin, Ourofino Saude Animal, Sao Paulo, Brazil.

g.

Morphasol, Forte Healthcare Ltd, Meath, Ireland.

h.

Harlton's mouth wedge speculum, Equine Dental Instruments, Elmwood, Wis.

i.

Mepivacaine, Ceva Animal Health Pty Ltd, Glenorie, NSW, Australia.

j.

Ilium Ketamil, Troy Laboratories Pty Ltd, Smithfield, NSW, Australia.

k.

Bute granules, Randlab, Peakhurst, NSW, Australia.

l.

Ilium Xylazil-100, Troy Laboratories Pty Ltd, Smithfield, NSW, Australia.

m.

Ilium Diazepam, Troy Laboratories Pty Ltd, Smithfield, NSW, Australia.

n.

IsoFlo, Abbott Laboratories Ltd, Maidenhead, England.

o.

Vicryl, Johnson & Johnson International, Diegem, Belgium.

p.

PDSII, Johnson & Johnson International, Diegem, Belgium.

q.

Doxylag, Labatec Pharma SA, Vezia, Switzerland.

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