Abstract
Significance Statement
Reinke’s edema is common. It is important to recognize that it does not always require treatment. In some cases, treating Reinke’s edema can make the voice sound worse even though the vocal folds look better. This article highlights the value of Reinke’s edema in compensating for the contralateral vocal fold scar, as well as the importance of leaving Reinke’s edema undisturbed in such cases.
A 66-year-old female presented with gradually worsening dysphonia that had been present for several years. She had smoked approximately 15 cigarettes a day for 40 years and had decreased her smoking to 10 cigarettes per day over the 6 months prior to her visit. Her voice was coarse and low in pitch. She also complained of “post-nasal drip.” During her initial examination, bilateral Reinke’s edema (RE), laryngopharyngeal reflux, compensatory muscle tension dysphonia, and mild diffuse chronic laryngitis that is consistent with smoking were identified. Vocal fold paresis was suspected, but laryngeal electromyography was normal. The diagnosis of laryngopharyngeal reflux was confirmed by a 24-hour pH impedance test; however, medical treatment only partially improved her symptoms. Esophageal manometry revealed normal peristalsis. Eventually, she underwent Nissen fundoplication and achieved adequate reflux control. She also stopped smoking.
Approximately 2 years prior to the examination discussed herein, the patient underwent submucosal evacuation and partial excision of RE on the right 1 and extremely conservative partial reduction with blue laser of RE on the left. Postoperatively, with slight stiffness on the right and the planned residual edema on the left (Figure 1), her habitual pitch was approximately a third higher than it had been preoperatively, her hoarseness and muscle tension dysphonia had resolved, phonation was effortless, and she considered her voice normal.
The strobovideolaryngoscopy image is from approximately 2 years following surgery. Moderate residual Reinke’s edema is seen on the left which renders the mild right mucosal scar/stiffness asymptomatic.
Although many surgeons resect RE bilaterally, the senior author (RTS) has avoided doing so in nearly all cases for more than 30 years. Patients who undergo bilateral resection often have clinically acceptable voice outcomes. However, despite using a conservative, submucosal evacuation technique, severe complications occur occasionally. Because of the flaccidity of the mucosa on both sides and inflammation created by submucosal suction/evacuation, severe webs can occur. Even when that is not the case, the procedure occasionally results in stiff or even adynamic mucosa. If that happens bilaterally, phonation threshold pressures increase, phonation becomes effortful and fatiguing; and patients are worse functionally than they were before surgery. If there is stiffness on one side and RE on the other, phonation threshold pressures and phonatory effort usually are normal. Staged procedures are always planned in our patients, with the first surgery evacuating the RE on the more affected vocal fold and with little to no evacuation on the contralateral vocal fold. Roughly 90% of our patients are happy with their voice after the first procedure and choose not to proceed with further surgery, as illustrated by the case presented here.
