International Journal of Otorhinolaryngology and Head and Neck Surgery

Ben Ishai M et al. Int J Otorhinolaryngol Head Neck Surg. 2025 Apr;11(2):153-157

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Case Report

DOI: https://dx.doi.org/10.18203/issn.2454-5929.ijohns20250793

A novel surgical procedure for medial canthal fistula closure in midline destructive lesions: two case reports

Meydan Ben Ishai1,2*, Simerdip Kaur1,2, Huw Oliphant1,2, Saul Rajak1,2

1Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, BN2 5BF, Brighton, UK

2Brighton and Sussex Medical School, University of Sussex, BN1 9PX, Brighton, UK

Received: 22 September 2024

Revised: 05 February 2025

Accepted: 06 February 2025

*Correspondence:

Dr. Meydan Ben Ishai,

E-mail: Meydan.benishai@nhs.net

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Medial canthal fistula in the context of destructive processes poses a significant surgical challenge. We report the closure of the fistula using a novel Back-to-Back Sandwich Flap (B2BSF) in two patients. The surgery involves fashioning a paired inner layer inverted local skin flap covered by an outer layer skin glabellar to create a double layer back-to-back flap to cover the defect. It was used to close a 2.5 by 2.5 mm fistula in one patient with CIMDL and a 0.5 by 1 mm in a second patient with radiotherapy damage post-SCC. Three months post-surgery, the fistula remained closed in both patients. Medial canthal fistula can compromise the ocular surface and vision and is unsightly and uncomfortable. It is difficult to close the fistula, particularly in a destructive process with unhealthy and avascular surrounding tissue. The B2BSF appears to be an effective surgical reconstructive strategy for this challenging situation.

Keywords: Canthal fistula, CIMDL, Surgery, Flap

INTRODUCTION

Medial canthal fistula is an abnormal communication between the nasal cavity and the skin and/or caruncular area. They are typically congenital, deriving from defects in the developmental process.1 Acquired medial canthal fistulas are rarely described in the literature but anecdotally are not infrequently encountered, typically with traumatic/post-surgery or a destructive or revascularizing process such as malignancy, radiotherapy, or cocaine abuse.2,3–6

Surgical correction of those fistulae can be very challenging, with different approaches described according to the location and size of the fistula.3,4,7–11 Cocaine is among the oldest known and widely used recreational drugs. It is frequently inhaled powdered for its rapid-acting effect through the highly vascularized nasal mucosa. When used in a high-velocity insufflation process, the crystals and contaminants present in the drug may cause mucosal irritation and trauma to the mucous membranes. The vasoconstriction, irritation, inflammation, ulceration, and ultimately ischaemic necrosis of the drug and contaminants can cause cocaine-induced midline destructive lesions (CIMDLs) with destruction and perforation of osseocartilaginous structures in the midface.12,13

Squamous cell carcinoma is the most common sinonasal malignancy, and 75% to 89% of tumours of the nasal cavity are identified at an advanced stage.14,15 They are usually treated with complete surgical resection followed by adjuvant radiotherapy (RT).16,17 Avascular necrosis and fistula can complicate radiotherapy.17 Authors present a novel surgical procedure using a back-to-back sandwich flap (B2BSF) to close a medial canthal fistula in two patients with different destructive aetiologies. The study was conducted in accordance with the amended Declaration of Helsinki. Both patients signed consents for the use and publication of their photographs, and the consents are on file.

The surgical procedure

The surgery was done under general anaesthesia. The fistula area was marked with two halves of 2-4 mm skin flap squares on both sides. The double inverted full-thickness skin flaps are to be created and flipped over to cover the defect (Figure 2). Both flaps were sutured together, with the skin side facing the intra-nasal space, thereby closing the fistula as the first (internal) layer. The exposed side of the inverted flaps is then covered with another skin flap, such as the glabellar flap, thereby creating a double-layer flap with skin on the external sides of the flap. The surgical video was added as supplemental digital content.

CASE REPORTS

Case 1

A 46-year-old man with CIMDL had a large left medial canthal fistula. He had already lost the left eye secondary to corneal perforation presumed to result from chronic exposure and infection due to his fistula. He also had a further large nasal fistula, saddle nose deformity and destruction of the nasal cavity and sinuses (Figure 1).

Previous nasal mucosa biopsies showed non-specific ulceration and inflamed granulation tissue. Sinus and orbital computerized tomography (CT) scans demonstrated extensive destruction of the midline osseocartilaginous structures, with loss of the hard palate, nasal septum, lateral walls of the nasal cavity, medial walls of both orbits and ethmoid air cell complexes.

The patient's surgery used a B2BSF closure with the inner layer paired flaps formed from (1) inverted eyelid skin and (2) inverted nasal skin, and the external layer was a glabellar flap.

The postoperative recovery was uneventful, and the fistula remains closed at three months post-surgery. (Figure 3).

Case 2

A 54-year-old developed a left medial canthal fistula after routine endoscopic DCR surgery. She had previously had SCC and had lateral rhinotomy surgery with postoperative radiation therapy (RT). The patient developed a medial canthal fistula a few months after her DCR surgery (Figure 4). The fistula prevented her main hobby of swimming. In February 2024, the patient underwent medial canthal fistula closure surgery using a B2BSF with the inner layer paired flaps from inverted nasal skin and an external small glabellar flap. The fistula remains closed at three months, except for a very small hole. This hole does not affect the patient's quality of life; she has returned to swimming (Figure 4).

Figure 1: (A) A photograph of a patient's face depicts a severe saddle-nose deformity and a large medial canthal fistula through the nasal cavity. In this photo, the eyelids are not in contact with the cornea medially, and the eye is positioned in an adducted position pointing toward the exposed nasal cavity; (B) the medial canthal fistula: a closer look.
Figure 1: (A) A photograph of a patient's face depicts a severe saddle-nose deformity and a large medial canthal fistula through the nasal cavity. In this photo, the eyelids are not in contact with the cornea medially, and the eye is positioned in an adducted position pointing toward the exposed nasal cavity; (B) the medial canthal fistula: a closer look.
Figure 2: Theatre photos. (A) Photograph from the theatre of the markings on the double breast flaps (arrows) and the glabellar flap (star); (B) the superior flap is incised; (C) elevation of the superior flap; (D) the superior and inferior flaps are sutured together; (E) a glabellar flap is created & (F) the final result is the glabellar flap covering the double breast flaps.
Figure 2: Theatre photos. (A) Photograph from the theatre of the markings on the double breast flaps (arrows) and the glabellar flap (star); (B) the superior flap is incised; (C) elevation of the superior flap; (D) the superior and inferior flaps are sutured together; (E) a glabellar flap is created & (F) the final result is the glabellar flap covering the double breast flaps.
Figure 3: Three months post-op photograph of case 1 in the clinic; the fistula completely closed.
Figure 3: Three months post-op photograph of case 1 in the clinic; the fistula completely closed.
Figure 4: (A) An image of the patient's face demonstrating the medial canthal fistula; (B) an image of a theatre's double breast (arrows) and glabellar flap (stars); (C) a minor hole remained three months after the surgery, which had no adverse effect on the patient's quality of life.
Figure 4: (A) An image of the patient's face demonstrating the medial canthal fistula; (B) an image of a theatre's double breast (arrows) and glabellar flap (stars); (C) a minor hole remained three months after the surgery, which had no adverse effect on the patient's quality of life.

DISCUSSION

Medial canthal fistula in the context of destructive and avascular tissue is an extremely challenging situation. The B2BSF is a promising and simple surgical technique that closes the fistula with multiple layers.

Problems with having a medial canthal fistula

Fistulas of the medial canthus are associated with both aesthetic and functional difficulties. Fistulas in this region may affect the function of the eyelids, the patency of the lacrimal drainage system, and ocular protection. They may also be uncomfortable and unsightly. Furthermore, medial fistulas can affect breathing and interfere with daily activities such as swimming or scuba diving.

Literature on medial canthal fistula closure

Some fistulas may close with time and conservative management, such as antibiotics, if there is evidence of infection or immunosuppression for inflammation.10 There is a lack of literature on surgical strategies for fistula closure. Medial canthal fistula reconstruction surgery was first described by Putterman in 1989 using a nasolabial flap combined with a forehead flap to reconstruct a post-surgical fistula.11 Other surgical methods described include myocutaneous flap, dermis fat graft, split-thickness skin graft, free flap, granulation, or a combination.4

Spontaneous closure is extremely unlikely in the setting of devascularised tissue and impaired healing and/or a fistula that has already been present for a significant period of time. Moreover, primary closure, skin grafts, and simple local flaps will likely have high failure rates. Therefore, two-layer closure with good vascularisation to both layers is vital.18,19

Nelson et al described a four-layer galeafrontalis and pericranial extension technique in four patients in 2014 with good functional and cosmetic results, and other papers have described a range of other double-layer closure techniques using galeapericranial, pericranial and nasolabial flaps.11,20–22 A hard-palate graft and overlying skin flap have also been described, but we anticipate that the poor surrounding blood supply in the present cases may not support the graft.23-29

Our described method is based on the same principles. We aimed to create a double-layer closing solution for the fistula, using simple adjunct tissue harvesting while avoiding radical periosteal and skull-based intra-mouth procedures, with good aesthetic and functional results.

Potential benefits of the B2BSF

There are many advantages to using the B2BSF. This double internal flap facilitates flaps with a small length-to-width ratio, thereby improving vascularity and the likelihood of survival. The external flap (the glabellar flap in the present case) is also laid on a vascular bed (on the opposite side of the internal flaps), improving vascularity. It is a relatively straightforward surgical technique that does not require a steep learning curve. The surgery is short and can be performed under general or local anaesthesia.

Potential downsides to the B2BSF

There may be some downsides to the B2BSF. The flap places a small window of skin in the nasal cavity. This is not optimal compared to nasal mucosa as, theoretically, it could sweat, cause irritation or inflammation, and not effectively move debris secretions. However, the nasal cavity and mucosa in the present cases are so damaged and devitalized that a small area of skin is unlikely to have any consequences.

B2BSF elsewhere

Back-to-back flaps, or similar, have been described and used in other medical subspecialties. One of the most common uses is in cleft palate reconstruction surgery, which uses Bardach's two-flap palatoplasty technique.30 Using this technique, the palatal cleft can be completely closed, with the hard palate closed in two layers and the soft palate closed in three. Similarly, a two-layer back-to-back technique has been described in the gynecological field for reconstructing vaginal septum or vesicovaginal fistulas.31,32

This paper reports only two cases, with follow-ups of 3-4 months, and further cases need to be conducted to get greater insight into the risk of failure and other complications and pitfalls.

CONCLUSION

This case describes a unique presentation of medial canthal fistulas in the context of CIMDL and postoperative RT, which has not been described in the literature before. The fistula caused ocular surface insult, delayed corneal surface healing, and caused great distress to our patients. Our cases illustrate a useful, straightforward surgical technique for closing large and complicated fistulas.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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