Reinke's Edema

What is Reinke's oedema? 

Reinke's oedema is a term used to describe the vocal folds when they become chronically and irreversibly swollen. Other terms for the condition include:

• Polypoid vocal cord, polypoid degeneration or polypoid hypertrophy, caudal polyposis, or polypoid corditis.
• Chronic oedema of vocal folds.
• Pseudomyxoma or pseudo myxomatous laryngitis
• Smoker's larynx

Aetiology

It occurs almost exclusively in moderate to heavy smokers. It occurs due to voice strain, extra oesophageal reflux, and hypothyroidism, which can be a concomitant feature

Pathology

The epithelium shows non-specific changes, and the basement membrane layer is usually thickened. In Reinke's space, there are lakes of oedema, extravasated erythrocytes, and thickening of the walls of the subepithelial vessels.

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Symptoms

The most common symptoms are the following: Deepening of the pitch of the voice with women often being mistaken for a man, particularly on the telephone

• Gruffness of the voice
• Effortful speaking
• An inability to raise the pitch of the voice
• Choking episodes
• Other symptoms are associated with extra oesophageal reflux.

On Examination

Typically the vocal folds are gray or yellowish in color with prominent superficial vessels. Alternatively, the edematous folds may appear diffusely red when coexistent esophageal reflux should be suspected. Leukoplakia is uncommon but may be due to hyperplasia, dysplasia, or very rarely carcinoma in situ. In severe cases, the vocal folds look like bag of fluids that flopup and down through the glottis with respiration.

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Grading of Reinke's Oedema

Treatment depends on

• Symptoms
• Severity of the oedema
• Presence of the leukoplakia

Conservative measures

• Reassurance
• Vocal hygiene advice
• Smoking cessation
• Hypothyroidism, upper airway infections and allergies, and extra oesophageal reflux should be treated

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Changes after Surgery

Friends and relatives may not recognize them by their voice. The singing voice may be permanently altered. Speaking may be more effortful for up to 1 year (or occasionally permanently), particularly if excessive mucosa is removed due to stiffness from scarring and anterior web formation. The voice seldom returns to normal but is generally 7 of better quality.

The reinke's oedema is likely to return within 2 years if the patient continues to smoke

Principles of Surgery for Reinke's Oedema

It reduces the bulk of the mucosa of the vocal fold. Obtaining a straight mucosal edge. Avoiding damage to and exposure of the underlying ligament, thereby reducing the chance of scarring and web formation

Surgical treatment

The myxoematous material from the superficial lamina propria layer is aspirated, removed with forceps, or vaporized, and the epithelial edges apposed following excision of redundant mucosa as necessary. Phonosurgery can be done with cold instruments or one of the new generations of microspot lasers. KTP laser treatment can be done local anesthesia via a channelled endoscope as an OPD procedure.  Care should be taken not to remove excised epithelium and not to overheat the vocal cord ligament, as this may result in a permanent scar and hoarseness.

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Endocrine causes

Hyperthyroidism has been associated with increased anxiety, hoarseness, and tremor affecting the voice. The vocal folds have been reported as looking 'hypervascularized and hyperkinetic’.

Hypothyroidism is associated with:

• Hoarseness
• Deepening of the pitch of the voice
• Voice fatigue and weakness
• Dryness of the throat
• Slow and hesitant speech

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