MANAGEMENT OF LARGE IATROGENIC NASOANTRAL FISTULAS:A NARRATIVE REVIEW, EVIDENCE SYNTHESIS, AND ILLUSTRATIVE CLINICAL CASE

Background:Large iatrogenic nasoantral fistulas remain a challenging problem in maxillofacial surgery because chronic inflammation, epithelialization of the tract, and poor local tissue quality often compromise healing. Successful treatment requires not only closure of the communication but also restoration of normal sinonasal function and long-term tissue stability. Objective:To review contemporary surgical approaches for the management of large nasoantral fistulas and to illustrate the clinical application of current reconstructive principles through a representative clinical case. Methods:A narrative review of the literature was performed using PubMed, Scopus, and Web of Science databases. Publications addressing nasoantral and oroantral fistulas, buccal fat pad reconstruction, palatal mucosal grafting, endoscopic sinus surgery, and postoperative stabilization techniques were analyzed. To demonstrate the practical implementation of these concepts, a patient with a large chronic iatrogenic nasoantral fistula following previous Caldwell–Luc surgery was treated using a multilayer reconstructive approach. Results:The reviewed literature indicates that while conventional flap techniques remain effective for small defects, larger fistulas generally require more complex reconstructive strategies. Multilayer closure combining vascularized tissue support and epithelial surface coverage appears to provide greater stability and lower recurrence rates. In the presented case, reconstruction using a vascularized buccal fat pad, palatal mucosal graft, endoscopic assistance, and silicone stabilization resulted in complete closure of the fistula without postoperative complications or recurrence during follow-up. Conclusions:Current evidence supports a biologically oriented approach for the treatment of large nasoantral fistulas. Reconstruction based on vascularized tissue transfer, epithelial barrier restoration, preservation of sinus physiology, and adequate postoperative stabilization offers a predictable solution for complex defects. The presented case illustrates the successful clinical application of these principles and highlights the importance of combining reconstructive and functional surgical concepts.