|Year : 2011 | Volume
| Issue : 2 | Page : 72-74
Extrusion of Gore-tex implant after medialization thyroplasty
Evren Erkul, Hakan Cincik, Ahmet Ural
Department of Otolaryngology Head and Neck Surgery, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey
|Date of Web Publication||19-Sep-2011|
GATA, Haydarpasa Egitim Hastanesi, KBB Klinigi, 34668 Kadikoy, Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Various materials such as autogenous cartilage, silicone, hydroxylapatite, Gore-tex (expanded polytetrafluoroethylene), and titanium have been used for medialization laryngoplasty. We report an extrusion of Gore-tex implant after 11 months of medialization laryngoplasty. We believe tha t thought Gore-tex is a safe and easy-to-use implant for medialization laryngoplasty, the possibility of extrusion after the operation must not be ignored.
Keywords: Extrusion, Gore-tex, Medialisation, Thyroplasty
|How to cite this article:|
Erkul E, Cincik H, Ural A. Extrusion of Gore-tex implant after medialization thyroplasty. J Laryngol Voice 2011;1:72-4
| Introduction|| |
Gore-tex (expanded polytetrafluoroethylene [e-PTFE]), is one of the many available materials like autogenous cartilage, silicone, hydroxylapatite, and titanium that have been used for medialization laryngoplasty. Gore-tex is a well-tolerated and easy to handle material. Extrusion of Gore-tex material after medialization laryngoplasty has been rarely reported. We present a case of a 25-year-old man with extrusion of the Gore-tex material after medialization laryngoplasty.
| Case|| |
A 25-year-old man was referred to our ENT clinic due to an idiopathic unilateral left inferior laryngeal nerve paralysis since childhood. The medical history was unremarkable. Dysphonia was the most severe symptom of the patient. In the clinical examination, the left vocal cord was found immoblie in an intermediate position. After a discussion with the patient about management choices, the patient accepted to undergo thyroplasty type 1 with silicone implant in November 2005. On follow-up, the symptoms did not improve and, therefore, we decided to change the implant. In March 2006, a revision surgery was done and the Gore-tex implant inserted under local anesthesia. During the revision procedure, we used the window through thyroid cartilage created during the previous operation. The Gore-tex implant was inserted and inner pericondrium of the thyroid cartilage was kept medial to the implant, though the inner perichondrium looked granulated. The patient's speech and voice were noted at the same time. During the postoperative follow-up, the patient's voice improved and only the sensation of a foreign body in the throat was left as a complaint.
After 11 months, the patient visited our clinic with a persistant cough and a sore throat. His speech and voice got worsened. On endoscopic examination, the left vocal cord and arytenoid cartilage was found to be immoblie. Edema and hyperemia was observed starting from the supraglottic part, extending to the glottic region on both sides. The glottic gap was observed to be narrow. The blood count revealed leucocytosis and, on magnetic resonance imaging investigations, diffuse edema was observed at the left glottic portion of the larynx [Figure 1]. Taking all these findings into consideration, Gore-tex implant extrusion was suspected. Although, initially, we tried to treat the patient conservatively with antibiotics and low-dose steroid orally for 20 days, we could not observe any improvement and we decided to remove the Gore-tex implant. Gore-tex bands were removed under general anesthesia through an external approach [Figure 2]. During the operation, we observed inflammation and edema in all parts of the window, and we observed a scant amount of pus. After the operation, cough and sore throat disappered, but dysphonia could not be relieved. Our experiences about Gore-tex implant for medialization laryngoplasty since 2005 has been 10 applications, and this was the first extrusion.
|Figure 1: Magnetic resonance imaging fi ndings of the extruded left Gore-tex|
Click here to view
| Discussion|| |
Medialization laryngoplasty is a common procedure used to restore glottic competence. Although a number of subsequent investigators described variations, systematic approaches to the problem were reported first in 1974 by Isshiki. Medialization laryngoplasty has become increasingly popular because it has been found to be safe and effective. But, the choice of the implant material remains controversial.
Various materials such as autogenous cartilage, silicone, hydroxylapatite, Gore-tex (e-PTFE), and titanium have been used for vocal fold medialization. Gore-tex (e-PTFE) was discovered by W.L. Gore toward the end of the 1960s. Gore-tex has been used in cardiovascular surgery, rhinoplasty, lip augmentation, facial paralysis rehabilitation, and medialization laryngoplasty for many years.  It has also been reported in the facial plastics literature as being used to augment soft tissue. The biocompatibility of the implant in facial plastic surgery is very good.  McCulloch and Hoffman are the first authors to report the clinical use of Gore-tex implant for unilateral laryngeal nerve paralysis.  Several analytic studies regarding the utility of Gore-tex showed that this material was soft and easy to implant and remove if necesarry. During this surgery, the implant can be shaped easily after insertion and can be removed and modified. ,
Cashman investigated the soft tissue response of the larynx to Gore-tex implants by rabbits.  According to his report, Gore-tex implants were biocompatible in the rabbit larynx. The implants remained sufficiently secure in the soft tissue; migration and extrusion were not observed. Ustundag et al.  compared soft tissue response at larynx of silicone, Gore-tex, and irraditated cartilage. In the histologic examination of Gore-tex, they found a slight inflammatory reaction with foreign body giant cells present at the interface of the implant and the tissue. The porous structure of Gore-tex permits limited soft tissue infiltration and cellular attachment, with minimal capsule formation, and it was similar with Cashman's  investigation. They found out that Gore-tex is also a suitable material for the purpose of medialization. Compared with silicone, the fibrous capsule formation around Gore-tex is weaker. In our case, we first used silicone, but because no improvement was observed, we changed it with Gore-tex. Several reports described this implant in clinical use for medialization laryngoplasty. Giovanni et al.  had 11 patients and Zietels  reported 60 patients with Gore-tex medialization. Both studies had no extrusion and migration complications and had minimal complications.
We found only three case of extrusion Gore-tex implant after medialization laryngoplasty. Laccourreye et al. reported one case, with extrusion observed 49 months later. They thought that the possible reason of extrusion was removel of the inner pericondrium and impossibility of locking the implant to the window made in the thyroid cartilage lamina. Halum et al. reported two cases, and suggested that implant extrusion is related to lack of surgeon experience and improper implant placement. In the window placement technique, great attention must be paid in order not to cause granulation tissue in the transepithelial part of the inner perichondrium during the blunt dissection and palcement of the material. In medialization laryngoplasty, the outer pericondrium is incised and elevated off the window. Great care must be taken to preserve the inner pericondrium, which is elevated in a circumferential fashion from the thyroid lamina. As a result, the prosthesis is placed lateral to the inner pericondrium of the thyroid lamina and, thereby, the structural integrity of the vocal fold is preserved. This allows medialization in the presence of a mobile vocal fold. If the window is fashioned correctly, the shim will fit securely, preventing the migration of the implant.
Extruding implants can be safely and effectively removed by either endoscopic or external approaches.  Endoscopic removal may be preferred in cases associated with extrusion into the airway. In our case, we used an external approach as edema did not allow the performance of the endoscopic approach.
Both open revision laryngoplasty and injection laryngoplasty are successful at providing improved vocal outcomes. However, the results are often temporary after injection, and multiple procedures may be essential.  A variety of safe, effective revision techniques are available with a high success rate.  We preferred open revision thyroplasty in order to decrease the necessity for multiple procedures.
We believe that Gore-tex is a safe and practical implant for medialization laryngoplasty. However, the surgeon must be careful intraoperatively not to damage the inner perichondrium, especially in revision cases. Moreover, the possibility of extrusion after revision surgery must not be ignored.
| References|| |
|1.||McCulloch TM, Hoffman HT. Medialization laryngoplasty with expanded Polytetrafluoroethylene: Surgical technique and preliminary results. Ann Otol Rhinol Laryngol 1998;107:427-32. |
|2.||Herbst A. Extrusion of an expanded polytetrafluoroethylene implant after rhinoplasty. Plast Reconstr Surg 1999;104:295-6. |
|3.||Giovanni A, Vallicioni JM, Gras R, Zaneret M. Clinical experience with Gore-tex for vocal fold medialization. Laryngoscope 1999;109:284-8. |
|4.||Cashman S, Simpson CB, McGuff HS. Soft tissue response on rabbit larynx to Gore-tex implants. Ann Otol Laryngol 2002;111:977-82. |
|5.||Ustundag E, Boyaci Z, Keskin G. Soft tissue response of the larynx to silicone, Gore-tex, and irradiated cartilage implants. Laryngoscope 2005;115:1009-14. |
|6.||Zeitels SM, Mauri M, Dailey S. Medialization laryngoplasty with Gore-tex for voice restoration secondary to glottal incompetence: Indications and observations. Ann Otol Rhinol Laryngol 2003;112:180-4. |
|7.||Laccourreye O, Hans S. Endolaryngeal extrusýon of expanded polytetrafluoroethylene ýmplant after medialization thyroplasty. Ann Otol Rhinol Laryngol 2003;112:962-4. |
|8.||Halum S, Postma G, Koufman J. Endoscopic management of extruding medialization laryngoplasty implants. Laryngoscope 2005;115:1051-4. |
|9.||Andrews BT, Van Daele DJ, Kamell MP. Evaluation of open approach and injection laryngoplasty in revision thyroplasty procedures. Otolaryngol Head Neck Surg 2008;138:226-32. |
|10.||Cohen JT, Bates DD, Postma GN. Revision Gore-Tex medialization laryngoplasty. Otolaryngol Head Neck Surg 2004;131:236-40. |
[Figure 1], [Figure 2]