Managing glottal incompetence following Teflon injection.

A 76-year-old woman came to the office with a 2-year history of progressive dysphonia. Her voice had been fluctuating in quality and was weak in nature. She had received a Teflon injection 20 years earlier for left vocal fold paralysis secondary to thyroid surgery. She had noted a moderate improvement in her voice after the procedure.

The patient did not complain of dysphagia, but she did cough excessively. She had recently been diagnosed with Parkinson's disease. She denied weight loss or pneumonia. Her head and neck examination was notable for a mild palatal tremor that was consistent with her neurologic disease.

Laryngovideostroboscopy revealed an immobile left vocal fold and severe bilateral vocal fold atrophy (figure 1). Phase asymmetry and amplitude asymmetry were detected, with irregular periodicity. Glottic closure was incomplete, and there was a suggestion of a height disparity between the right and left vocal processes. Her maximum phonation time (MPT) was 9 seconds. Her dysphonia was thought to be the result of her Parkinson's disease, a left vocal fold paralysis, and a bilateral vocal fold atrophy. Computed tomography (CT) of the larynx revealed the presence of Teflon in the lateral aspect of the left paraglottic space (figure 2).

The patient underwent microlaryngoscopy with a superficial injection of autologous collagen on the left and lipoinjection on the right. The lipoinjection was placed at the posterior membranous vocal fold with an overcorrection of approximately 30%. The injection material was placed deep and lateral to the membranous vocal fold.

One month postoperatively, the patient's voice quality and strength had improved, as had her maximum phonation time (MPT) (15 sec) and vocal fold closure as seen on laryngovideostroboscopy. One year following surgery, her voice improvement was sustained and she still had an MPT of 15 seconds.

This case illustrates the challenges of managing a patient who has received a Teflon injection. CT was used to confirm that there had been only a unilateral injection and that the Teflon was located in the vocal fold.

Given that the Teflon seen on CT was in the lateral aspect of the paraglottic space, it was deemed safe to proceed with a superficial vocal fold injection without incurring a high risk of triggering a clinically evident Teflon granuloma.

The contralateral atrophic vocal fold was treated with a lipoinjection in view of the fact that no Teflon was seen on CT and that Teflon is the best material currently available for augmentation of a mobile vocal fold.

From the Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, and the University of Pittsburgh Voice Center.