A Clinico-pathological study of Reinke'S oedema

Reinke's Edema and Risk Factors, A Case-Control Study

Reinke's edema (RE) is a benign pathological non-inflammatory disorder of the vocal folds with a wide range of clinical manifestations. We aim to investigate the relationship between Reinke's edema and some common inhalant abuse. In this case-control study, subjective consisted of 23 patients with RE (the cases), and 50 patients with sinusitis (control) who underwent surgery in the Department of Otolaryngology, between 2015 and 2020. Demographic characteristics, history of some related disease, methods, and the duration of cigarette, and opium consumption were collected through the patients' files. The chi-square (χ²) test was run to analyze the differences in the categorical and, and the Independent Sample T-test was used to compare two sample means from unrelated groups. A significant level (p-value) was considered less than 0.05. The mean age was 54 ± 12 years, and 42 ± 11 years, respectively for Reinke's edema and sinusitis. More women had been recorded in the RE group, compared to men. Allergy, unprincipled use of voice and talkativeness, history of laryngeal surgery, and type of disease were correlated to RE (p < 0.05). Also, cigarette smoking was significantly correlated with Reinke's edema. The average number of cigarettes per day, the duration of smoking, and opium consumption were more frequent in RE (P < 0.05). 90% of the RE and 4% of sinusitis patients were opium consumers. There was a statistically significant difference in the methods of substance use in the two groups of cases and control (p < 0.0001). Among the different methods, the poker and stone method was the most common (69.6%), and the opium smoking pipe was the second most common method. This study also confirmed the hazardous effects of smoking and inhaling opiates in the formation of lesions of the pharynx and larynx. In particular, longer use of these substances will be associated with more serious side effects. Therefore, it seems that people who are addicted to opiates should undergo periodic visits and counseling to reduce and stop their use.

The Relationship between Posture and Muscle Tensive Dysphonia in Teachers: A Systematic Scoping Review

Teachers usually present work-related pain such as neck pain. Their posture could be the cause of these problems; indeed, it is often a sway-back posture. Furthermore, teachers can also experience problems with their voice such as dysphonia, specifically muscle tension dysphonia (MTD). This scoping review aims to find the correlation between teachers' posture and MTD. It also studies how a posture-based treatment can influence this disorder. Randomized controlled trials, controlled clinical trials, prospective cohort studies, and cross-sectional studies that considered the relationship between posture and MTD and that included teachers in their sample. The search led to an initial number of 396 articles; after the screening process, a final number of eight articles were included. A total of 303 patients were analyzed and all showed altered alignment of the head around the cervical spine with hypertonus of the cricothyroid, suprahyoid, and sternocleidomastoid muscles. Although MTD is a disorder with a multifactorial etiology, the articles revealed a correlation between posture and MTD related to a forward protraction of the cervical spine with a hypertonus of the laryngeal and hyoid musculature. This study also detected that an intervention in posture could reduce vocal disorders.

Impact of the Severity of Reinke's Edema on the Parameters of Voice

Objective

This study aimed to classify the degree of edema in patients with Reinke's edema (RE) and examine its impact on their voice parameters using both objective and subjective assessment methods.

Methods

Objective and subjective voice data of 104 patients diagnosed with RE between 2018 and 2021 were evaluated retrospectively. RE is classified into 4 groups (types 1, 2, 3, and 4). The evaluation included videolaryngostroboscopic examination, acoustic voice analysis, and aerodynamic measurements, GRBAS, Voice Handicap Index-10 (VHI-10), Voice-Related Quality of Life Scale (V-RQOL), and Reflux Septum Index (RSI).

Results

Patients with type 1 RE had a significantly lower mean age than those with types 3-4. Although there were no significant differences in acoustic and aerodynamic parameters between the groups, it was observed that F0 and the maximum phonation time decreased as the degree of edema increased. The GRBASTotal, G, and R scores of types 1 and 2 were significantly lower than those of types 3 and 4, as were the scores of type 1 S. There were no statistically significant differences between the RE groups in terms of VHI-10, V-RQOL, and RSI scores.

Conclusion

It has been observed that as the severity of RE increases, voice perception and quality (especially types 3 and 4) are negatively affected. Determining the degree of edema will guide the clinician in both the planning of the intervention phase and the follow-up phase.

Voice outcomes in high-grade Reinke's edema: Comparing microflap excision and microdebrider surgery

Objectives

Patients presenting with hoarseness and diagnosed with high-grade Reinke's edema (RE) will often require surgical intervention for polypoid changes of the true vocal folds. We compared patient outcomes in patients who had microflap or microdebrider excision surgeries.

Methods

Patients with the diagnosis of grade II or grade III RE based on laryngoscopy or videostroboscopy who failed conservative management underwent surgery using the standard excision practice of the primary surgeon. Voice outcomes were compared using VHI-30 (Voice Handicap Index), V-RQOL (Voice-Related Quality of Life), and MPT (maximum phonation time) preoperatively and at 1-month and 6-months postoperatively.

Results

Of the 115 patients included, there were 46 RE grade II patients and 69 RE grade III patients with 52 patient undergoing microflap surgery and 63 patients undergoing microdebrider surgery. Both procedures resulted in significant improvement in VHI-30, V-RQOL, and MPT at 1-month and 6-months postoperatively. The microdebrider group had better 6-month VHI scores (40.84) than the microflap group (44.54) (CI -7.27 to -0.12). The microdebrider group also had better 6-month V-RQOL measures (62.56) than the microflap group (57.79) (CI 0.38-9.16).

Conclusion

Both microflap excision and microdebrider excision for high-grade RE lesions resulted in significant improvement in VHI-30, V-RQOL, and MPT at 1-month and 6-months postoperatively with the microdebrider excision group scoring statistically significantly better at 6 months in comparison to the microflap group. Overall, the results support the use of both surgical modalities for treating high-grade RE patients.

Level of evidence

3.

Reinke's Edema: New Insights into Voice Analysis, a Retrospective Study

PURPOSE

Reinke's edema (RE) is a pathological condition involving increased volume of the vocal folds and resulting in significant impact on speech, fundamental frequency, and vocal range. Literature reports few studies which analyze vocal features according to the severity of RE. The aims of this study were to investigate the aerodynamics, acoustic characteristics, and sound spectrograms of a group of RE patients and to assess whether there was any correlation with their endoscopic grading.

METHODS

A total of 98 patients were included in the study, 49 patients with RE and 49 healthy volunteers (HV). Multidimensional Voice Program was used to perform objective voice assessment. Maximum phonation time (MPT) and Voice Handicap Index (VHI) questionnaire were collected. The spectrograms of the vowel /a/ and of the word /aiuole/, which contains the five Italian vowels, of each patient were analyzed according to the classification of Yanaghiara modified by Ricci Maccarini and De Colle. Laryngological assessment was used to record vocal folds morphology according to Yonekawa's classification. Univariate analysis was used to compare group outcomes. Bivariate analysis was used to compare endoscopic grading and voice analysis results.

RESULTS

Univariate analysis of the HV and RE groups revealed statistically significant differences (P < 0.05) for the following parameters: jitter%, shimmer%, harmonic-to-noise ratio (NHR), voice turbulence index (VTI), MPT, VHI except for soft phonation index. Spearman's rank correlation showed a positive correlation between vocal parameters such as jitter%, shimmer%, NHR, VTI, and RE gradings. A negative correlation was found between MPT and RE gradings. Bivariate analysis indicated a strong positive correlation between RE grading and the spectrogram classification performed both with the vowel / a / (Rho 0.86; P = 0.0001) and with the word / aiuole / (Rho 0.81; P = 0.0001).

CONCLUSION

The present study demonstrates that patients with RE have different voice characteristics compared to HV. In particular, the voice analysis highlighted acoustic parameters that correlated to differing degrees of RE. In addition, spectrogram analysis should be considered for acoustic assessments before and after medical and surgical therapy and also in forensic medicine.

Treatment of relapsing functional and organic dysphonia: a narrative literature review

Information about failure and relapses is critical in deciding whether and how to treat a given condition, as well as during patient counselling before therapy. This paper aims to perform a non-systematic review of relapses and failure of dysphonia treatment in the adult population. Studies on failure and relapses after treatment of benign vocal fold lesions, functional dysphonia and neurogenic dysphonia were analysed. The frequency and the duration of follow-up were heterogeneous, and the management of relapses was reported in only a portion of the studies. Relapses after surgical treatment of benign vocal fold lesions ranged between 1% and 58% of cases, and their management was mainly surgical. Rates of relapse after voice therapy for functional dysphonia and spasmodic dysphonia were 12%-88% and 8%-63%, respectively. Rates of relapse after surgical treatment for unilateral and bilateral vocal fold paralysis were 10%-39% and 6%-25%, respectively; treatment was mainly represented by surgical revision. In conclusion, failure and relapses of functional and organic dysphonias after therapy are not rare, but treatment modalities are seldomly reported. The data from this non-systematic review stresses the need for further research in this area.

Unsedated Office-Based Blue Laser Therapy in Female Patients With Reinke's Edema: A Retrospective Review of 8 Cases

OBJECTIVES

To report on the outcomes of unsedated blue laser therapy in female patients with Reinke's edema.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of female patients undergoing unsedated office-based blue laser treatment of Reinke's edema between February 2020 and March 2022 at the Hamdan Voice and Swallowing Unit at the American University of Beirut Medical Center in Beirut, was conducted. Patients were assessed before and after the procedure with a follow-up interval of 3-6 weeks. Demographic data included age, history of smoking and grade of Reinke's edema. Voice outcome measures included the Voice Handicap Index-10 questionnaire, perceptual evaluation (GRBAS scale), acoustic analysis and maximum phonation time. Vocal fold lesions were evaluated using indirect laryngeal endoscopy.

RESULTS

A total of eight patients were reviewed. The mean age was 59.63 ± 7.98 years. One patient was lost to follow-up. We report on a total of 10 Reinke's edema lesions treated with the blue laser. There was a significant decrease in the mean VHI-10 score (14.86 ± 5.84-6.71 ± 7.32; P < 0.01) as well as in the means of three perceptual evaluation parameters (G, R, B; P < 0.05). There was also a nonstatistically significant increase in the mean fundamental frequency and habitual pitch. Laryngeal examination showed complete regression in 50% of the lesions, and partial regression in the remaining 50%.

CONCLUSIONS

Office-based blue laser treatment of Reinke's edema under local anesthesia can be considered an effective treatment modality as evidenced by improvement in post-procedure voice outcome measures.

Reinke's edema management and voice outcomes

Objectives

Reinke's edema is a chronic disease of the respiratory tract that occurs in adults with a history of chronic smoke exposure. Also known as polypoid corditis, polypoid laryngitis, and polypoid degeneration of the vocal fold, it is strongly associated with smoking, frequently with vocal misuse/abuse, and occasionally with laryngopharyngeal reflux. Reinke's edema remains a cause of chronic dysphonia that is difficult to manage. This review provides perspectives on current and future management of Reinke's edema.

Results

Reinke's edema impacts <1% of the population. The excessive mass is seen in polypoid degeneration results in a loss of pitch control and a rough voice. Women are more likely to present for treatment as the characteristic lowering of vocal pitch is more noticeable in women than men. Multiple grading systems have been proposed within the literature. The current standard of care is surgical excision, after smoking cessation. The microflap technique remains the approach of choice for bulky lesions. Surgical management of Reinke's edema has evolved with the introduction of various lasers into otolaryngologic practice; some which can now be used in the office setting. While many management approaches have been described within the literature, there is a little direct comparison and no obvious superior method of Reinke's edema management.

Conclusion

To date, the biology of Reinke's edema is not well understood. Additional research is needed further elucidate the role of uncontrolled reflux in the development and recurrence of Reinke's edema.

Voice Quality Analysis of Reinke's Edema According to Recent New Classification

OBJECTIVE

Reinke's edema is a benign laryngeal disease characterized by inflammation and swelling of the superficial layer of the lamina propria of the vocal fold, known as Reinke's space. The aim of this study was to evaluate the quality of voice by quantitative acoustic measurements in patients affected by RE according to new classification proposed by de Vincentiis.

STUDY DESIGN

Prospective case-control.

METHODS

We enrolled 76 consecutive patients with RE: eight type 1, 36 type 2, four type 3. and 28 type 4. A population of 30 healthy subjects was enrolled too. A voice recording for each subject was performed and the analysis were performed using the Multi-Dimensional Voice Program. The parameters considered were: fundamental frequency (F0), Jitter% (Jitt%), Shimmer% (Shim%), and Noise Harmonics to Ratio (NHR). Statistical analyses were performed using GraphPad Prism 8 software. A level of significance of P < 0.05 was used.

RESULTS

The mean values and standard deviation for each parameter for the male group of patients affected by RE are: F0 101.06 (± 9.56) Hz, Jitt% 2.254 (±0.93), Shim% 9,037 (±2.21) and NHR 0.235 (±0.099). About the female group, the mean values are: F0 147,58 (±13.68) Hz, Jitt% 3,733 (±1.12), Shim% 11.172 (±3.54) and NHR 0.278 (±0.12). The difference between the types of RE and reference sample people in male and female groups are statistically significative (P < 0.05) for each parameter. In the female group all outcomes are statistically different except the F0 and NHR between healthy people and type III RE patients.

CONCLUSIONS

RE is one of the most common diseases of true vocal folds and the classification proposed by de Vincentiis is a synthesis of endoscopic findings. In this paper we underline the change in vocal quality before surgery according a new type of RE classification.

Reinke's Edema

Reinke's edema (RE) is the polypoid degeneration of one or both vocal folds within Reinke's space. The viscoelastic properties of the mucosal folds are characteristically altered by the expansion of the subepithelial space. Most frequently, patients present with dysphonia, with women being more affected than men. The primary risk factor is tobacco use. Voice overuse and laryngopharyngeal reflux are also considered to be contributory. Although RE shares the same primary risk factor as malignancy, the risk of malignancy is low, and dysplasia is found only in 0% to 3% of cases. Treatment is focused on decrease of risk factors, such as implementation of smoking cessation, voice therapy, and reflux control. Surgical techniques aim to decrease redundant polypoid mucosa in order to improve voice and restore the glottic airway. Recurrence of RE is high.

Efficacy of microsurgery in Reinke's oedema evaluated by traditional voice assessment integrated with the Vocal Extent Measure (VEM)

SUMMARY

There are few data analysing to what specific extent phonomicrosurgery improves vocal function in patients suffering from Reinke's oedema (RE). The recently introduced parameter vocal extent measure (VEM) seems to be suitable to objectively quantify vocal performance. The purpose of this clinical prospective study was to investigate the outcomes of phonomicrosurgery in 60 RE patients (6 male, 54 female; 56 ± 8 years ([mean ± SD]) by analysing its effect on subjective and objective vocal parameters with particular regard to VEM. Treatment efficacy was evaluated at three months after surgery by comparing pre- and postoperative videolaryngostroboscopy (VLS), auditory-perceptual assessment (RBH-status), voice range profile (VRP), acoustic-aerodynamic analysis and patient's self-assessment using the voice handicap index (VHI-9i). Phonomicrosurgically, all RE were carefully ablated. VLS revealed removal or substantial reduction of oedema with restored periodic vocal fold vibration. All subjective and most objective acoustic and aerodynamic parameters significantly improved. The VEM increased on average from 64 ± 37 to 88 ± 25 (p #x003C; 0.001) and the dysphonia severity index (DSI) from 0.5 ± 3.4 to 2.9 ± 1.9. Both parameters correlated significantly with each other (rs = 0.70). RBH-status revealed less roughness, breathiness and overall grade of hoarseness (2.0 ± 0.7 vs 1.3 ± 0.7). The VHI-9i-score decreased from 18 ± 8 to 12 ± 9 points. The average total vocal range enlarged by 4 ± 7 semitones, and the mean speaking pitch rose by 2 ± 4 semitones. These results confirm that: (1) the use of VEM in RE patients objectifies and quantifies their vocal capacity as documented in the VRP, and (2) phonomicrosurgery is an effective, objectively and subjectively satisfactory therapy to improve voice in RE patients.

Does Reinke's Edema Grade Determine Premalignant Potential?

OBJECTIVE

Reinke's edema (RE) is a benign disease of the vocal folds with a wide spectrum of clinical severity. We aim to evaluate the clinical impact of RE grade and determine if RE grade correlates with severity of dysplasia and tobacco exposure.

METHODS

Patients with isolated RE who underwent surgical excision between December 2010 and December 2014 were retrospectively reviewed. The RE grade was determined from archived laryngeal videostroboscopy exams. Pathologic severity of dysplasia, categorized by squamous intraepithelial neoplasia (SIN) classification, and tobacco history were extracted from medical records.

RESULTS

Of 95 lesions, 3 (3.16%) were RE grade 1, 33 (34.74%) were RE grade 2, 24 (25.26%) were RE grade 3, and 35 (36.84%) were RE grade 4. Fifty-nine lesions (62.11%) had no dysplasia (SIN0), 19 (20.00%) had mild dysplasia (SIN1), 15 (15.79%) had moderate dysplasia (SIN 2), and 2 (2.11%) had severe dysplasia (SIN3). The 2 patients with severe dysplasia had grade 4 lesions. No statistical correlation was identified between RE grade and the severity of dysplasia. Furthermore, no statistical correlation was seen between tobacco exposure and the severity of dysplasia or the RE grade.

CONCLUSIONS

Size of RE lesion does not reflect premalignancy. The majority of RE lesions, regardless of size, have little to no premalignant potential. Severe dysplasia/carcinoma in situ may be more likely seen in grade 4 lesions; however, the paucity of severe dysplasia published in RE data and in this cohort preclude any formal inference. Further study of grade 4 lesions is warranted.

The incidence of premalignant and malignant disease in Reinke's edema

Reinke's edema is a benign lesion of the vocal folds affecting the subepithelial space. As part of a study of the management of Reinke's edema, we aimed to determine the prevalence of dysplasia and malignancy in histologically proven Reinke's edema. A retrospective analysis of all laryngeal biopsies performed in north Glasgow, United Kingdom, between 2001 and 2010 was carried out. Clinical and pathological data from patients with histologically confirmed Reinke's edema were recorded with specific respect to the reporting of dysplasia and malignancy. From the 10-year cohort, a total of 3902 laryngeal biopsies were performed. In total, 189 patients (18 males and 171 females) had histologically proven Reinke's edema. Of this cohort, 170 (90%) had no dysplasia, 16 (8%) had mild dysplasia, 2 (1%) had moderate dysplasia, and 1 (<1%) had severe dysplasia. There was no malignancy reported. In our predominantly female smoking population, the epithelium appears to differentiate to benign Reinke's edema rather than malignancy. Patients can be reassured with regard to the low risk of malignancy in classic Reinke's edema.

Refining the ‘cucumber’ technique for laryngeal biopsy

Objectives:

To refine the case selection process for the ‘cucumber’ mounting system for laryngeal biopsies.

Methods:

We conducted a retrospective audit of cucumber technique specimens taken between January 2002 and December 2008. We analysed the clinical indications for biopsy and the pathological diagnosis, for each specimen, in order to inform our case selection process.

Results:

The cucumber technique was used for 125 laryngeal specimens. 60 specimens were taken for diagnostic sampling, 46 were taken during endoscopic laser resection, and 19 for overtly benign pathology. The cucumber technique was most useful for the interpretation of margins in endoscopic laser resection specimens.

Conclusion:

The cucumber technique is most useful for endoscopic resection cases in which tumour, dysplasia or suspicious lesions have been excised. Detailed information on resection margins is invaluable during multidisciplinary team discussions on patient management. Detailed photography of mounted specimens enables both laryngologist and pathologist to orientate and interpret specimens accurately.