Polymethylmethacrylate Granuloma After Septoplasty

Matías-Sánchez, Manuel; Oviedo-Ramírez, María Isabel; Díaz-Manzano, José Antonio
doi:10.1016/j.otoeng.2021.07.002
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together with computerised tomography&#44; the findings of which are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Nuclear magnetic resonance &#40;MMR&#41; imaging revealed a focal increase of soft tissue in the nasal dorsum compatible with a malformation vascular type of lesion&#46; Fine-needle puncture aspiration showed a cytologic substrate of epithelioid granulomas&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Surgical examination of the nasal dorsum was chosen using an open rhinoplasty approach&#44; and complete resection of the described lesion&#46; Histopathological analysis is contained in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The postoperative period was uneventful and no recurrences have presented in the 24 months of follow-up&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">PMMA is a material used in plastic surgery for the correction of wrinkles&#44; depressed acne scars or to increase the lip volume&#44; among many other uses&#46; It is polymerised in the form of microspheres and commonly suspended in liquid collagen for injection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Complications from these PMMA injections for aesthetic purposes have been described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> Most of them start immediately&#44; basically haematomas&#44; allergic reaction to some of the components of the injected fluid and local inflammatory reaction&#44; which is usually treated with topical corticoids or intralesional corticoids&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A few cases of cutaneous necrosis have also been described&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Regarding late complications&#44; granulomatous reactions to foreign bodies are outstanding&#44; which are very common during the first few years due partly to the use of small PMMA microspheres &#40;&#60;20 &#956;m&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> New materials &#40;Artecoll&#174;&#44; Artefill&#174;&#41; with 40&#8211;80 &#956;m microspheres have led to the reduction in the prevalence of these granulomas at 1&#46;9&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> with a latency of appearance of between 6 months and 15 years&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the field of nasal surgery&#44; PMMA injections have been used for the correction of asymmetries after rhinoplasty<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> or primarily within the areas of non-surgical rhinoplasty&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> but always with aesthetic intent&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the case of our patient&#44; there was no intervention on the nasal pyramid&#44; only a septoplasty&#46; Initially treated as a case of facial cellulites&#44; the absence of response to treatment and the lesion characteristics &#40;essentially diffusion through the subcutaneous tissue&#41;&#44; led to the investigation and discovery of the use of PMMA in this surgery&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is of interest to point out that imaging tests &#40;CT and ultrasound&#41; did not offer information regarding the nature of the lesion&#44; although other processes were important to underline&#44; such as an abscess or a neoplasm&#46; With regards to RMN&#44; this hindered management on proposing differential diagnosis as vascular malformation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Among the treatments used&#44; intralesional therapy with corticoids has been described&#44; with a satisfactory result in 82&#37; of cases&#46; Surgical excision&#44; both initially and after medical treatment failure&#44; shows high rates of resolution&#44; but may lead to major aesthetic sequelae regarding lesion extension&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The intralesional 5-fluorouracil was also used with similar results to the cortidoids<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#59; and one case of complete resolution with oral alopurinol has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our case&#44; surgery was chosen with a two-fold therapeutic and diagnostic intent&#44; due to the doubts which arose from the unusual presentation form&#46; Migration of the lesion is characteristic behaviour&#44; which has been described in PMMA<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> granulomas&#44; and in granulomatous reactions compared with other synthetic materials such as silicones&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of Interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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