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Nasal septal surgery is one of the most common otolaryngology procedures performed, with rare occurrences of major postoperative complications. Oronasal fistula is a rare complication of septal surgery, with only few cases being reported in the literature. It is commonly caused by a congenital cleft palate, cleft palate surgery, traumatic injuries, infections, or neoplasms; however, it does not usually occur post-septal surgery. Here, we report the case of a 55-year-old male who presented with a symptomatic oronasal fistula post-septoplasty. Unlike other reported cases, there were no features of underlying palatal pathologies, and no previous history of other nasal or oral procedures. We described a multilayer surgical closure technique that was utilized in this case, with no recurrence seen during a 6-month follow-up period. Additionally, we reviewed the other 3 reported cases of this complication, and discussed the possible etiology in this case.
Septal surgery is one of the most commonly performed otolaryngologic operations.1-3 It is primarily indicated to improve the nasal airway in patients presenting with nasal obstruction due to a deviated nasal septum.1-3 Various surgical techniques have been described in the literature, including submucosal resection (SMR), conventional septoplasty, and more recently, endoscopic septoplasty.1-3 The most common complications of septal surgeries include the persistence of nasal obstruction, bleeding, septal hematoma, and septal perforation.4 Rare complications include saddle nose deformities, cerebrospinal fluid rhinorrhea, and ocular complications;4 however, an oronasal fistula is one of the rarest complications of septal surgery.5 It is most commonly caused by a congenital cleft palate, cleft palate surgery, traumatic injuries, infections, or neoplasms.5 The main complaints associated with an oronasal fistula and necessitating early surgical repair are nasal regurgitation and hypernasality.6 Here, we present the case of an oronasal fistula as a complication of septal surgery, without any previous underlying palatal pathology. The aim of presenting this rare complication was to highlight the possible causes and available surgical approaches, and to increase awareness among the general otolaryngology community.
A 55-year-old gentleman presented with a history of nasal regurgitation and hyper-nasality post-septoplasty. The original surgery was carried out in another institute under general anesthesia 2 months prior to his presentation to our clinic. The fistula was unnoticed intra-operatively, and the patient's symptoms began on the third postoperative day, after which he underwent multiple failed attempts at closure under local anesthesia at the other institution. He denied having any other nasal or oral procedures in the past, and had not been treated for any infections in the same area. The in-office examination revealed a 3-mm oronasal fistula starting just off the midline on the right side of the hard palate, and ending in the right nasal floor adjacent to the mid-septum (Figures Figures1A1A--1B1B). There were no signs of a submucosal cleft palate, cleft palate, high arched palate, cleft lip, ulceration, or any current or reported previous infections in the area. A noncontrasted CT scan of the paranasal sinuses was performed, and showed a bony defect in the hard palate corresponding to the site of the oronasal fistula, as seen on the clinical examination, and an absence of the majority of the vomer bone posteriorly (Figure 1C).
He underwent a surgical repair of the oronasal fistula using multilayer reconstruction under a general anesthetic. Initially, the fistula tract was resected transorally and transnasally utilizing nasal endoscopy. Then, a palatal mucoperiosteal flap was raised on the left based on the greater palatine vessels. Irradiated fascia lata Tutoplast® (RTI Surgical, Inc., USA) was placed as the first layer covering the fistula on the oral side, and the mucoperiosteal flap was rotated and advanced as the second layer. The flap was sutured to the surrounding mucosa with absorbable sutures, followed by the application of BioGlue® (CryoLife, Inc., USA) over the flap to further support and seal the reconstruction (Figure 2). The nasal surface of the fistula was also reconstructed using a free mucosal graft harvested from the left nasal cavity floor, after removing the mucosa surrounding the fistula site on the nasal aspect. The intraoperative endoscopic examination of the surrounding area revealed the absence of a large portion of the bony vomer, with intact mucosa. The nasal reconstruction was also held in place with BioGlue® and absorbable packing. During the 6-month postoperative follow-up period, this patient's symptoms resolved, with no evidence of recurrence upon examination (Figure 3).
An oronasal fistula is a pathological defect that connects the nasal and oral cavities.6 It is considered to be one of the rarest complications of septal surgery. Upon reviewing the literature, only 3 cases of this complication have been previously reported. Thompson et al5 described the case of an oronasal fistula in a patient who underwent septal surgery complicated by a fungal infection. Four months postoperatively, the patient showed signs of swelling and ulceration at the midline of the hard palate, which progressed within 8 months to a complete palatal perforation.5 A biopsy from the ulcerative edges confirmed the presence of candida albicans.5 A repeated biopsy after 3 months of oral antifungal therapy was negative for fungus. The patient then underwent a successful surgical repair of the defect with an oral mucosal flap.5 Ersoy et al7 presented a case with a palatal fistula of the hard palate immediately after septal surgery in a patient with an undiagnosed submucosal cleft palate. The fistula was repaired successfully using 2 vascular layers composed of a nasal mucosal flap for the nasal layer, and a rotational mucoperiosteal flap from the oral cavity for the oral layer, with no recurrence.7 Gökdemir et al8 reported the third case of a palatal perforation immediately after septal surgery in a patient with a high arched palate, which was repaired using mucoperiosteal flaps to cover the nasal and oral parts of the defect.
In contrast to the other case reports, no underlying palatal abnormality or pathology was present in our case. We presume that this unusual complication was the result of a vigorous resection of the maxillary and palatine crests of the nasal septum, with the possible use of an osteotome angled inferiorly. We also believe that this was overlooked intra-operatively due to the narrow and bloody surgical field of view posteriorly in a routine septoplasty. This could have been prevented with use of rigid nasal endoscopy to optimize the visualization in that area.
Various techniques have been described to repair a palatal fistula, depending on its site and location.9 To decrease the risk of recurrence, the closure is most commonly performed with 2 vascularized mucosal layers, with the nasal layer being closed by a nasal mucosal flap and the oral layer being closed by mucoperiosteal transposition flap.9 Murrell et al10 described a 3-layer closure of oronasal fistulas consisting of a septal mucosal flap, bone or cartilage graft, and palatal mucosal flap, with no recurrence after one year of follow-up. We utilized a similar surgical technique with 3 layers for the closure of the defect. It consisted of a free nasal mucosal graft, an irradiated fascia lata allograft (Tutoplast®), and a rotational mucoperiosteal flap from the oral cavity adjacent to the fistula. Our results showed good healing with no recurrence of the fistula or symptoms after a 6-month follow up period.
In conclusion, an oronasal fistula is an unusual complication of septal surgery. Care should be taken preoperatively to identify those patients at risk, including patients with a high arched palate or a submucosal cleft palate. Any resection of the deviated bony maxillary and palatine crests in high risk patients during septal surgery should be attempted under direct vision, with great care. Endoscopic visualization may help in preventing such a complication during septoplasty, especially when dealing with posterior deviations of the nasal septum. Early identification and surgical repair are important to reduce the negative impact of an oronasal fistula on the patient's quality of life. Moreover, a 3-layer repair can be utilized for the closure of an oronasal fistula, with a low recurrence rate.
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
Clinical Practice Guidelines must include a short abstract. There should be an Introduction section addressing the objective in producing the guideline, what the guideline is about and who will benefit from the guideline. It should describe the population, conditions, health care setting and clinical management/diagnostic test. Authors should adequately describe the methods used to collect and analyze evidence, recommendations and validation. If it is adapted, authors should include the source, how, and why it is adapted? The guidelines should include not more than 50 references, 2-4 illustrations/tables, and an algorithm.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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This Marine batted the enemy's grenades back at them
At the outbreak of the Korean War, Hector Cafferata, Jr. was a semi-professional football player serving in the United States Marine Corps Reserve. He received just two weeks of additional training before being shipped overseas.
Assigned to Fox Company, 2nd Battalion, 7th Marines just days before landing at Inchon, he, along with the rest of the 1st Marine Division, battled his way into North Korea. By November 1950, Cafferata and the Marines were preparing for an offensive in the vicinity of the Chosin Reservoir.
As the Battle of Chosin Reservoir began, the Marines of Fox Company were defending the Toktong pass. On the night of Nov. 28, the Chinese attacked to dislodge them.
What happened next is a legendary story in the Marine Corps — and Cafferata had a large role to play in that.
The Marines of Fox Company had been unable to properly dig in due to the frozen ground and instead cut and gathered tree branches and whatever else they could find to provide cover and concealment.
Due to an intelligence failure, the Marines were unaware that the entire Chinese 9th Army was advancing on their position. That night they crawled into their sleeping bags with minimal security on watch.
At around 0130, the Marines of Fox Company were awoken to a terrible surprise as all hell broke loose around their position. An entire Chinese division, the 59th, were attacking into the Toktong pass to cut off the 1st Marine Division.
The only things standing in their way were Cafferata and the rest of Fox Company.
Hearing the sounds of the attack, Cafferata sprung from his sleeping bag and hurried into the firing line. In his rush to get into the action, he left behind his boots and heavy coat.
In the opening minutes, most of Cafferata's squad became casualties so he rushed from position to position gathering ammo and pouring fire into the attacking Chinese.
This video is an animation produced by Veterans Expeditionary Media that depicts the battle conditions that night.
He was joined by another Marine, Kenneth Benson, who was temporarily blinded after a grenade explosion had ripped his glasses right off his face. Together they made their way to a small depression and set up to make their stand against the Chinese onslaught.
As the Chinese pressed forward, Cafferata, a crack shot with his M-1 Garand, would empty his clip into the advancing infantry — eight shots, eight communists down.
He would then hand the weapon to Benson to reload while he threw grenades. When the Chinese attacked with their own grenades, he threw them back.
At one point he picked up his entrenching tool and batted the enemy's grenades right back at them. According to a 2001 interview, Cafferata said he "must have whacked a dozen grenades that night."
As the Chinese continued to advance, threatening to breakthrough his thinly held portion of the line, he gave them everything he had. He fired his weapon so much he had to pack snow on it to cool it off.
Eventually, Cafferata's luck began to run out. As he hurled back yet another Chinese grenade, it went off just after leaving his hand. The explosion severed part of his finger and severely damaged his right hand and arm.
Though he was injured, Cafferata's quick reaction saved several of his comrades.
Despite his wounds, he fought on. The Chinese couldn't get past him.
Finally, just after daybreak, Cafferata was wounded by a sniper's bullet and evacuated from the line. When the medics brought him to the aid station, they realized he was suffering from frostbite after fighting in subzero temperatures in his socks all night.
Despite Cafferata being out of action, the rest of Fox Company and the Marines at Chosin Reservoir still had quite a fight on their hands.
According to the Medal of Honor citation for Capt. William Barber, Fox Company's commander, his 220 Marines held out "5 days and 6 nights against repeated onslaughts by fanatical aggressors."
And of those 220 Marines, only 82 "were able to walk away from the position so valiantly defended against insuperable odds." They carried their wounded out with them, including Cafferata and Barber who were both wounded on the first day of fighting.
Cafferata's wounds earned him 18 months of recovery in various hospitals. His actions earned him the Medal of Honor.
The day after Cafferata's amazing stand, the Marines "counted approximately one hundred Chinese dead around the ditch where he fought that night," but according to one source, they "decided not to put that figure in their report because they thought no one would believe it."
Cafferata was officially credited with fifteen enemy kills.
Cafferata, always humble, would later state, "I did my duty. I protected my fellow Marines. They protected me. And I'm prouder of that than the fact that the government decided to give me the Medal of Honor."
Hector Cafferata, Jr. passed away on April 12, 2016 at the age of 86.
These are the military traditions for deployed troops celebrating Thanksgiving
While you're deployed, weekends aren't really a thing — neither are most holidays. Thanksgiving, however, is a moment when the military slows down.
Forget multitasking, this Navy squadron has only one mission — rescue people
The Navy has an entire squadron for search and rescue, and it is the only squadron in the Navy that has an advance life-support helicopter platform.
How the Coast Guard intercepts half a million pounds of cocaine
For the last couple decades, the Coast Guard has pushed out further, taking more aggressive stabs at the flow of drugs that make their way into the U.S.
More remains of Special Forces soldier found in Niger
The Department of Defense announced that military investigators found additional remains that they have positively ID'd as Sgt. La David T. Johnson.
'Butcher of of Bosnia' sentenced to life in prison for genocide
"The Butcher of Bosnia" was handed a life sentence on November 22nd, 2017, for war crimes and the slaughter of 8,000 men and young children.
New engravings on the USMC War Memorial honor Iraq and Afghanistan Marines
On Nov. 22, the U.S. Marine Corps War Memorial was updated to include Afghanistan and Iraq in the list of campaigns that runs along the memorial's base.
ISIS may focus on a virtual caliphate after losing real-world war
As the Islamic State loses the in real life war they've waged against the world, they've moved their game online- waging war in the virtual world.
Everything you need to know about Zimbabwe's ousted dictator
The dictator of Zimbabwe announced his resignation on Nov. 21, 2017 after the county's army took of the capital and family, forcing the resignation.
Watch this Marine get pinned by his 3-year-old son
Watch this adorable little boy steal into the hearts of all the Marines and civilians present as he promotes his dad and pins on his promoted rank.


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"'I must not communicate with that' will wind up, sooner or later, in you deciding that you can be hurt. …
"Now, when you ask somebody to handle an airplane, touch it and touch it and touch it and touch it and touch it… you're actually running out, eventually, his idea that he can be hurt. …
"He's decided he could be hurt by so many vehicles, and he's proven it to himself so often, that he eventually becomes, again, superstitious—leaves it all up to chance and says, 'If I am lucky.'
"You can have luck anytime you want to have luck. Just postulate you're going to have some luck. Say, 'Well I haven't been lucky for a long time, haven't won any grand prizes or anything; I guess I'll win some grand prizes.'"
"If your life is not all you want it to be, it may be that you have some forgiving to do."
An Unknown Author
Your action for today is to see if you are feeling resentment towards someone who you feel has wronged you, and today try to forgive them.


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Forum indexPortrait and People PhotographyChange forum
Pet portraits for constructive C&C
Started Dec 23, 2012 | Discussions thread
Thomas Kolenich • Senior Member • Posts: 2,085
Re: Pet portraits for constructive C&C
In reply to barbossa3127 • Jan 4, 2013
I appreciate the comments. What I meant to say was that I am a portrait photographer who specializes in weddings. I have done some high school seniors, but was thinking of doing pet portrait photography. Do you think there is a market for that considering everyone has a camera on their phone?
Tom Kolenich
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Adaptation of Microorganisms to Intensive Disorders
Bacteria can survive in numerous places with mixed enviromentally friendly scenarios. Definitely one popular characteristic of those locales is because provide you with the solution platform, pure matter, along with the power source to guarantee the surviving about the microorganism.a essay In this case, dwelling microorganisms point out the assortment of being given out into a trio of areas, which include Archaea, and Eukarya. Besides that, drastic circumstances are defined by various kinds of stresses which include dryness, large or minimum temperatures, higher radiations, acidic or alkaline diseases. Organisms inhabiting extraordinary areas exhibit exclusive components most notably absolutely interlinked healthy proteins stores, inflexible excess fat in membranes, and static Deoxynucleic and ribonucleic acids, which allow them to stay alive.
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When: Tuesday, October 27th, 2015 (Registration at 10 a.m.)
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Product description
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2 Comments
Sounds good, do you know how much the packs weigh?
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A Reputation Built On Trust
Property Details for MLS® # C4138580
2 Storey Detached Home for Sale
Property For Sale In Oakridge, Calgary
- Size: 1,840 sq ft
- Price: $549,999
- Bedrooms: 5
- Bathrooms: 3(full) 1(half)
- Parking: 4
- Status: Active
- Year Built: 1979
This 4 bedroom up 2 storey home is nestled amongst mature pine trees in a private setting in a very desirable community. This home has had renovations in the last 5-7 years, with a NEWER SHINGLE ROOF Dec (2016).The main floor has 2 living rooms and a wood burning fireplace. The kitchen has GRANITE & QUARTZ countertops and STAINLESS STEEL appliances that overlooks the MASSIVE back yard which has an awesome deck for summertime enjoyment. The ceiling is tastefully decorated with beam accents. The upstairs has 4 BEDROOMS with a very spacious master bedroom and a 4 pc. ensuite. Close to schools, shopping and transportation. Don't miss out and book your showing today. A MUST SEE!
Contact Rob Johnstone About MLS® C4138580
Rob Johnstone, 403-730-2330 at RE/MAX R.E.(Mountain View)Ltd., 222, 4625 VARSITY DRIVE N.W., CALGARY, Alberta, T3A 0Z9
property information
- Property Type: Detached Home
- Style: 2 Storey
- Year Built: 1979
- Total Floor Area: 1,840 sq.ft
- Finished Levels: 3
Community Information
- Neighbourhood: Oakridge
- City: Calgary
- Postal Code: T2V 4W8
- Included: Dishwasher-Built-In, Dryer, Hood Fan, Refrigerator, Storage Shed, Stove-Electric, Washer
- Bedrooms: 5 (Bedrooms Above: 4)
- Bathrooms: Full: 3 / Half: 1
- Rooms Above Grade: 8
- Basement: Full, Fully Finished
- Floor Finish: Ceramic Tile, Cork Flooring, Hardwood
- Exterior Features: Fenced, Level Land, Treed Lot
- Exterior Finish: Brick, Wood
- Construction: Wood Frame
- Foundation: Concrete
- Roof: Asphalt Shingles
- Front Exposure: West
- Frontage: 15.6200 metres
- Depth: 43.8000 metres
Upper Level Room Dimensions
- Master Bedroom: 4.72m x 3.63m
- Bedroom: 3.84m x 2.72m
- Bedroom: 3.43m x 2.62m
- Bedroom: 3.30m x 2.82m
Main Floor Room Dimensions
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- Kitchen: 4.78m x 2.95m
- Family Room: 5.33m x 3.89m
- Dining Room: 3.53m x 2.92m
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Item Description
Excellent quality proshot HBO broadcast of the Little River Band, live in Melbourne, Australia in 1983. Total running time is 60 minutes, quality is about 9/10, and features the following tracks: Please don't ask meThe netHappy anniversaryThe other guyCool changeTake it easy on meReminiscingWe twoDYou're driving me out of my mindNight owlsJust say that you love meDown on the borderSt Louis Region Free NTSC Format PC Friendly Case Box with Cover Artwork Discs Labeled $ 10 to USA, $ 10 to Others Countries. Payment Method: PAYPAL & CREDIT CARDS BUYER WILL RECEIVE SECURE CHECKOUT LINK TO PAY WITH PAYPAL OR CREDIT CARDS.
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Israel News
Middle East
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Edition française
Green Israel
A GROUP of residents from Har Bracha south of Nablus in the West Bank visit the Temple Mount on Sunday.
(photo credit:PESACH GOLDMAN)
A record number of Jews visited the Temple Mount over Passover, breaking the record for most Jewish visitors to the site in one day as well as over the course of Passover.Approximately 1,600 Jews visited the site throughout the seven days of Passover, compared to last year's Passover record of 1,015, according to Yirah, an organization that encourages the presence of Jewish worshipers on the Temple Mount.
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How Do Drones Assist With Logistics and Transport goods
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Class 6. English/Western
Pleasure 2 gait
Mid America's Grand Slam 48th Annual Show
July 9, 10 & 11, 2015
id America's Grand Slam 48th Annual Show
July 9, 10 & 11, 2015
Ozark Empire Fairgrounds, Springfield Missouri
Class # 41
Ladies Foxtrot
This is a new traveling trophy that has been made for Class # 41
Ladies Foxtrot Championship Traveling Trophy In Loving Memory Of
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Please join us in honoring Fran's love of the Missouri Foxtrotting
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high waisted floral skirt
Multicolour high waisted floral skirt from Marni featuring an a-line shape, a ruffled design, a rear zip fastening and an asymmetric hem.
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Designer Style ID: GOMAT16J00TV457
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Item fits true to size
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