An Accurate Method of Teflon InjectionUsing Functional PhonosurgeryDavid M. Alessi, MD; Gerald S. Berke, MD; Terrance K. Trapp, MD; Bruce R. Gerratt, PhD; David G. Hanson, MD

\s=b\A technique for Teflon injection isdescribed that allows the laryngologist toassess vocal fold vibration during generalanesthesia. A tracheostomy tube fittedwith a rostral air line allows translaryngealairflow. During endoscopy with a bivalvedlaryngoscope, the cords are approximat-ed manually. Vocal fold vibration is pro-duced with the cords adducted. The pre-cise site of defects in glottic closure isclearly seen and corrected with Tefloninjection. In cases where standard Tefloninjection has failed, utilization of thismethod has allowed substantial voiceimprovement. The ability to assess vibra-tory function of the vocal folds duringdirect suspension laryngoscopy en-

hances the precision of vocal fold aug-mentation technuques in difficult rehabili-tation cases.

(Arch Otolaryngol Head Neck Surg1988;114:1321-1323)

The ultimate goal in vocal rehabili¬tation is to prevent aspiration

and to achieve good phonatory func¬tion. Teflon (polytef) injection hasbeen highly efficacious in the treat¬ment of laryngeal paralysis.13 Al¬though Teflon is most commonly used

Accepted for publication March 14, 1988.From the Division of Head and Neck Surgery,

UCLA, and the West Los Angeles VeteransAdministration Medical Center.Presented in part at the International Voice

Symposium, Edinburgh, Aug 13, 1987.Reprint requests to Division of Head and Neck

Surgery, Center for the Health Sciences, Univer-sity of California, Westwood, CA 90024 (DrBerke).

for augmentation of a cord with a

recurrent nerve paralysis, there areseveral other uses. Arnold4 lists thefollowing indications: (1) some con¬

genital laryngeal defects, (2) vocalcord defects after removal of benignlesions such as nodules or polyps, (3)excessive glottic chink after aryte-noidectomy, and (4) various cases ofcordectomy or partial laryngectomy.After partial laryngeal surgery, the

immobile pseudocord can be aug¬mented with Teflon to prevent aspira¬tion and to improve the voice. Thisconstitutes approximately 2.2% ofcases selected for injection,5 even

though there are many patients whocould potentially benefit from Teflonaugmentation after partial laryngec¬tomy. The postoperative voice was

studied in a review of 30 patients whounderwent vertical hemilaryngecto-my: 11 (36%) had a good to excellentvoice; 8 (27%) had a weak, breathyvoice; and 11 (36%) had a poor, barelyaudible voice.6 Underutilization ofTeflon injection in these patientsmay, in part, be due to difficultieswith the procedure.For unilateral recurrent paralysis,

the procedure of Teflon injection ismost often performed during directlaryngoscopy utilizing either topicalor general anesthesia. The injection isideally made along the lateral aspectof the thyroarytenoid muscle, and oneprocedure is usually sufficient torestore good phonatory function.3Since the paralyzed cord is on the

same level as the functional cord,there is little chance of a postopera¬tive vertical height mismatch.With more complex laryngeal

pathology, the relationships of thevocal cords in the vertical dimensionare also likely to be abnormal. Forexample, a complete vagai paralysiswill leave the cords at different lev¬els.7 Further distortion occurs afterpartial laryngeal surgery. In theheavily scarred larynx, accuracy ofinjection is paramount, in that anyfurther injection after the first maylead to extrusion of material from theinjection site.8 Recognizing the impor¬tance of the vertical level of injection,Lewy5 advocated topical anesthesiaand phonatory cooperation of thepatient to improve control over thesite of injection. Suspension laryngos¬copy and general anesthesia were rec¬

ommended for difficult cases where a

stabilized larynx was essential.9 How¬ever, the latter precludes phonatoryassistance by the patient. The recent¬ly described method of transcutane-ous Teflon injection allows for activepatient participation.10To overcome the difficulties in the

functional assessment of a complexcase of glottic insufficiency, the fol¬lowing method of phonosurgery was

developed. The procedure is primarilyused for patients after surgery (par¬tial laryngectomy) and requires a tra-cheostomy. Because laryngeal edemamay develop after injection of thescarred neocord, a tracheostomy may

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Fig 1.—Diagram of tracheostomy tube inplace. Rostral airflow line passes air transla-ryngeally.

be a consideration with any method ofTeflon injection when used on thepartially resected larynx.10

MATERIALS AND METHODSSince this procedure is reserved for diffi¬

cult Teflon augmentation cases, generalanesthesia is required. With the oral endo-tracheal tube in place, a tracheostomy isperformed. A tracheostomy tube (Fig 1)with a rostral airflow port (Communitrach1, Implant Technologies Ine, Minneapolis)is placed, and the patient is ventilatedthrough the tracheostomy tube, allowingremoval of the oral endotracheal tube. Thesuspension bivalved laryngoscope (Fig 2) isused to allow adequate room for instru¬ments and affords excellent exposure ofthe larynx. Compressed, humidified air isthen forced through the speaking airflowline, simulating normal translaryngealairflow. The normal true vocal cord is thenbrought medially to contact the neocord byatraumatically pushing the affected aryte-noid over with endolaryngeal forceps. Thesound quality, as well as the appropriatevertical level, is assessed for Teflon injec¬tion. The injection is then carried outslowly, continuously rechecking the soundquality. Postoperatively, the patient isdecannulated when the airway is secure,usually on the second postoperative day.To assess the difference between phona¬

tion induced manually, in comparison withnatural cord vibration, a canine larynx wasmanipulated in a similar manner. Oneadult mongrel male dog was anesthetizedwith phénobarbital. A tracheostomy wasthen performed, and the dog was venti¬lated transtracheally. A rostral airflowline was also inserted through a tracheoto¬my. A 0° telescope (Storz) was coupled to a

strobe light source (Storz 8000) and a cam¬era (Circón CCD). With retrograde trans¬laryngeal airflow, the arytenoids were

brought to the midline using a laryngealforceps. This was then compared with pho¬nation produced by stimulating the laryn¬geal nerves.12 The larynx was stroboscopi-cally analyzed, and the resultant imagewas recorded on a videorecorder (Sony).

REPORT OF A CASEA 71-year-old man had near aphonia

after a vertical hemilaryngectomy forradiation-failure T, left true vocal cordcarcinoma. The left neocord was formed byimbricating remaining false vocal cord

Fig 2.—Side view of bivalve laryngoscope.

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mucosa, leaving the patient with poor glot¬tic closure. One and two years postopera-tively, the patient underwent direct laryn¬goscopy and Teflon injection of the leftneocord. The second laryngoscopy was per¬formed with the patient under local anes¬thesia to assess glottic incompetence underphysiologic conditions. However, thepatient's emphysema prevented him fromcooperating fully. Because the patient hadonlyminimal improvement in his voice andoccasional aspiration, he underwent athird direct laryngoscopy. A tracheostomywas performed as a precaution againstpostoperative edema. Using the method ofphonosurgery described above, it was obvi¬ous that the prior Teflon injections medial-ized the neocord superior to the functionallevel of the right true cord. Teflon was

injected to fill the functional defects. Thepatient was decannulated one week aftersurgery. Subsequent evaluation of thepatient revealed the glottic closure to becomplete and the voice much improved.Eighteen months later, the voice remainsadequate and the patient does not aspi¬rate.

COMMENT

The most common complication ofTeflon injection of the vocal cord isfailure to improve the voice, usuallycaused by inadequate closure of theglottic chink.11 Because this occurs in10% to 20% of all cases, multipleoperations may be required.10 Withthe patient awake, assessing the cord

size, position, and relationships dur¬ing phonation allows for more accu¬rate injection. Voice quality improve¬ment during the procedure is an

important and reliable guide to theamount of Teflon needed for injection.The patient described here had under¬gone two prior injections, both ofwhich failed to sufficiently narrowthe glottic chink. The technique ofphonosurgery described above simu¬lated phonation in the anesthetizedpatient, permitting precise injection.Normal phonation is a complex phe¬

nomenon that requires a steadystream of subglottic airflow throughstiffened and adducted vocal cords.The translaryngeal airflow creates a

characteristic vocal cord vibratorypattern. In laboratory animals, thesepatterns have been documented usingvideostroboscopy during stimulationof both canine recurrent laryngealnerves.12In the canine experiment performed

in this study, the stroboscopie pat¬terns of the vocal folds were examinedduring manual adduction and com¬

pared with those seen with recurrentlaryngeal nerve stimulation. Manual¬ly adducting the canine vocal cordswith a constant stream of subglotticair created a stroboscopie pattern ofvocal fold vibration that differed fromthat found with nerve stimulation.

Specifically, there was a decrease inthe two-margin (upper and lower)system of vibration. However, thevocal fold vibrations were in phasefrom the anterior to the posteriorglottis, and the resultant phonationwas of normal intensity.Similarly, in the case reported, pho¬

nation produced during the phonosur¬gery was not normal. The vocal foldvibrations produced by manuallyinduced phonation would be expectedto differ from those seen with normalintrinsic laryngeal muscle activation.However, the adequate voice obtainedwith this technique demonstrates itsefficacy in defining the vertical levelof injection and in guiding the amountof Teflon injected.

CONCLUSIONS1. This case report demonstrates a

new technique of functional phono-surgery.2. The procedure described allows

precise determination of the appropri¬ate level and amount of Tefloninjected.3. The outcome may be more accu¬

rately predicted at the time of sur¬gery.4. Teflon injection during function¬

al phonosurgery is useful in difficultcases, especially in the correction ofpostsurgical defects.

References

1. Kirchner FR, Toledo PS, Svoboda DJ:Studies of the larynx after Teflon injection. ArchOtolaryngol Head Neck Surg 1966;83:350-354.2. Von Leyden J, Yanagihara N, Werner\x=req-\

Kukuk E: Teflon in unilateral vocal cord paraly-sis. Arch Otolaryngol Head Neck Surg 1967;85:666-674.3. Montgomery WW: Laryngeal paralysis Tef-

lon injection. Ann Otol Rhinol Laryngol 1979;88:647-657.4. Arnold GE: Vocal rehabilitation of paralyt-

ic dysphonia: IX. Technique of intracordal injec-tion. Arch Otolaryngol Head Neck Surg 1962;76:358-368.

5. Lewy RB: Experience with vocal cord injec-tion. Ann Otol Rhinol Laryngol 1976;85:440-450.6. Maceri DR, Lampe HB, Makielski KH, et al:

Conservation laryngeal surgery: A critical analy-sis. Arch Otolaryngol Head Neck Surg 1985;111:361-365.7. Ward PH, Hanson DG, Berci G: Observa-

tions on central neurologic etiology for laryngealdysfunction. Ann Otol Rhinol Laryngol 1981;90:430-441.8. Ford CN, Bless DM: A preliminary study of

injectable collagen in human vocal fold augmen-tation. Otolaryngol Head Neck Surg 1986;94:104\x=req-\112.

9. Lewy RB: Teflon injection of the vocal cord:Complications, errors, and precautions. Ann OtolRhinol Laryngol 1983;92:473-474.10. Ward PH, Hanson DG, Abemayor E:

Transcutaneous Teflon injection of the paralyzedvocal cord: A new technique. Laryngoscope1985;95:644-649.11. Rubin HJ: Misadventures with injectable

polytef (Teflon). Arch Otolaryngol Head NeckSurg 1975;101:114-116.12. Moore DM, Berke GS, Hanson DG, et al:

Videostroboscopy of the canine larynx: The effectof asymmetrical laryngeal tension. Laryngoscope1987;97:543-553.

Editorial Footnote

The technique described in this article isattractive because of the claim of precisioninjection and superior voice quality afterpartial laryngectomy. The procedure canbe used for other types of laryngeal pathol¬ogy as well, and the concepts that are

proposed seem quite sound.Our reviewers felt that this information

should be shared with you. However, someimportant issues are not addressed, and

several key questions are left unanswered.Most instances of postoperative aphoniaare the result of absent tissue that hasbeen partially replaced by scarring. Injec¬tion of Teflon into these areas is usuallyimpossible or inadequate.This report should be considered prelim¬

inary in nature. We shall await more expe¬rience and more details, as well as clarifi¬cation of the method of forceps manipula-

tion and movement of the vocal cord tissue.We hope to see more in the way of quanti¬tative aerodynamic and acoustic documen¬tation of vocal improvement in a controlgroup and in patients who are treated bythis method.

Byron J. Bailey, MDChief Editor

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