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• W2099366947 abstract "Laryngoscope, 2010 Teflon (polytetra fluroethylene) was a commonly utilized substance for vocal fold medialization.1 Although this product is rarely used at this time, the sequelae of Teflon injection proves to be a challenging problem. The major complications are mainly due to overinjection or delayed granuloma formation. The latter is a problem that becomes apparent some time after injection and is still a relatively common finding for laryngologists. Multiple techniques have been used to remove Teflon granulomas; however, the procedures may have several limitations that include recurrence of the granuloma, an extensive operation, poor voice quality, and/or destruction of the vocal fold. Many laryngologist attempt removal with a CO2 laser; however, this removal is difficult and granulomas can recur. According to Sataloff et al.,2 a case study outlines a patient who underwent six operations using the CO2 laser to remove his laryngeal granulomata, with little success. In addition, the CO2 laser causes an extensive plume, reflects off of the Teflon granuloma that limits surgical dissection, and prolongs operating room time. Other extensive operations are described to remove the Teflon granulomas. For instance, Netterville et al.3 described an open lateral laryngotomy technique to remove the granuloma. Despite the impressive results from the procedure, several comorbities accompany an open procedure that include infection, bleeding, external scar, and risks of anesthesia.4 This study outlines a new surgical technique utilizing the Arthrocare Procise LW Coblator to aid in excision of Teflon granulomas while preserving operative time, using a direct microlaryngoscopic approach, and significantly improving voice quality. The larynx is evaluated microscopically through a suspension laryngoscope. The Teflon granuloma is viewed at the anterior–superior aspect of the left true vocal fold, buldging the fold medially, and partially obstructing the airway (Fig. 1). Using small cupped forceps, a specimen was taken and sent for histopathological evaluation that later confirmed a Teflon granuloma. A prominent vocal fold granuloma, obstructing the airway. The larynx of patient from case 1. The dissection of the Teflon granuloma utilized the PROcise LW Coblator device (ArthroCare, Sunnyvale, CA) on a power setting of 7 for Coblation and 3 for Coagulation. The coblator device tip uses radiofrequency energy through a saline medium to create a plasma. The plasma's energized particles break molecular bonds within the tissue, causing the tissue to dissolve at relatively low temperatures (typically 40°C to 70°C). The result is removal of the target tissue with minimal damage to the surrounding tissue.5 The device was used to make an incision on the upper surface of the vocal fold. Preserving the medial mucosa, a careful dissection was used to ablate the granuloma laterally with the coblator wand preserving the medial mucosa. The bipolar cautery from the coblator was used to control any sites of bleeding. The dissection was continued until the left vocal fold appeared straight and the airway appeared larger (Fig. 2). The granuloma was completely excise with minimal soft tissue trauma and preservation of the medial mucosa. The airway became more patent. The larynx from patient in case 1. A 64-year-old female with a history of left true vocal fold paralysis, following a left hemithyroidectomy, developed severe dysphonia. She had a silastic medialization laryngoplasty and Teflon vocal fold injection medialization, both at an outside institution, which failed to improve her dysphonia. The Teflon injection medialization became detrimental when she developed a granuloma. She previously underwent microflap excision of the granuloma with recurrence of disease. The patient represented with continued dysphonia and voice fatigue. Videostroboscopy revealed a large granuloma on the anterior–superior aspect of her left true vocal fold, absent mucosal waves on the left and decreased on the right (Fig. 1). The patient underwent removal of the Teflon granuloma using the Arthrocare Procise LW. The coblator was used lateral to the mucosa to remove enough granuloma to result in a straight vocal fold edge (Fig. 2). She had an uneventful postoperative course. She represented to the Otolaryngology office 2 months after her operation, and her voice significantly improved. Two years postoperatively, the vocal fold healed well with no evidence of granuloma with repeat videostroboscopy (Fig. 3). Preoperative and postoperative Voice Handicap Index (VHI) scores are shown in Table I. The coblator had the advantage of removing the granuloma where the previous microflap excisions failed and prevented recurrence. (a) Patient from case 1. Videostrobe >24 months postoperatively. No evidence of granulom formulation. (b) Patient from case1. Videostrobe >24 months postoperatively. No evidence of granuloma formulation. A 51-year-old male with a history of a right true vocal fold paralysis, status post a total thyroidectomy, develops severe hoarseness. He underwent a Teflon injection of his right true vocal fold and initially had a good result with dramatic improvement of his voice. One year postinjection, he developed worsening dysphonia. At times, he noted that his voice would fatigue easily and become breathy. Videostroboscopy disclosed a large submucosal mass of the immobile right vocal fold with decreased mucosal waves on the left and absent on the right. The patient elected to undergo excision of the granuloma using the Arthrocare Procise LW. The patient tolerated the procedure well. He returned to the Otolaryngology office 3 weeks after his operation and his voice dramatically improved. On videostroboscopy, the surgical site healed well and the right vocal fold was straight and in the midline. The left vocal fold had improved mucosal waves. The patient continues to have an improved voice 2 years after the operation. Preoperative and postoperative VHI scores are shown in Table I A 59-year-old woman with a history of a left vocal fold paralysis following thyroidectomy was injected with Teflon. When her voice did not improve, she was injected a second time. Her voice worsened with the second injection. The patient subsequently had five attempts at removal of the granuloma with a CO2 laser without success. She was concerned not only with her voice quality but with substantial shortness of breath, and stridor with exertion. On presentation, she had a weak and breathy voice with mild inspiratory stridor. She was noted to have a large Teflon granuloma with an anterior commissure web and shortening of the left ary-epiglottic fold (Fig. 4). Patient from case 3, who had received five prior resections without improvement. Note large granuloma on the left with restricted airway with right vocal fold in abduction. The patient underwent coblation removal of the supraglottic, false vocal fold mass, and a lateral resection of the true vocal fold granuloma. On return visits 3 weeks and 12 weeks later she had substantial improvement of her voice and no exercise limitations (Fig. 5). Preoperative and postoperative VHI scores are shown in Table I. The coblator was able to excise the granuloma successfully where the CO2 laser previously failed, and the patient noted a dramatic improvement in her voice. (a) Abduction. Patient from case 3 postoperatively. Note relatively straight vocal fold edge, substantially improved airway, and good closure. Normal mucosal wave and amplitude was noted on stroboscopy for the right vocal fold. (b) Adduction. Patient from case 3 postoperatively. Note relatively straight vocal fold edge, substantially improved airway, and good closure. Normal mucosal wave and amplitude was noted on stroboscopy for the right vocal fold. A 75-year-old woman with an idiopathic left vocal fold paralysis underwent a Teflon vocal fold injection in 1985. She had no significant improvement in her voice and has been poor since the procedure. She began to have worsening of her voice and was seen for evaluation. She underwent a coblation removal of her Teflon granuloma. Her 6-week follow-up evaluation showed marked subjective improvement in her voice and VHI (Table I). Her maximum phonatory time, which was 7 seconds preoperatively, improved to 25 seconds postoperatively. The use of the PROcise LW coblator has distinct advantages for removal of Teflon granulomas. The coblator functions at a low temperature, which prevents significant lateral heat distribution into the tissue. Also, the coblator serves to control superficial bleeding that might obstruct the field. Any more significant areas of bleeding are easily managed with the bipolar cautery. Overall, the coblator allows relatively precise dissection with minimal to no damage of surrounding tissue, little bleeding, and time saved in the operating room. Microdissection has the disadvantage of difficulty in controlling bleeding. The CO2 laser has the disadvantage of higher heat distribution into the tissues. In addition, the CO2 laser reacts with the Teflon causing thick-obstructing plume, and the Teflon reflects the CO2 laser. This prolongs operating room time and makes the removal of the Teflon granuloma more difficult. Coblation would mitigate all of these difficulties and save operating room time. In these four patients, short-term results have revealed substantial subjective improvement of voice quality and statistically significant improvement in quality of life as measured by the VHI, where an improvement of 8 for each of the subscales or 18 in the total score is significant.6 The patients noted little postoperative pain both right after the surgery and at their first follow-up 2 to 3 weeks after resection. All three patients noted that their voice quality improved significantly after the procedure. Although the substantive improvement has occurred, the first two cases revealed improved VHI scores 2 years postoperatively. The patient in case 1 showed a well-healed vocal fold greater than 24 months after surgery with no evidence of recurrence (Fig. 3). Shortcomings of this case series reveal VHI scores of only two patients longer than 24 months and small sample size. Otherwise, all four patients in this case series benefitted from coblation technology." @default.
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• W2099366947 date "2010-09-07" @default.
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• W2099366947 title "Coblation removal of laryngeal Teflon granulomas" @default.
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