Conservative Management of Early Grade of Unilateral Reinke's Edema With Laryngopharyngeal

Reflux

Tatalaksana Konservatif Edema Reinke Unilateral Derajat Awal yang Disertai Dengan Refluks
Laringofaringeal

ABSTRACT
Reinke's edema is described as fluid-filled vocal folds in Reinke's space. Unilateral cases are uncommon and may be
due to gastrointestinal reflux. We report a 61-year-old man with complaints of hoarseness that was felt about one year
ago and had been getting worse for the last two months. Examination of the RSI obtained a score of 23 and an RFS
score of 11. Examination of the flexible fiber laryngoscopy showed that the right vocal fold size was thicker than the
contralateral side, greyish in color, soft, and did not bleed easily. The patient was then given conservative therapy with
Proton Pump Inhibitors (PPIs), corticosteroids, and mucolytics accompanied by lifestyle modifications. Clinical
improvement was found at four weeks of evaluation. To conclude, the response to conservative therapy and
elimination of risk factors for early-stage Reinke's edema correlates well with disease recovery, particularly those
caused by laryngopharyngeal reflux.

Keywords: Conservative, early stage, reinke's oedema, unilateral, laryngopharyngeal reflux

ABSTRAK

Edema Reinke merupakan kelainan pita suara yang berisi cairan di ruang Reinke. Kasus unilateral jarang terjadi dan
mungkin disebabkan oleh refluks gastrointestinal. Kami melaporkan seorang laki-laki berusia 61 tahun dengan keluhan
suara serak yang dirasakan sekitar satu tahun yang lalu dan semakin memburuk selama dua bulan terakhir.
Pemeriksaan RSI memperoleh skor 23 dan skor RFS 11. Pemeriksaan laringoskopi serat fleksibel menunjukkan bahwa
ukuran pita suara kanan lebih tebal dari sisi kontralateral, berwarna keabu-abuan, lunak, dan tidak mudah berdarah.
Pasien kemudian diberikan terapi konservatif dengan Proton Pump Inhibitors (PPIs), kortikosteroid, dan mukolitik
disertai dengan modifikasi gaya hidup. Perbaikan klinis ditemukan pada empat minggu evaluasi. Sebagai kesimpulan,
respon terhadap terapi konservatif dan eliminasi faktor risiko untuk stadium awal edema Reinke berkorelasi baik
dengan pemulihan penyakit, terutama yang disebabkan oleh refluks laringofaringeal.

Kata Kunci: Edema Reinke, konservatif, refluks laringofaringeal, tahap awal, unilateral

INTRODUCTION
When someone spoke, the Reinke chamber would vibrate and produce sound. Reinke's edema is swelling of the vocal
cords due to fluid accumulation (edema) in the Reinke space (1). The main cause of Reinke's edema is smoking. The
risk of Reinke's edema increases with age and prolonged exposure to secondhand smoke. Other risk factors that play a
role include alcohol consumption, gastroesophageal reflux, chronic laryngitis, laryngopharyngeal reflux, allergies,
inadequate fluid intake, and long-term excessive use of voice (2). The pathomechanism of Reinke's edema is not fully
understood, but the chemicals in cigarettes can potentially increase blood vessel permeability so fluids can enter
Reinke's space (3).
Reinke's edema is characterized by a sac-like form of translucent white fluid in the vocal cords (2). The most frequent
clinical symptoms are hoarseness, dysphonia, and decreased voice level. Examining the vocal folds in a patient with
Reinke's edema at the microscopic level will reveal low levels of collagen, elastin, and extracellular matrix proteins.
This characteristic can be used to diagnose Reinke's edema (4). Reinke's edema is known as a benign polyp that can
develop into pre-cancerous lesions (4,5).
Laryngopharyngeal reflux (LPR) is a risk factor that can cause Reinke's edema (6). To help diagnose LPR, doctors can
use the reflux symptom index (RSI) questionnaire, which consists of nine questions and asks the patient to determine
the severity of the symptoms. A score over 13 is diagnosed as LPR. Examination of the flexible fiber larynx was carried
out using the reflux finding score (RFS) to determine signs of laryngeal inflammation in patients. The highest score is
26; if it is more than seven, it is considered LPR (7).
The first step in treating Reinke's edema is eliminating the risk factors that can cause the disease. Controlling risk
factors such as smoking cessation, controlling gastric reflux by adjusting diet, proton pump inhibitors, corticosteroids
to reduce inflammation, and vocal rest for 4-6 weeks (3). Surgical intervention is performed in patients with airway
obstruction or who have failed conservative therapy (4,5). Several surgical techniques can be used,i.e., cold excision,
CO2 laser excision, micro debridement, and hemoglobin-specific laser therapy (4,8).
CASE REPORT
A 61-year-old man came to the ENT polyclinic complaining of a hoarse voice that had been felt since one year ago and
worse in the last two months. There were no complaints of swallowing pain, but sometimes the patient had difficulty
swallowing solid food. Patients also complain of a throat lump, choking, and intermittent cough. History of active
smokers about one pack per day. A history of taking antacid drugs accompanied a history of heartburn, and a history
of using loud voices was denied. From the results of the RSI calculation (Table 1), a score of 24 was obtained
(exceeding the normal limit of 13), so the initial diagnosis in this patient was laryngopharyngeal reflux.

Table 1. RSI examination results

No Symptom Score
1 Hoarse voice 4
2 Throat clearing 3
3 Postnasal drip 2
4 Difficulty swallowing 2
5 Coughing after eating or lying down 2
6 Difficulty breathing/choking 2
7 Annoying cough 2
8 A lumpy feeling in the throat 4
9 Chest pain, heartburn, indigestion 3
Total Score 24

The axial neck CT scan showed a thickening of the right vocal folds (Image 1). From flexible fiber laryngoscopy, it was
found that there was thickening in the right vocal fold, a soft impression, bleeding less, and gray (Image 2). The
movement of the right adductor vocal fold is slower than that of the contralateral side. The RFS assessment obtained a
score of 11 with partial ventricular obliteration, erythema, and larynx edema, accompanied by thick endolaryngeal
mucus. The results of laboratory tests were within normal limits.

Image 1. Axial neck CT scan found right vocal cord thickening (red circle)

A C

B D

Image 2. Flexible fiber laryngoscopy reveals Reinke's edema right (A). Lingual tonsillar hypertrophy with erythema of the larynx
and endolaryngeal mucus (B, C). Four weeks follow-up showed a satisfactory response to therapy (D)

Patients are then educated to avoid risk factors by stopping smoking, eating 2 hours before bed, and avoiding spicy
and high-fat foods and drinks that increase acidity, such as coffee. Medical therapy was given with proton pump
inhibitors (lansoprazole 20 mg per 12 hours), methylprednisolone (48 mg per day) for two weeks, followed by tapering
off, and mucolytics (ambroxol 30 mg per 8 hours). The evaluation was carried out after four weeks of therapy, and the
control results obtained a significant improvement in symptoms. The results of fiber-control laryngoscopy showed
minimal thickening of the right plica vocalis, an impression of improvement from the previous condition.

DISCUSSION
The first case of Reinke's edema was documented in 1891 by M. Hajek, followed by F. Reinke in 1895. Reinke's edema
is considered a benign (non-cancerous) polyp (protrusion) that represents 10% of benign pathologies of the larynx (2).
In this case report, the diagnosis of Reinke's edema was established based on history, physical examination, flexible
fiber laryngoscopy, and radiological examination. Various factors are suspected of causing Reinke's edema in this case,
namely a history of smoking and laryngopharyngeal reflux.
Several clinical studies have reported that LPR leads to the development of significant macroscopic and microscopic
histological changes in the vocal cord mucosa. Epithelial cell dehiscence, Reinke's space edema, dry mucosa, and
epithelial thickening are associated with LPR (6). Histological changes in the vocal cord tissue can cause hoarseness.
From the patient's history of complaints and the RSI score, the factors causing Reinke's edema in this patient were due
to a previous LPR history.
Based on Yonekawa's classification, Reinke's edema was divided based on laryngoscopy results. Grade 1 polypoid
lesions cover less than 25% of the glottic airway, grade 2 lesions expand by 25-50%, grade 3 when the lesion is 50-75%,
and grade 4 when the obstructive lesion covers more than 75% of the glottic airway (1,9). In this case, the lesion on
the right vocal fold is less than 25%, so it fits the Yonekawa grade 1 classification.
Treatment of Reinke's edema includes eliminating risk factors, conservative therapy with PPIs and corticosteroids, and
surgical intervention if conservative therapy fails or airway obstruction develops (3,4,5,10). Conservative therapy, in
this case, was considered because Reinke's edema is still in its early stages and has not yet caused symptoms of airway
obstruction.
In conclusion, the first-line therapy for treating Reinke's edema is to control the risk factors that cause the disease,
vocal rest, and medication in the form of proton pump inhibitors and corticosteroids. In this patient, satisfactory
results were obtained after four weeks of control after conservative therapy, so no surgery was needed.

ACKNOWLEDGEMENT
The authors would like to thank Farhamna Academic for assisting in preparing this manuscript. Thanks to the ear,
nose, throat, head, and neck surgery department staff of the Hasanuddin University Medical Faculty who have
assisted in providing treatment and monitoring variables in these reporting patients.

REFERENCES
1. Tan M, Bryson PC, Pitts C, et al. Clinical Grading of Reinke's Edema. The American Laryngological Rhinological and
Otological Society. Laryngoscope. 2017;127:2310-3
2. Jain S, Varma R, Hazarika B, et al. Reinke's Edema. Indian J Radiol Imaging. 2009;19(4): 296-7
3. Steven Z, Hillman R, Bunting GW. Reinke's Edema: Phonatory Mechanisms and Management Strategies. Ann Otol
Rhinol Laryngol. 2015; 6 : 533-43.
4. Swain SK, Sahu MC. Management of Laryngeal Airway in Reinke's Edema: An Anesthetic Overview.
Otorhinolaryngology Clinics: An International Journal. 2017 ; 9(1) : 35-7
5. Sreedharan R, Chhabada S, Khanna S. Reinke's Edema : Implications for Airway Management. The American
Society of Anesthesiologists. 2018 ; 129 : 810
6. Lechien JR, Schindler A, Robotti C, Lejeune L, Finck C. Laryngopharyngeal reflux disease in singers:
Pathophysiology, clinical findings and perspectives of a new patient-reported outcome instrument. Eur Ann
Otorhinolaryngol Head Neck Dis. 2019 June ; 136(3S) : S39-S43.
7. Eckley CA, Tangerina R. Using RSI and RFS scores to differentiate between reflux-related and other causes of
chronic laryngitis. Braz J Otorhinolaryngol. 2021 Oct 17 : S1808-8694(21)00155-5
8. Singh SP, Sethi A, Sethi D, et al. Surgical Management of Reinke's Edema: A Retrospective Analysis. IOSR Journal of
Dental and Medical Sciences (IOSR-JDMS). 2018; 17(5) : 56-9
9. Tan M, Bryson PC, Pitts C, Woo P, Benninger MS. Clinical grading of Reinke’s edema. The Laryngoscope.
2017;127(10):2310-2313. doi:10.1002/lary.26647
10. Dewan K, Chhetri DK, Hoffman H. Reinke’s edema management and voice outcomes. Laryngoscope Investig
Otolaryngol. 2022;7(4):1042-1050. doi:10.1002/lio2.840