Reinke's edema is the swelling of the vocal cords due to fluid (Edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.
Reinke's edema is characterized by the "sac-like" appearance of the fluid-filled vocal cords. The disease is more often cited in women than in men, because lower voice changes are more noticeable in women. followed by F. Reinke in 1895. In his investigations, Reinke injected a stained glue into the superficial lamina propria (Reinke's space) to mimic edema. Reinke's edema is considered to be a benign (non-cancerous) polyp (protrusion) that represents 10% of all benign laryngeal pathologies. Treatment of Reinke's edema starts with the elimination of associated risk factors, such as smoking, gastric reflux, and hypothyroidism. Advanced cases may undergo phonosurgery to remove the fluid from the vocal cords.
Signs and symptoms
List of common symptoms:
- A "sac-like" appearance of the vocal folds
- Hoarseness and deepening of the voice The most common clinical symptom associated with Reinke's edema is an abnormally low pitched voice with hoarseness. The low pitch voice is a direct result of increased fluid in the Reinke's space, which vibrates at a lower frequency than normal (females <130 Hz; males <110 Hz).
Edema usually occurs on both vocal cords. This is known as bilateral Reinke's edema. In addition, cigarette smoke can create reactive oxygen species that alter the environment of the vocal cords. Tissue analysis of Reinke's edema shows decreased amounts of the proteins fibronectin, elastin, collagens I and III, and extracellular matrix proteins. This leads to an overall decreased stiffness of the tissue layer, which vibrates more slowly and produces a deeper sounding voice.
Diagnosis
thumb|Rigid [[Laryngoscopy|laryngoscope instrument ]]
Reinke's edema is often diagnosed by an ear, nose and throat (ENT) specialist (an Otorhinolaryngologist or Otolaryngologist) by examination of the vocal folds ("cords"). First, the doctor will review the patient's medical history and symptoms, such as hoarseness, dysphonia, and reduced vocal range. There is no familial or hereditary link to Reinke's edema. The doctor will need to know if the patient is a habitual smoker. Once the patient's history is reviewed, the vocal cords will be visualized using laryngoscopy, a technique in which a tube with a camera (endoscope) is passed through the nose and down the larynx. Laryngoscopes can be rigid or flexible. Flexible laryngoscopes, such as fiber laryngoscopes, allow the patient to produce sound as the tube is placed, and therefore allows the doctor to visualize movement of the vocal cord. Mucosal waves describe the waves produced by vibration of the vocal cords during speech. Stroboscopes produce flashes of light that are timed to the patient's vocal frequency. Every time the light is flashed, it will create a still frame image of the vocal cords at that particular moment in time. These are combined to produce an image of the wave. In the case of Reinke's edema, structural changes to the vocal cords will result in abnormal wave patterns.
Treatment
The first step in treating Reinke's edema is to eliminate or control those risk factors that are causing the disease. This includes the cessation of smoking, the control of gastroesophageal reflux using antacids or proton-pump inhibitors (eg, Protonix®), and the discontinuation of activities that cause vocal distress. Most cases of Reinke's edema are caused by the long term usage of cigarettes. In this case, it is important to make lifestyle changes to stop smoking. While this will not resolve or improve the edema, the cessation of smoking will halt the disease's progression. Most procedures follow the microflap technique set in place by Hirano. The flap is then re-draped and trimmed to the appropriate size. Other complications of surgery include tissue scarring due to damage to the vocal ligament during the incision and vocal cord stiffening due to over-suctioning of the superficial lamina propria (Reinke's space). was the most common procedure used to correct Reinke's edema. Vocal stripping was often performed without magnification and with a monocular laryngoscope, instead of a binocular scope. This led to major complications such as vocal ligament scarring.
Women are more likely than men to undergo surgery due to a greater change in vocal pitch and quality. Surgery is capable of restoring the voice, with the condition that smoking is not resumed after surgery. Reinke's edema is not a life-limiting pathology unless the tissue becomes precancerous. Cigarette smoke was discovered to increase COX-2 and prostaglandin E2 (PGE2) expression in fibroblasts, which could explain the role of cigarette smoke in Reinke's edema.
While smoking is a clear risk factor for Reinke's edema, others are being investigated to explain Reinke's edema in nonsmokers. Research has suggested the role of bacterial colonies in non-neoplastic lesions such as Reinke's edema. In one study using pyrosequencing, thirty-one of the forty-four non-neoplastic lesions sampled were found to have Streptococcus pseudopneumoniae bacterial strains as the dominant bacteria present. Species of Streptococcus were present in every lesion analyzed, representing 72.9% of all bacteria found specifically within Reinke's edema lesions and 68.7% of bacteria across all the vocal fold lesions sequenced. While smoking, gastric reflux, and vocal abuse have been more widely agreed upon in literature as risk factors for Reinke's edema, the altered bacterial cultures could be developed as a diagnostic tool in the future.
The majority of the research within the last ten years focuses on improving surgery for Reinke's edema. Due to the importance of the Reinke's space in speech, it is important that minimally-invasive techniques be perfected that minimize the risk of complications. The carbon dioxide laser has been successfully incorporated into the surgical technique; there are several other lasers being investigated for use in Reinke's edema. These include photoangiolytic lasers and potassium titanyl phosphate lasers.
See also
- List of voice disorders
- Histology of the vocal folds