Reflection

Medical history Neville Wran’s voice: how the Premier’sTeflon-coated vocal cords came unstuck

His gravelly voice became one of the successful politician’s most defining features

eville Kenneth Wran was the colourful and 1 Neville Kenneth Wran, AC, CNZM, QC (1926e2014) charismatic Premier of from N 1976 to 1986. He was widely respected for his quick wit, engaging informality, and committed representation of blue collar voters. The youngest of eight siblings, he was born in 1926 and raised in the Sydney suburb of Balmain, then a working class stronghold of the Australian Labor Party1 (Box 1). After receiving his law degree from the in 1948, Neville Wran was admitted as a solicitor in 1951, and became a Queen’s Counsel in 1968. Commencing his political career in 1970, he was elected leader of the NSW and then NSW Premier in 1976. Wran achieved some of the most convincing electoral victories in Australian political history, including landslide wins in 1978 (13-seat swing) and 1981 (a further 6-seat swing), each of which saw the then leaders of the opposition Liberal Party lose their own seats. It was in 1980 that Wran developed his distinctively raspy voice, which became a political trademark throughout the latter part of his career.1 We clarified the clinical circumstances of its development during discussions with members of Mr Wran’s family and clinicians directly involved in his medical treatment. fi Mr Wran was rst noted to have a weak and breathy Courtesy of Mrs Jill Wran. u voice during a pre-operative anaesthetic workup for pending transurethral prostate surgery in early 1980. The assessing anaesthetist discussed his findings with Evangelos early 1980s, so the nodule was excised. During the Tseros1,2 the on-site otolaryngologist and the prostate procedure ’ procedure, the left recurrent laryngeal nerve was noted 1,2 was postponed so that Wran s dysphonia could be Faruque Riffat fi to be intact and unremarkable. Histopathology investigated. In-of ce indirect laryngoscopy revealed a fi 1,2 con rmed the presence of a benign thyroid adenoma; Carsten E Palme lateralised left vocal cord with reduced mobility. At that neck tomography and chest imaging failed to identify point, his medical history was unremarkable apart from Hedley G any other reason for his left vocal cord palsy. The final Coleman3 prostatic hypertrophy and occasional smoking. On working diagnosis was that Mr Wran had a long further questioning, Wran reported that he had noticed Narinder P standing idiopathic, partially compensated vocal cord 1,2 that his voice had been weaker than normal over several Singh palsy that may have been exacerbated by a recent upper years, requiring greater effort in conversations and respiratory tract infection. 1 ,

11 December 2017 during telephone calls. His voice was reported to Sydney, NSW. j have further deteriorated in the weeks before the Wran’s reduced vocal volume meant that he found 2 University of Sydney, Sydney, NSW. laryngoscopy following a viral infection. As the cause of himself unable to project his voice in parliamentary 3 Institute for Clinical his vocal cord palsy was unknown, Wran was examined debates, which sources close to Wran at the time noted Pathology and Medical Research, Westmead under anaesthetic, and this investigation excluded any was distressing for him. He considered his voice a major

MJA 207 (11) Hospital, Sydney, NSW. sinister pathology in the larynx. Neck examination political asset, and believed that this weakness might narinder.singh@ revealed a left thyroid nodule, correlated with a cold reduce his prospects for advancing to the Australian sydney.edu.au nodule on a radioactive iodine scan, raising the Prime Ministership. Concerned about the possible threat 468 possibility of a thyroid malignancy. Fine needle to his career, he discussed management options with his doi: 10.5694/mja17.00198 aspiration biopsy was not routinely performed in the treating otolaryngologist. Reflection

2 Granulomatous multinucleated giant cell foreign 3 Endoscopic view of right laryngeal Teflon body reaction to injected Teflon material (arrows: granuloma with supraglottic inflammation (arrow) central areas of basophilia)

Haematoxylineeosin staining, high power. Courtesy of Associate Professor Hedley Coleman. u Courtesy of Dr Ian Cole. u

Normal speech requires both vocal cords to adduct and to granulomas could be attempted with a trans-oral come into contact. Unilateral vocal cord palsy often results approach or with lateral laryngotomy. However, such in the paralysed cord remaining in a lateral, abducted procedures were technically challenging and could cause position, unable to adequately contact the opposing vocal cord scarring. As a result, Teflon fell out of favour in normal cord.2 This results in a significant loss of vocal light of the newer, safer alternatives.8 volume and increased air escape during speech, At the time of Wran’s initial dysphonia (1980), vocal fold producing a weak, hoarse, breathy voice. injection with Teflon was still widely employed to treat Procedures to return the lateralised cord to a more medial symptomatic vocal cord palsy with glottic insufficiency, position may restore relatively normal vocal function. and was accordingly recommended for his case. His Vocal fold injection or injection laryngoplasty, first paralysed left vocal fold was medialised during a routine described in 1911, involves the trans-oral or trans-cervical procedure, but when he returned to the post-operative injection of an inert filler material lateral to the vocal cord, ward, an acute inflammatory response developed in his into the paraglottic space (immediately lateral to the larynx. His airway remained patent and he was managed thyro-arytenoid and lateral crico-arytenoid muscles), conservatively during his hospital stay. His breathing was 2,3 thereby medialising the affected cord. stable and, apart from an obviously husky voice, he was Filler materials used for vocal fold augmentation are otherwise well. After discharge, Wran noted that his voice categorised as either temporary or long lasting, and have had not returned to its original character, but he was historically included materials such as silicone, paraffin pleased that he could maintain his speaking volume ’ and Teflon (polytetrafluoroethylene resin, DuPont).4 In without fatigue. Over the following months, Wran s voice current practice, these materials have been replaced by became increasingly raspy, but his volume and power alternatives with more predictable biomechanical properties and a lower risk of triggering foreign body reactions in the larynx. Alternative materials include 4 Axial, non-contrast computed tomography image autologous fat, hydroxyapatite, bovine gelatine, collagen, (soft tissue windows), showing right laryngeal and hyaluronic acid.2-6 The development of new Teflon granuloma (arrow) injectable materials and high definition endoscopic technology has significantly advanced the field of injection laryngoplasty.2 Until the early 1990s, Teflon was a popular choice as an injectable material for vocal fold augmentation because its (11) 207 MJA texture and viscosity permitted easy injection, it was non- toxic, its results were long lasting, and it was thought to be inert. However, a number of early case reports and long term studies indicated that Teflon injections could elicit j 1Dcme 2017 December 11 foreign body granulomatous reactions in some patients4-8 (Box 2). During the 1980s and 1990s, the incidence of Teflon granulomas increased, presenting on direct visualisation of the larynx as erythematous, submucosal swellings (Box 3) and as unilateral, well circumscribed masses on computerised tomography imaging (Box 4). Such granulomas compromise normal vocal cord function by preventing the propagation of a normal physiological waveform, resulting in a harsh, gravelly voice.8,9 Courtesy of Dr Ian Cole. u 469 Removing the injected Teflon and surrounding Reflection

remained unaffected. Accordingly, he elected not to infrastructure and public transport development, undergo any corrective procedures, wishing to avoid the institutional reform, environmental protection risk of further injury. (including the establishment of 20 new national parks), and social rights advancement (creating the Ethnic The characteristic changes to Wran’s voice have been Affairs Commission, the Anti-Discrimination Board, the attributed to both an acute inflammatory response to the Women’s Advisory Council, and the Ministry of Teflon injection, together with Teflon-related granuloma Aboriginal Affairs), as well as public health initiatives secondary to a chronic foreign body reaction. that included random breath testing of motorists to During his ensuing 6 years as Premier, Wran’s unique reduce drink-driving, lead-free petrol, and a ban on voice became a trademark feature that distinguished him smoking on public transport.10 He died in 2014, from adversaries and colleagues alike. As news of the aged 87. medical cause of his condition became known and his Competing interests: No relevant disclosures. political fortunes advanced, he acquired the nickname of Provenance: Not commissioned; externally peer reviewed. n the “Teflon-coated Premier”.1 ª 2017 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved. Wran resigned from Parliament in 1986, having realised an ambitious, if sometimes controversial agenda of References are available online at www.mja.com.au. 11 December 2017 j MJA 207 (11)

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1 Steketee M, Cockburn M. Wran: an unauthorised biography. Sydney: Allen & of the European Laryngological Society. Eur Arch Otolraryngol 2013; 270: Unwin, 1986. 2491-2507. 2 Mallur PS, Rosen CA. Vocal fold injection: review of indications, techniques, 7 Dailey SH, Ng K, Gunderson M, Petty B. Vocal fold reconstruction: a novel and materials for augmentation. Clin Exp Otorhinolaryngol 2010; 3: 177-182. flap. Laryngoscope 2013; 123: 2793-2797. 3 Sanderson JD, Simpson CB. Laryngeal complications after lipoinjection for 8 Pagedar NA, Listinsky CM, Tucker HM. An unusual presentation of Teflon vocal fold augmentation. Laryngoscope 2009; 119: 1652-1657. granuloma: case report and discussion. Ear Nose Throat J 2009; 88: 746-747. 4 Meslemani D, Benninger MS. Coblation removal of laryngeal Teflon 9 Loehrl TA, Smith TL. Inflammatory and granulomatous lesions of the larynx granulomas. Laryngoscope 2010; 120: 2018-2021. and pharynx. Am J Med 2001; 111 Suppl 8A: 113s-117s. 5 Li L, Stiadle JM, Lau HK, et al. Tissue engineering-based therapeutic strategies 10 Bramston T. Wran’s plan a way back for NSW Labor. The Australian for vocal fold repair and regeneration. Biomaterials 2016; 108: 91-110. (Sydney). 4 June 2011. http://www.theaustralian.com.au/national-affairs/ 6 Friedrich G, Dikkers FG, Arens C, et al. Vocal fold scars: current concepts wrans-plan-a-way-back-for-nsw-labor/news-story/d434e7b75b1dd86d2b8 and future directions. Consensus report of the Phonosurgery Committee da564b4d1d015 (accessed Sept 2017). - J 0 (11) 207 MJA j 1Dcme 2017 December 11

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