What is the best management approach for a middle-aged female heavy smoker with Reinke's edema, who has failed conservative measures and presents with swollen and asymmetrical vocal cords, undergoing Microlaryngoscopy (MLB)?

From the Guidelines

For a middle-aged female heavy smoker with Reinke's edema who has failed conservative management and is undergoing microlaryngoscopy with biopsy (MLB), the best approach would be option C: superior cordotomies and aspiration. This technique involves making small incisions in the superior surface of the vocal folds and aspirating the accumulated fluid (gelatinous material) that causes the characteristic swelling in Reinke's edema. The provided evidence from 1 suggests that surgery is reserved for benign vocal fold lesions when a satisfactory voice result cannot be achieved with conservative management, and the voice may be improved with surgical intervention. Key considerations for this approach include:

• Preserving the vocal fold mucosa while removing the edematous material
• Offering the best balance between symptom relief and voice preservation
• Avoiding unnecessarily aggressive procedures like complete stripping (option A) that could lead to permanent voice changes
• Limiting deep biopsies (option B) to suspicious areas only to prevent damage to the vocal ligament
• Avoiding the microdebrider (option D) due to its higher risk of removing normal tissue along with the edematous material Following the procedure, the patient must commit to smoking cessation as continued smoking will likely cause recurrence, as highlighted in 1 which notes the association between smoking and an increased risk of polypoid vocal fold lesions. Voice therapy post-procedure will help optimize vocal outcomes, aligning with the guideline's emphasis on conservative management and the importance of addressing underlying etiologies to prevent postsurgical recurrence of lesions 1.

From the Research

Treatment Options for Reinke's Edema

The patient in question has Reinke's edema, which is a condition characterized by the accumulation of fluid in the vocal cords, often caused by smoking. Given that the patient has already tried conservative measures and is undergoing Microlaryngoscopy and Bronchoscopy (MLB), the following treatment options can be considered:

• Strip: This option involves removing the affected tissue, but there is no direct evidence in the provided studies to support this approach for Reinke's edema.
• Deep biopsies of biggest bits: Biopsies can be taken to confirm the diagnosis, but this option does not address the treatment of the condition itself.
• Superior cordotomies and aspiration: This option is not directly mentioned in the provided studies as a treatment for Reinke's edema.
• Microdebrider: The use of a microdebrider for the treatment of Reinke's edema is supported by a study 2, which found that microdebrider excision of subepithelial vocal fold lesions, including Reinke's edema, is feasible and can result in improved voice quality.

Microdebrider Procedure

The microdebrider procedure involves the use of a small blade to excise the affected tissue, and has been shown to be safe and effective in various studies 3, 4, 5, 6. The procedure can be used to treat a range of conditions, including benign and malignant lesions, and can be performed under general anesthesia or sedation.

Advantages of Microdebrider

The microdebrider procedure has several advantages, including:

• Precise and rapid removal of lesions
• Minimally invasive
• Low risk of complications
• Can be used to treat a range of conditions, including benign and malignant lesions
• Can be performed under general anesthesia or sedation, as seen in studies 3, 4, 6