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An unusual presentation of Teflon granuloma: case report and discussion.

Abstract

For more than 25 years, Teflon was the most commonly used material for injection laryngoplasty. However, the incidence of Teflon granuloma and the consequent deterioration of glottic function ultimately led to the development of other injectable materials, and as a result, Teflon granulomas are no longer frequently encountered. We present a case of Teflon granuloma that was unusual in that (1) a long period of time had elapsed between the injection and the granuloma formation and (2) there was no change in the patient's glottic function.

Introduction

Injection laryngoplasty is an important element in the armamentarium of a clinician who manages unilateral vocal fold paralysis. Several substances have been used, and optimal injection techniques vary according to the characteristics of the injected material. (1) Currently available materials include bovine collagen, hydroxyapatite, Gelfoam, autologous fat, micronized acellular human dermis, hyaluronan, and Teflon (polytetrafluoroethylene). Available in a glycerin suspension as Polytef (Mentor Corp.; Santa Barbara, Calif.), Teflon was introduced for vocal fold injection in 1962. (2) It was extremely popular for more than 25 years thereafter, but it fell out of favor because of its propensity to form granulomas and because it was difficult to remove. (1) We describe a Teflon granuloma with an unusual presentation, and we discuss injection laryngoplasty techniques.

Case report

A 41-year-old woman presented with a painless neck mass that had slowly enlarged over the previous 2 months. Her voice had remained unchanged. Her history was significant for a resection of a left vagal schwannoma 20 years earlier. Four months postoperatively, she underwent a procedure to improve her voice; this procedure included the injection of Teflon into the left vocal fold. She experienced an immediate improvement in glottic function. However, 3 months after the injection, she presented with a granuloma, although her voice was unchanged. She underwent successful local excision at that time. For almost 2 decades, she had no difficulty with swallowing, and she was pleased with her voice.

At this most recent presentation, physical examination revealed the presence of a firm, nontender, 1-cm mass fixed to the left border of the cricoid cartilage. Non-contrast axial computed tomography (CT) identified a variably hyperdense left-sided mass at the level of the cricothyroid ligament and the upper cricoid cartilage. An excisional biopsy revealed a firm mass fixed to the larynx at the left edge of the cricothyroid membrane. This is precisely the expected location of the lesion as the inflammatory mass expanded and followed the path of least resistance inferiorly through the loose tissue of the paraglottic space. The mass was excised, and pathologic evaluation of the excised mass was reported as islands of refractile foreign material surrounded by inflammatory infiltrate and multinucleated giant cells. Postoperatively, the patient's symptoms resolved.

Discussion

In the case of vocal fold medialization that is performed for vocal fold atrophy or scarring, the preferred technique is to inject hyaluronan or collagen into the medial portion of the fold. (1) When medializing a malpositioned immobile fold, a bulk-forming material such as Teflon or hydroxyapatite is preferred. Proper injection results in placement of the appropriate volume of material into a space bordered medially by the conus elasticus and laterally by the ala of the thyroid cartilage.

[FIGURE OMITTED]

As described by Tucker, the procedure is performed under topical anesthesia. (3) The tip of the laryngoscope is used to lateralize the false vocal fold, and the needle is inserted into the superior surface of the vocal fold as far laterally and posteriorly as possible (figure). The depth of injection should be such that the injection volume is deposited just lateral to the thyroarytenoid muscle so that the presence of the injected material results in medialization of the arytenoid cartilage. The volume of injection is determined by subjective voice improvement as well as visualization of the deficient vocal fold; typically, satisfactory results require a volume of 0.8 to 1.2 ml. Atrophy of the body of the vocal fold may be remedied by a small supplemental injection more anteriorly. The final effect of this procedure on glottic function cannot be assessed completely for at least 3 months.

Overinjection results in extrusion, either through the needle hole immediately after injection or more slowly through the inferior communication of the paraglottic space with the exterior of the larynx lateral to the cricothyroid membrane. Inappropriately deep placement of Teflon would result in the immediate appearance of a mass in this location, as described by Rubin. (4)

Extralaryngeal migration of Teflon particles is a known risk after injection. Wassef et al reported a patient with a "teflonoma" that mimicked a thyroid mass; the authors attributed the formation of this lesion to a probable injection across the thyroid capsule into the gland. (5) McCarthy et al described a patient who was discovered to have a submucosal Teflon granuloma in the upper trachea 4 years after injection. (6) Mittleman and Marraccini also reported the discovery of Teflon granulomas in the lungs of a patient who had received periurethral injections for urinary incontinence, a finding that raised serious concerns about the long-term safety of soft-tissue Teflon injection. (7) These concerns contributed to the transition to other substances for injection laryngoplasty as they became available.

Our patient presented with recurrent Teflon granuloma after 19 asymptomatic years. The most striking aspect of this presentation is the absence of dysphonia. Varvares et al described two groups of patients: those who did not have a good vocal result after injection and those who initially had a good result but later developed dysphonia. (8) They concluded that the first group likely had an improper injection, while the second group experienced granuloma formation resulting in unfavorable changes in vocal fold function. Our unusual case does not fall into either category, as the patient's glottic function remained stable despite the partial escape of the Teflon from the paraglottic space. We conclude that although Teflon is no longer used for laryngoplasty, it should remain in the thoughts of clinicians.

References

(1.) Courey MS. Injection laryngoplasty. Otolaryngol Clin North Am 2004;37(1):121-38.

(2.) Arnold GE. Vocal rehabilitation of paralytic dysphonia. VIII. Phoniatric methods of vocal compensation. Arch Otolaryngol 1962;76: 76-83.

(3.) Tucker HM, ed. The Larynx. 2nd ed. New York: Thieme Medical Publishers; 1993:253-5.

(4.) Rubin HJ. Misadventures with injectable polytef (Teflon). Arch Otolaryngol 1975;101(2):114-16.

(5.) Wassef M, Achouche J, Guichard JP, Tran Ba Huy P. A delayed teflonoma of the neck simulating a thyroid neoplasm. ORL J Otorhinolaryngol Relat Spec 1994;56(6):352-6.

(6.) McCarthy MP, Gideon JK, Schnadig VJ. A Teflon granuloma presenting as an endotracheal nodule. Chest 1993;104(1):311-13.

(7.) Mittleman RE, Marraccini JV. Pulmonary Teflon granulomas following periurethral Teflon injection for urinary incontinence. Arch Pathol Lab Med 1983;107(11):611-12.

(8.) Varvares MA, MontgomeryWW, Hillman RE. Teflon granuloma of the larynx: Etiology, pathophysiology, and management. Ann Otol Rhinol Laryngol 1995; 104(7):511-15.

Nitin A. Pagedar, MD; Catherine M. Listinsky, MD; Harvey M. Tucker, MD, FACS

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Pagedar and Dr. Tucker) and the Department of Pathology (Dr. Listinsky), Case Western Reserve University and University Hospitals of Cleveland.

Corresponding author: Harvey M. Tucker, MD, FACS, Department of Otolaryngology-Head and Neck Surgery, 11100 Euclid Ave., Lakeside 4500, Cleveland, OH 44106. Phone: (216) 844-4773; fax: (216) 844-5727; e-mail: tucharv@aol.com
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Title Annotation:ORIGINAL ARTICLE
Author:Pagedar, Nitin A.; Listinsky, Catherine M.; Tucker, Harvey M.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Jan 1, 2009
Words:1219
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