Letters to the Editor: Letters & Announcements
To the Editor:
D’Hulst et al. (1) present a valuable and instructive case study of airway obstruction from glottic abnormality during laryngeal mask airway ventilation. However, they conflate the two distinct pathologic entities of vocal fold polyps and Reinke’s edema; as a result it is possible to draw erroneous conclusions about patient management from this report. The confusion no doubt results from ambiguity in the laryngologic nomenclature regarding Reinke’s edema, which has been variously referred to as “polypoid corditis,” “polypoid hyperplasia,” or “polypoid degeneration” in the literature. In fact, polyps and Reinke’s edema are very different processes that do not share etiology, appearance, or, most importantly, the same potential for airway problems.
Vocal fold polyps, which are indeed “one of the most often diagnosed benign organic lesions causing voice disorder” (a feature the authors ascribe to Reinke’s edema), are likely the product of a local hemorrhage resulting from phonotrauma, or the biophysical stresses upon the vibratory tissues of the vocal fold caused by voicing. Polyps are discrete, well-localized lesions that usually appear singly or in pairs at the midpoint of the vibratory portion of the vocal fold, where the shear forces caused by phonatory vibration are the greatest (Figure 1).
Reinke’s edema, on the other hand, is a swelling of Reinke’s space, the subepithelial matrix of elastin, collagen, and other extracellular proteins that permits high-frequency mucosal vibration. It involves the entire length of one or both vocal folds (Figure 2). In contrast to polyps, Reinke’s edema results from smoking—it is simply not found in persons who have never smoked. It may represent a specialized tissue reaction to thermal insult. Although gastroesophageal reflux and heavy voice use may worsen the condition, they do not cause it. Reinke’s edema is considerably less common than polyps. It does not occur more frequently in women, but women are far more likely to seek evaluation for the simple fact that the characteristic low-pitched gravelly voice of Reinke’s edema is likelier to provoke comment in females. It is typical, for instance, for woman with Reinke’s edema to complain on presentation that she is being mistaken for a man on the telephone.
The distinction of consequence in the context of the case report of d’Hulst et al., is that although polyps and Reinke’s edema both have acoustic consequences, only Reinke’s edema is likely to have aerodynamic ones. Simply put, polyps almost never reach sufficient size to cause airway problems. Reinke’s edema frequently does. In addition, Reinke’s edema is inevitably associated with the usual smoker’s co-morbidities, including pulmonary pathology, as in the case presented. Although finesse and prudence are called for in caring for the airway of any patient with vocal fold pathology, there is no need to forego LMA ventilation in a patient with a polyp or treat the situation as if an airway problem is likely. If the diagnosis is not clear preoperatively, it is not unreasonable to ask for any patient with hoarseness to have an evaluation of the vocal folds.
Lucian Sulica, MD
Center for the Voice
Department of Otolaryngology
Beth Israel Medical Center
New York, NY
1. d’Hulst D, Butterworth J, Dale S, Oaks T, Matthews B. Polypoid hyperplasia of the larynx misdiagnosed as a malpositioned laryngeal mask airway. Anesth Analg 2004;99:1570–72.