Use of the Microdebrider for Reinke's Edema Surgery

Numerous terms have been used to denote the clinical entity we recognize as Reinke's edema. These terms include polypoid corditis, 1. polypoid laryngitis, polypoid degeneration, 2. and chronic hypertrophic laryngitis. 3. Reinke's edema, a condition of diffuse polypoid changes in the subepithelial compartment, has been observed as clinical entity since the introduction of the conventional laryngoscope and the origin of laryngology. Kajek 4. credited Reinke with identification of the subepithelial compartment of the vocal fold that is superficial to the vocal ligament, bounded anteriorly by Broyle's ligament, and limited posteriorly by the vocal process of the arytenoid cartilage. Hirano 5. has identified this compartment as the superficial lamina propria. Zeitels 6. noted that this compartment underlies the vibratory epithelium of the musculo-membranous vocal fold, which can be identified caudally by the inferior arcuate line. Most series have reported a much higher percentage of women with Reinke's edema; however, this probably reflects the social unacceptability of the voice quality for women, which leads to their seeking medical attention. There may also be an endocrinological aberration that has not yet been elucidated. 7. A strong association between smoking and Reinke's edema is reported, 8., 9. frequently with vocal abuse. 1., 3. Laryngopharyngeal reflux was cited recently as a potential cofactor in the development of Reinke's edema. 7., 10. The surgical management of this disorder is necessary when the voice remains objectionable to the patient. Often, the common practice of stripping the polyps away results in aphonia for many weeks after surgery, and the final voice achieved may sound unacceptably high and husky to the patient. 11. Edema reduction with minimal mucosal damage is the surgical strategy recommended for earlier and optimal return of voice. 12. The aim of this report is to present a new technique to achieve this strategy (edema reduction and minimal mucosal damage) with a new surgical tool—the microdebrider—in the surgical therapy for Reinke's edema. Surgical exposure is obtained with the suspension laryngoscope and the use of the operating microscope (original magnification × 4–6) (Fig. 1). An incision is made on the superior surface of the vocal fold. The incision is extended with upturned microscissors. Subsequently, an epithelial lateral microflap (as described by Courey et al. 13.) is raised with an elevator dissector. While this microflap is held medially with the Bouchayer heart-shaped forceps, the myxoid stroma in the superficial lamina propria is suctioned and excised using a microdebrider with laryngeal blade (Xomed, Jacksonville, FL). This procedure is carried out in a similar fashion to the technique described by Hirano et al., 12. but using the microdebrider instead of a suction tip. During suctioning, great care is taken to leave a normal or slightly increased volume of superficial lamina propria to avoid undesirable fibrosis and iatrogenic vocal fold scar (Fig. 2). For optimal results, the microdebrider should be used with low suction pressure and high blade spin-speed. In case of viscous myxoid stroma, suctioning is even easier with the use of the laryngeal microdebrider. After the superficial lamina propria is reduced in volume to the desired contour, the excessive mucosa is trimmed to allow perfect healing; then a lateral microflap is redraped into position (Fig. 3). Total vocal rest is recommended for 7 days. Operative view of Reinke's edema. Lateral microflap is raised to facilitate microdebrider resection of myxoid superficial lamina propria to desired contour. Final result after phonomicrosurgical resection with the microdebrider, which demonstrates normal vocal fold contours and epithelial edges that appose well. Five patients were included in this series. All of them were women and had a history of smoking. The patients had videoendoscopic laryngeal evaluation with stroboscopy and perceptual voice analysis in the preoperative and postoperative periods. Preoperative videoendoscopic evaluation revealed that the edema of the lamina propria was more precisely localized on the superior and medial surface of the vocal folds. All patients had symmetrical bilateral disease, three of them showed contact of vocal folds confined to the anterior two thirds of the musculo-membranous vocal folds, and two of them showed contact that extended to the posterior third. All of the patients were judged to have accompanying laryngopharyngeal reflux and were treated with inhibitor of hydrogen-potassium adenosine triphosphatase (omeprazole) for 2 months in the postoperative period. Postoperative evaluation was carried out at the sixth postoperative month. All patients had no recurrence of the edema of the lamina propria and were not smoking since surgery. This evaluation revealed close-to-normal mucosal waves in all patients regarding amplitude and phase symmetry. There was a recovery in loudness and pitch in all patients. Also, the voice changed from "rough, breathy" to a "normal, near-normal" voice. All patients were satisfied with the voice outcomes. Some authors have noted that Reinke's edema can be accompanied frequently by keratosis with atypia, although this was not observed by Zeitels et al. 7. Therefore the suctioning surgical technique is typically used to maximally preserve the glottal epithelial contours and the superficial lamina propria leading to a more appropriate volume. Resection of Reinke's edema using the microdebrider with a laryngeal blade allows the surgeon to take great care with the mucosa, superficial lamina propria, and vocal ligament. This is very important, to avoid excessive removal of disease with consequent iatrogenic adherence—scar—of the epithelial basement membrane to the vocal ligament. Also, viscous myxoid stroma of the superficial lamina propria that requires excision with cold instrumentation is more easily resected with the microdebrider. For optimal results with the microdebrider technique, it is important to use low suction pressure and high blade spin-speed, to avoid producing damage in the underlying tissues or accidentally resecting the mucosal microflap from the vocal fold. As advantages over the sucking technique, the microdebrider reduces the actual operating time and probably produces minimal damage to the lamina propria components as a result of the use of a lower suction pressure as compared with the sucking technique. The postoperative evaluation encourages the use of the microdebrider in surgery for the treatment of Reinke's edema. Although these results are from five patients only, the microdebrider technique does not appear to have any disadvantages or complications. The microdebrider with laryngeal blade is a useful tool that improves the care of the vocal fold components and makes easier the original sucking technique described by Hirano et al. 12. Further investigation comparing the efficacy of both techniques is important.