A Case of Reinke’s Edema Causing Difficult Extubation

SESSION TITLE: Student/Resident Case Report Poster - Critical Care III SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Reinke's edema, also called polypoid chorditis, is a chronic accumulation of fluid in the subepithelial layer of the true vocal cord mucosa. It is an uncommon lesion of the vocal cord known to cause potential complications during airway management. We report a case of acute on chronic respiratory failure secondary to acute exacerbation of COPD in the setting of Reinke's edema which lead to a very difficult extubation. CASE PRESENTATION: 53 years old female with PMH of chronic respiratory failure secondary to COPD on home oxygen presented with worsening shortness of breath, wheezing and inspiratory stridor. She had history of chronic cough and hoarseness of 6-month duration. She was requiring increasing oxygen as compared to baseline and was in severe respiratory distress. Nasopharyngolaryngoscopy (NPL) showed true vocal cord swelling with no obvious obstruction. She was intubated for airway protection with a size six endotracheal tube. She was treated with intravenous antibiotics and intravenous steroids for COPD exacerbation and laryngeal edema. She also received racemic epinephrine and bronchodilators. Her COPD exacerbation responded appropriately. However, multiple attempts at spontaneous breathing trial failed due to absence of cuff leak. CT scan of the neck with contrast showed upper airway edema with no visible mass. She was eventually extubated after 10 days. NPL was repeated post-extubation which revealed fluid filled boggy edema of the mucosa overlying the true vocal cords, arytenoids and aryepiglottic folds. These findings were consistent with Reinke's edema which was the cause of her stridor and difficult extubation in our patient. DISCUSSION: Reinke’s edema, commonly seen in female gender, often presents with hoarseness and gradual deepening of voice. Risk factors include smoking, gastro-esophageal reflux disease and vocal cord abuse. It can cause inspiratory stridor in severe cases and can complicate airway management causing difficulties with intubation or extubation. Reinke’s edema may explain why even minimal laryngeal edema can cause clinically significant airway obstruction in some patients. Treatment for Reinke’s edema involves elimination of risk factors and if this fails, surgery may be required in rare cases. In the event of difficult airway management and presence of risk factors for Reinke’s edema, an otolaryngology consultation and CT scan of the neck should be undertaken. CONCLUSIONS: Reinke’s edema is an important, underdiagnosed cause of difficult extubation and post-extubation stridor. Management is supportive including risk factor modification in most cases. Reference #1: Cortegiani A, Russotto V, Palmeri C, Raineri SM, Giarratano A. Previously undiagnosed Reinke edema as a cause of immediate postextubation inspiratory stridor. A A Case Rep. 2015;4(1):1-3. DISCLOSURE: The following authors have nothing to disclose: Siddharth Shah, Sumendra Joshi, Anil Ghimire No Product/Research Disclosure Information