Objectification of the severity of Reinke's edema.

According to the severity, Reinke's edema (RE) of the vocal folds can be divided into three stages as classified by Yonekawa. We evaluated open and closed quotients of vocal folds vibratory cycles using Videostrobokymography (VSK) in a cohort of patients with RE. Parameters were measured from the anterior, medial and posterior third of the vocal folds. Mean values from RE group were OQ (0.44; 0.46; 0.52); CQ (0.56; 0.54; 0.48). Results from the whole glottis OQ and CQ in RE were: OQ=0.48 and CQ=0.52. Significant differences were found for OQ and CQ mean values as well as values measured from each third of the glottis between the control group and patients with RE. In the first Yonekawa group no statistically significant differences were found compared to the control group, but there were significant differences in the remaining two groups. The correlation between the stage of edema on the Yonekawa classification and the mean values of OQ and CQ was 70%.

[Morphologic classification of Reinke's edema through optical coherence tomography]. / Morphologische Klassifikation des Reinke-Odems mittels optischer Kohärenztomografie.

OBJECTIVE: Several classification systems for Reinke's edema have been proposed in the past, which are somewhat less than morphologically ideal. The objective of the present study is to evaluate the ability of optical coherence tomography (OCT) to attain a reproducible graduation of Reinke's edema. MATERIAL AND METHODS: In a prospective study, 30 consecutive patients underwent endolaryngeal, microsurgical resection of their Reinke's edema. Graduation was performed through OCT based on morphologic criteria, where each result was compared with that of other classification systems. RESULTS: In Reinke's edema grade I according to Glanz, a feathered pattern is found, while Reinke's edema grade II demonstrates a lacunar and Reinke's edema grade III a confluent pattern. Correlation between the different classification systems was uniformly weak and not significant. CONCLUSIONS: Due to the three different recognizable patterns, OCT qualifies as an objective and reproducible aid for the graduation of Reinke's edema and gives certain insights in its pathogenesis.

[Assessment of voice in patients with Reinke's oedemas treated with laser microsurgery]. / Ocena glosu u chorych z obrzekami Reinkego leczonych operacyjnie z uzyciem lasera CO2.

This investigation was undertaken for perceptual and acoustic analysis of voice in patients with Reinke's oedemas treated with laser microsurgery. Material of the study included 45 patients in the age of 23 to 65 presenting to Foniatric Clinic with dysphonia in Reinke's oedemas. Patients were divided into 3 groups according to Yonakawa's classification of Reinke's oedemas. All patients were treated with CO2 laser microsurgery. Voice assessment was made subiectively with GRBAS scale and objectively using multidimensional voice parameters analysis (MDVP). The examination was undertaken preoperatively and 4 weeks after operation. The results of our study show relationship between quality of voice after surgery and the stage of evolution of Reinke's oedemas according to the applied classification.

Measuring edema in irradiated head and neck cancer patients.

OBJECTIVES: Edema is a common side effect of radiotherapy for head and neck cancer. Systems have been developed to record and monitor changes that occur after radiotherapy. These lack the sensitivity to record edema in specific laryngo-pharyngeal structures. The aim of this study was to develop a rating scale to measure edema in the larynx and pharynx. METHODS: This was an exploratory study to develop a new measure, with the help of an expert panel, assessing interrater and intrarater reliability. A consensus group developed the rating scale. Eleven structures and 2 spaces were identified as areas sensitive to the development of edema. The terms no, mild, moderate, and severe were used to describe the degrees of edema. The scale was piloted and then tested for interrater and intrarater reliability on 5 speech and language therapists. They viewed 25 nasendolaryngoscopic images (23 patients who had had radiotherapy and 2 healthy volunteers). The images were rated with the scale. This process was repeated 1 week later. RESULTS: Images were taken from patients with oral, oropharyngeal, nasopharyngeal, or laryngeal cancer. All had had radiotherapy or chemoradiotherapy. All raters were experienced in viewing larynges via nasendolaryngoscopy. The interrater reliability for scoring the edema rating scale was moderate (weighted kappa, 0.54). Lower levels of agreement were found for the tongue base, valleculae, pharyngeal walls, and anterior commissure. The intrarater reliability was very good (weighted kappa, 0.84). CONCLUSIONS: The edema rating scale can be scored with very good test-retest reproducibility and moderate levels of agreement between clinicians. Modifications to the method are suggested to increase interrater reliability.

12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial.

BACKGROUND: The efficacy of corticosteroids in reducing the incidence of postextubation laryngeal oedema is controversial. We aimed to test our hypothesis that methylprednisolone started 12 h before a planned extubation could prevent postextubation laryngeal oedema. METHODS: We did a placebo-controlled, double-blind multicentre trial in 761 adults in intensive-care units. Patients who were ventilated for more than 36 h and underwent a planned extubation received intravenous 20 mg methylprednisolone (n=380) or placebo (381) 12 h before extubation and every 4 h until tube removal. The primary endpoint was occurrence of laryngeal oedema within 24 h of extubation. Laryngeal oedema was clinically diagnosed and deemed serious if tracheal reintubation was needed. Analyses were done on a per protocol and intention-to-treat basis. This trial is registered at ClinicalTrials.gov, number NCT00199576. FINDINGS: 63 patients could not be assessed, mainly because of self-extubation (n=16) or cancelled extubation (44) between randomisation and planned extubation. 698 patients were analysed (343 in placebo group, 355 in methylprednisolone group). Methylprednisolone significantly reduced the incidence of postextubation laryngeal oedema (11 of 355, 3%vs 76 of 343, 22%, p<0.0001), the global incidence of reintubations (13 of 355, 4%vs 26 of 343, 8%, p=0.02), and the proportion of reintubations secondary to laryngeal oedema (one of 13, 8 %vs 14 of 26, 54%, p=0.005). One patient in each group died after extubation, and atelectasia occurred in one patient given methylprednisolone. INTERPRETATION: Methylprednisolone started 12 h before a planned extubation substantially reduced the incidence of postextubation laryngeal oedema and reintubation. Such pretreatment should be considered in adult patients before a planned extubation that follows a tracheal intubation of more than 36 h.

The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation.

OBJECTIVE: The cuff-leak test has been proposed as a simple tool to clinically predict stridor or respiratory distress secondary to laryngeal edema following extubation. However, the true incidence of laryngeal edema in patients on long-term mechanical ventilation is uncertain. The relationship between upper airway obstruction (detected by video bronchoscopy) and the cuff-leak test value for patients with prolonged translaryngeal intubation during percutaneous dilatational tracheostomy (PDT) was investigated. DESIGN: Prospective, clinical investigation. SETTING: Intensive care unit of a university hospital. PATIENTS: Ninety-five patients with prolonged translaryngeal intubation requiring PDT were enrolled during a 12-month period. INTERVENTIONS: Cuff-leak test, PDT, video bronchoscopy. MEASUREMENTS AND MAIN RESULTS: The average duration of translaryngeal intubation was 28.1 +/- 17.6 days. The incidence of severe laryngeal edema was 36.8% (35/95). We chose 140 mL as the threshold cuff-leak volume below which edema is indicated. The rate of cuff-leak test positivity was 38.9% (37/95). The sensitivity and the specificity of the test were 88.6% and 90.0%, respectively. The positive and negative predictive values were 83.8% and 93.1%, respectively. Patients who developed severe laryngeal edema had a smaller leak volume than those who did not, expressed in absolute values (53.9 +/- 56.2 vs. 287.9 +/- 120.0 mL; p < .001) or in relative values (10.1 +/- 10.2 vs. 55.3 +/- 22.7%, p < .001). The occurrence of severe laryngeal edema was not associated with age, gender, body weight, respiratory failure due to pneumonia, duration of translaryngeal intubation, endotracheal tube diameter, Acute Physiology and Chronic Health Evaluation II score, or history of self-extubation. CONCLUSIONS: A reduced cuff-leak volume measured before PDT may signal the presence of severe laryngeal edema in patients on long-term mechanical ventilation.

Exudative laryngeal diseases of Reinke's space: a clinicohistopathological framing.

OBJECTIVE: To establish the relationship between the macroscopic and histologic diagnosis of nodules, polyps, and Reinke's edema of the true vocal folds and to propose a clearer clinical definition of them in the hope of settling the difference of opinion between otolaryngologists and pathologists. DESIGN: Retrospective study SETTING: Otolaryngology Department of "La Sapienza" University of Rome. METHODS: The pathologic reports of 203 patients subjected to direct laryngoscopy were studied. MAIN OUTCOME MEASURES: Examination of the histologic specimen of the epithelium and the chorion. RESULTS: Microscopic examination revealed a high percentage of normal epithelium both for nodules (33.79%) and polyps (40.65%). No dysplasia was observed, whereas dysplasia was present in 10 cases of Reinke's edema (7 laryngeal intraepithelial neoplasia 1 and 3 laryngeal intraepithelial neoplasia II). Five different stages of histologic progression resulted from the examination of the chorion in both nodules and polyps. CONCLUSIONS: Our suggestion is to consider polyps as "older" lesions and nodules as "younger" lesions. A polyp may be defined as an abnormal unilateral growth of vocal folds, a nodule as a bilateral growth situated between the anterior and medium third of the vocal fold, and Reinke's edema as a bilateral wound that extends to the whole of the true vocal fold.

[Vocal function in Reinke's edema--degree of the lesion and indication of the operation].

Fifty three cases of Reinke's edema were classified into 3 groups according to Yonekawa's proposed classification. Of these cases, 14 were Type I, 22 were Type II and 17 were Type III. In each case, psychoacoustic evaluation using the "GRBAS" scale and phonatory function tests (fundamental frequency, air flow rate, sound pressure level and maximum phonation time) using Nagashima PS-77 phonatory function analyzer were performed. Psychoacoustically, the voice quality before surgery was estimated moderately impaired, in general, with high grade Roughness accompanied by Asthenisity and Strainedness. Cases with more severe lesions showed much worse psychoacoustic evaluation results and severely impaired phonatoy function, but they also showed greater improvement after surgery. Phonatory function improved significantly within a month and psychoacoustic evaluation improved significantly from 1 to 3 months after surgery, though neither returned to the normal range. In conclusion, we consider that surgical therapy is appropriate in Type II and III cases, with voice therapy and cessation of smoking also necessary for good recovery.

Angioneurotic edema. A review of modern concepts.

We review the subject of angioneurotic edema with special emphasis on the more clearly defined entity of hereditary angioneurotic edema. The clinical presentations of the various forms of angioneurotic edema are discussed. Attention is directed toward the attempts that have been made to define this group of diseases in terms of their underlying biochemical mechanisms. A simplified schema of the serum complement system is presented. We conclude that only after we understand such biochemical interactions will we able to effect a more definitive form of therapy for the angioneurotic edemas.