Severe Reinke’s Edema

Significance Statement

Severe Reinke’s edema presents with dysphonia and is associated strongly with chronic exposure to cigarette smoking and laryngopharyngeal reflux. Dysphonia with a significant smoking history or with laryngopharyngeal reflux necessitates laryngeal examination for diagnosis and treatment of this rare condition when it causes symptoms that trouble the patient.

A 66-year-old female presented with a chief complaint of dysphonia. Two years previously, with no inciting event, she noticed a gradual increase in postnasal drip and hoarseness. She was not a voice professional. Her symptoms persisted and worsened gradually over time. She reported a history of smoking 3 to 4 packs of cigarettes per day for 40 years but was working on quitting by reducing 1 cigarette per week. The patient was advised on smoking cessation which she eventually accomplished. In addition, the patient had a past medical history of laryngopharyngeal reflux, for which she had undergone Nissen fundoplication, significantly improving her reflux symptoms. She had discontinued reflux medications and managed residual reflux through dietary modification. Her surgical history also included microdirect laryngoscopy, bronchoscopy, esophagoscopy, subtotal evacuation of the right Reinke’s edema with microflap, and partial reduction of the left Reinke’s edema with a blue laser. Furthermore, she was attending voice therapy to improve her voice quality. Stroboscopic examination revealed left Reinke’s edema with phase asymmetry (Figure 1), and her blood tests indicated normal thyroid function. Despite the patient’s previous management efforts, she was taken to the OR to decrease the edema because of persistent dissatisfaction with her voice.

Figure 1.

Severe Reinke’s edema in a smoker.

Discussion

Reinke’s edema is a chronic, benign, inflammatory condition of the superficial layer of the lamina propria of the vocal fold and frequently presents with dysphonia and occasionally with dyspnea. ¹ The prevalence of Reinke’s edema is less than 1% of the general population, and up to 80% of patients are females, potentially because women are more likely to complain of lowered voice as compared to men. ² Reinke’s edema can be associated with risk factors such as phonotrauma, laryngopharyngeal reflux, hypothyroidism, and most notably, smoking. Chronic irritation from an increased number of cigarettes smoked and duration of smoke exposure induces toxicity in fibroblasts, leading to structural alterations and increased hyaluronic acid secretion. ³ Reinke’s edema also is associated with chronic laryngitis, tumors, unilateral or bilateral vocal fold paresis, presbyphonia, phonotraumatic lesions, and muscle tension dysphonia. ⁴ Hence, comprehensive laryngologic evaluation is required in most cases. The current standard of care is surgical reduction, voice therapy, smoking cessation, and correction of underlying medical conditions. Despite its association with smoking, Reinke’s edema is associated with malignancy only rarely. ⁵