New Radiographic Features of Injectable Plastics in the Head and Neck · 2013. 7. 12. ·...
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Radiographic Features of Injectable Plastics in the Head and Neck Jeffrey D Suh MD 1 , Claudia F Kirsch MD 2 , Robert Lufkin MD 2 Sunita Bhuta MD 3 , Marilene B Wang MD 1 1 Division of Head and Neck Surgery, University of California Los Angeles 2 Department of Radiology, University of California Los Angeles 3 Department of Pathology, University of California Los Angeles Objectives: 1) Educate the otolaryngologist about the radiographic findings of injectable plastics used to treat head and neck pathology 2) Understand some of the many current and historical uses of Teflon and Silicone 3) Recognize that the radiographic features of injectable plastics can lead to false positive misinterpretation and potentially unnecessary interventions Introduction: Teflon (polytetraflouroethylene) was discovered in 1938 as an inert polymer. Teflon is best known for use in the treatment of vocal cord paralysis; however, other uses include treatment of patulous Eustachian tube and velopharyngeal insufficiency. Disadvantages to its use include foreign body granuloma formation at the injection site and local and distant migration. Teflon causes an immediate inflammatory reaction, which may lead to granuloma formation in 3 to 6 months. This foreign body reaction has been shown to cause markedly false-positive PET/CT scan findings due to the propensity of FDG accumulation in both lymphocytes and macrophages. Silicone (dimethylpolysiloxane) implants have been used extensively for soft-tissue augmentation. Another form of silicone, liquid injectable silicone (LIS), has not been approved by the Food and Drug Administration, and is presently used “off- label” and outside of the United States. Silicone uses include treatment of acne scars, glabellar lines, nasolabial furrows, marionette lines, chin and cheek augmentation, and for HIV associated lipoatrophy. Complications seen with silicone include implant slippage, and for LIS: beading, granuloma formation, and migration. The pathogenesis of granuloma formation is unknown, but is thought to be an immunologic reaction to the silicone. Methods and Materials: Retrospective case series illustrating the radiographic features of Teflon and silicone on PET/CT, MRI, and CT. Cases presented include Teflon use for patulous Eustachian tube, velopharyngeal insufficiency, vocal cord paralysis, and silicone use for cheek augmentation. Findings were reviewed by two neuroradiologists and a head and neck pathologist at an academic tertiary care medical center. Results: Teflon and silicone granulomas have similar radiographic findings of marked FDG accumulation on PET scan. On CT scans, Teflon and Silicone granulomas are characterized by heterogeneous hyperdensity. MRI demonstrates a soft tissue density isointense with muscle on T1-weighted images and hypointense to muscle on T2-weighted images. As seen in Case 5, Teflon appears as round to ovoid 50-100 micron particles with clear centers and dark borders. They are birefriengent under polarized light. In granulomas, multinucleated giant cells are prominent and are associated with mild chronic inflammation. Conclusions: Teflon and silicone have a myriad of uses in otolaryngology as synthetic injectable fillers. Teflon uses include the treatment of vocal cord paralysis, velopharyngeal insufficiency, and patulous Eustachian tube. Silicone is used extensively in soft tissue augmentation both as an implant and for injection. However, both have side effects, including granuloma formation and implant migration. These injectable plastics demonstrate consistent CT and MR findings, as well as marked FDG accumulation on PET. Knowledge of these radiographic characteristics as well as the clinical history is important to avoid misdiagnosis and unnecessary interventions. References: 1. Malizia AA Jr, Reiman HM, Myers RP, et al. Migration and granulomatous reaction after periurethral injection of polytef (Teflon). JAMA 1984; 251: 3277-3281. 2. Yerestsian RA, Blodgett TM, Branstetter BF, et al Teflon-induced granuloma: a false-positive finding with PET resolved with combined PET and CT. AJNR 2003; 24:1164-1166. 3. Harrigal C, Branstetter BF IV, Snyderman CH, et al. Teflon granuloma in the Nasopharynx: A potentially false-positive PET/CT finding. AJNR Am J Neuroradiol 2005; 26: 417-420. 4. Metzinger SE, McCollough EG, Campbell JP, Rousso DE. Malar augmentation: a 5-year retrospective review of the silastic midfacial malar implant. Arch Otolaryngol Head Neck Surg. 1999 Sep;125(9):980-7 5. Narins RS, Beer K.Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006 Sep;118(3 Suppl):77S-84S Case 1: 55 yo with a history of Teflon for patulous Eustachian tube (a) axial CT scan w contrast (b) PET scan with increased uptake in parapharyngeal space (c) T1 MRI Case 3: 67 yo s/p bilateral silicone injections (a) axial post contrast CT (b) PET image with increased FDG uptake Case 2: 58 yo s/p cleft palate repair and injection of Teflon for velopharyngeal insufficiency (a) axial non contrast CT (b) axial T1 w MRI (c) axial T2 w MRI Case 4: 66 yo s/p bilateral silicone cheek implants Case 5: Vocal Cord Teflonoma Figure 1: Bruning syringe
Transcript of New Radiographic Features of Injectable Plastics in the Head and Neck · 2013. 7. 12. ·...
Radiographic Features of Injectable Plastics in the Head and Neck
Jeffrey D Suh MD1, Claudia F Kirsch MD2, Robert Lufkin MD2
Sunita Bhuta MD3, Marilene B Wang MD1
1 Division of Head and Neck Surgery, University of California Los Angeles2 Department of Radiology, University of California Los Angeles3 Department of Pathology, University of California Los Angeles
Objectives:
1) Educate the otolaryngologist about the radiographic findings of injectable plastics used to treat head and neck pathology
2) Understand some of the many current and historical uses of Teflon and Silicone
3) Recognize that the radiographic features of injectable plastics can lead to false positive misinterpretation and potentially unnecessary interventions
Introduction:
Teflon (polytetraflouroethylene) was discovered in 1938 as an inert polymer. Teflon is best known for use in the treatment of vocal cord paralysis; however, other uses include treatment of patulous Eustachian tube and velopharyngeal insufficiency.
Disadvantages to its use include foreign body granuloma formation at the injection site and local and distant migration. Teflon causes an immediate inflammatory reaction, which may lead to granuloma formation in 3 to 6 months. This foreign body reaction has been shown to cause markedly false-positive PET/CT scan findings due to the propensity of FDG accumulation in both lymphocytes and macrophages.
Silicone (dimethylpolysiloxane) implants have been used extensively for soft-tissue augmentation. Another form of silicone, liquid injectable silicone (LIS), has not been approved by the Food and Drug Administration, and is presently used “off-label” and outside of the United States. Silicone uses include treatment of acne scars, glabellar lines, nasolabial furrows, marionette lines, chin and cheek augmentation, and for HIV associated lipoatrophy.
Complications seen with silicone include implant slippage, and for LIS: beading, granuloma formation, and migration. The pathogenesis of granuloma formation is unknown, but is thought to be an immunologic reaction to the silicone.
Methods and Materials:
Retrospective case series illustrating the radiographic features of Teflon and silicone on PET/CT, MRI, and CT. Cases presented include Teflon use for patulous Eustachian tube, velopharyngeal insufficiency, vocal cord paralysis, and silicone use for cheek augmentation. Findings were reviewed by two neuroradiologists and a head and neck pathologist at an academic tertiary care medical center.
Results:
Teflon and silicone granulomas have similar radiographic findings of marked FDG accumulation on PET scan. On CT scans, Teflon and Silicone granulomas are characterized by heterogeneous hyperdensity. MRI demonstrates a soft tissue density isointense with muscle on T1-weighted images and hypointense to muscle on T2-weighted images.
As seen in Case 5, Teflon appears as round to ovoid 50-100 micron particles with clear centers and dark borders. They are birefriengent under polarized light. In granulomas, multinucleated giant cells are prominent and are associated with mild chronic inflammation.
Conclusions:
Teflon and silicone have a myriad of uses in otolaryngology as synthetic injectable fillers. Teflon uses include the treatment of vocal cord paralysis, velopharyngeal insufficiency, and patulous Eustachian tube. Silicone is used extensively in soft tissue augmentation both as an implant and for injection. However, both have side effects, including granuloma formation and implant migration. These injectable plastics demonstrate consistent CT and MR findings, as well as marked FDG accumulation on PET. Knowledge of these radiographic characteristics as well as the clinical history is important to avoid misdiagnosis and unnecessary interventions.
References:
1. Malizia AA Jr, Reiman HM, Myers RP, et al. Migration and granulomatous reaction after periurethralinjection of polytef (Teflon). JAMA 1984; 251: 3277-3281.
2. Yerestsian RA, Blodgett TM, Branstetter BF, et al Teflon-induced granuloma: a false-positive finding with PET resolved with combined PET and CT. AJNR 2003; 24:1164-1166.
3. Harrigal C, Branstetter BF IV, Snyderman CH, et al. Teflon granuloma in the Nasopharynx: A potentially false-positive PET/CT finding. AJNR Am J Neuroradiol 2005; 26: 417-420.
4. Metzinger SE, McCollough EG, Campbell JP, Rousso DE. Malar augmentation: a 5-year retrospective review of the silastic midfacial malar implant. Arch Otolaryngol Head Neck Surg. 1999 Sep;125(9):980-7
5. Narins RS, Beer K.Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006 Sep;118(3 Suppl):77S-84S
Case 1: 55 yo with a history of Teflon for patulous Eustachian tube (a) axial CT scan w contrast (b) PET scan with increased uptake in parapharyngeal space (c) T1 MRI
Case 3: 67 yo s/p bilateral silicone injections (a) axial post contrast CT (b) PET image with increased FDG uptake
Case 2: 58 yo s/p cleft palate repair and injection of Teflon for velopharyngeal insufficiency (a) axial non contrast CT (b) axial T1 w MRI (c) axial T2 w MRI
Case 4: 66 yo s/p bilateral silicone cheek implants
Case 5: Vocal Cord Teflonoma Figure 1: Bruning syringe
