Teflon granuloma.

A 68-year-old diabetic woman presented to the Center for Voice and Swallowing with progressive dyspnea and dysphonia of 5 years' duration. She was a lifelong nonsmoker. Her medical history was notable for a right subtotal thyroidectomy for benign disease 50 years earlier. That surgery had been complicated by right vocal fold paralysis, and 31 years later, she underwent an injection medialization with Teflon at another institution.

At our center, fiberoptic nasopharyngeal laryngoscopy revealed the presence of a right submucosal mass that extended from the right true vocal fold to the subglottic region. The diameter of the airway was 3 to 4 mm. No granulation tissue was appreciated. Findings on the remainder of the head and neck examination were normal. Contrast-enhanced computed tomography (CT) of the neck demonstrated a large heterogeneous mass at the level of the right true vocal fold (figure 1). No cervical lymphadenopathy was identified.

[FIGURE 1 OMITTED]

The patient underwent excision of the well-circumscribed mass via a right laryngotomy approach (figure 2). The vocal fold was medialized with an inferiorly based thyrohyoid muscle flap, and an arytenoid adduction was performed through the laryngotomy window. The patient underwent a tracheotomy during the procedure to secure a severely compromised airway. Pathology revealed a Teflon granuloma (figure 3).

[FIGURES 2-3 OMITTED]

The patient did well postoperatively, and she was decannulated on postoperative day 9 without complication. Transnasal fiberoptic laryngoscopy and tracheobronchoscopy revealed a well-medialized right vocal fold with complete glottal closure. The airway was widely patent.

Teflon (polytetrafluoroethylene) has been supplanted by other materials because it is associated with a risk of granuloma formation after superficial injection, as well as a risk of migration. Also, Teflon has been known to stiffen the mucosal wave, and it can be difficult to remove. The reported incidence of Teflon granuloma is 2 to 3%, (1) but its true incidence may be higher.

Patients with Teflon granuloma likely fall into one of two groups: (1) those with an immediate reaction to overinjection or improper injection and (2) those with delayed symptoms secondary to an exuberant granulomatous response. (2) The duration between Teflon injection and granuloma removal has been reported to range from 4 months to 18 years (mean: 55 mo), which suggests that the inflammatory reaction to Teflon is highly variable. (3)

Teflon granulomas can be surgically managed via an endoscopic, open, or combined approach. (4) Many consider granuloma removal through a large laryngotomy window with strap muscle reconstruction and arytenoid adduction to be the surgical treatment of choice. (5)

References

(1.) Dedo HH. Injection and removal of Teflon for unilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1992;101:81-6.

(2.) Varvares MA, Montgomery WW, Hillman RE. Teflon granuloma of the larynx: Etiology, pathophysiology, and management. Ann Otol Rhinol Laryngol 1995;104:511-15.

(3.) Kasperbauer JL, Slavit DH, Maragos NE. Teflon granulomas and overinjection of Teflon: A therapeutic challenge for the otorhino-laryngologist. Ann Otol Rhinol Laryngol 1993;102:748-51.

(4.) Hsiung MW, Lin YL. Lateral thyrotomy with strap muscle transposition for Teflon granuloma. Eur Arch Otorhinolaryngol 2005;262:298-301.

(5.) Netterville JL, Coleman JR Jr., Chang S, et al. Lateral laryngotomy for the removal of Teflon granuloma. Ann Otol Rhinol Laryngol 1998;107:735-44.

James R. Tate, MD; Peter C. Belafsky, MD, PhD; Kristen Vandewalker, MD

From the Center for Voice and Swallowing, Department of Otolaryngology--Head and Neck Surgery (Dr. Tate and Dr. Belafsky), and Department of Pathology (Dr. Vandewalker), University of California-Davis Medical Center, Sacramento.