Reinke's Edema (Smoker's Voice)

What Reinke's edema is

Each vocal cord has a thin, loose layer just beneath its surface called Reinke's space. This layer lets the surface ripple freely as air passes, which creates the voice. In Reinke's edema, years of irritation damage the small blood vessels in this layer, and thick, gelatinous fluid collects in it. The vocal cords become heavy and swollen, almost like water-filled balloons.

Heavier vocal cords vibrate more slowly, which lowers the pitch of the voice. The swollen surface also vibrates irregularly, making the voice rough. In severe cases the swelling fills enough of the airway to cause breathing problems. It usually affects both vocal cords, though often one more than the other.

Reinke's edema differs from vocal cord nodules, which are small, firm bumps from voice overuse, and from a vocal cord polyp, which is usually a single lesion on one side.

Causes and risk factors

• Smoking: the main cause. The vast majority of people with Reinke's edema are or were heavy, long-term smokers. Smoke inflames the vocal cord lining and damages its blood vessels.
• Acid reflux: stomach acid reaching the throat (laryngopharyngeal reflux) adds to the irritation. See GERD.
• Heavy voice use: shouting, singing or talking a lot, especially while smoking.
• Hypothyroidism: an underactive thyroid can cause vocal cord swelling.
• Age: usually diagnosed between 40 and 60.

It is noticed more often in women, partly because the drop in pitch from a higher natural voice is more obvious.

Symptoms

• a deep, low-pitched, husky or gravelly voice, often called a "smoker's voice"
• hoarseness that has developed gradually over months to years
• voice that tires quickly or needs more effort
• a reduced pitch range, especially difficulty reaching high notes
• a feeling of something in the throat, and frequent throat clearing
• in severe cases, noisy breathing, breathlessness on exertion, and worse snoring or sleep apnea

How it is diagnosed

An ear, nose and throat specialist (ENT) or laryngologist will:

1. Ask about smoking, reflux, voice use, thyroid problems and how long the voice has changed.
2. Look at the vocal cords with a thin, flexible camera passed through the nose (laryngoscopy), usually in the office with numbing spray.
3. Perform videostroboscopy, a strobe-light exam that shows how the vocal cords vibrate in slow motion.
4. Check thyroid function with a blood test if needed.
5. Arrange a biopsy under anesthesia if any area looks suspicious, such as white patches (leukoplakia) or irregular growths.

Reinke's edema is benign, but smokers have a higher risk of laryngeal cancer, and early cancer can hide within swollen tissue. US guidelines advise a laryngoscopy for hoarseness lasting more than 4 weeks, or sooner if cancer is suspected.

Treatment

Stop smoking

Quitting is the most important step. It halts progression and can reduce mild swelling, although established swelling rarely disappears fully on its own. If you have surgery and keep smoking, the swelling usually returns. Free support is available at 1-800-QUIT-NOW in the US, along with nicotine replacement and prescription medicines.

Voice therapy

A speech-language pathologist teaches healthier voice habits, reduces strain and helps protect the vocal cords. Therapy is useful before and after surgery.

Treat contributing factors

• acid-reducing medicine and lifestyle changes for reflux
• thyroid hormone for hypothyroidism
• staying hydrated and limiting alcohol and caffeine

Surgery

For persistent hoarseness, breathing problems or suspicious areas, surgeons perform microlaryngoscopy under general anesthesia. Using a microscope, they make a small cut along the top of the vocal cord, suction out or trim the gelatinous material, and lay the surface lining back down (the microflap technique). This preserves the delicate covering needed for a good voice. When both sides are very swollen, the surgeon may treat one side at a time.

After surgery:

• A few days of voice rest are usually recommended, then a gradual return to talking with voice therapy.
• The voice usually becomes clearer and higher-pitched over several weeks.
• Some people, particularly those who liked their deep voice, are surprised by the change, so discuss expectations beforehand.

Outlook

Reinke's edema is not life-threatening in itself. Surgery combined with stopping smoking usually gives a lasting improvement in voice. Continued smoking leads to recurrence and keeps cancer risk high. Regular follow-up is recommended for people who continue to smoke.

Frequently asked questions

What is Reinke's edema?

It is swelling of both vocal cords caused by jelly-like fluid collecting in a thin layer under their surface called Reinke's space. It makes the voice deep, rough and husky. It is almost always caused by long-term smoking and is sometimes called smoker's voice or polypoid corditis.

Is Reinke's edema cancer?

No. Reinke's edema is a benign, non-cancerous swelling. However, the smoking that causes it also raises the risk of throat cancer, and swelling can hide early cancer. That is why anyone with long-lasting hoarseness should have their vocal cords examined.

Will my voice return to normal if I stop smoking?

Stopping smoking prevents the swelling from getting worse and can help mild cases improve. Larger, long-standing swelling rarely resolves completely without surgery. Quitting is still essential, because it makes surgery more successful and prevents the swelling from returning.

Is surgery for Reinke's edema worth it?

For people with persistent hoarseness, voice fatigue or breathing problems, microsurgery usually improves voice quality and raises the pitch. It also allows any suspicious tissue to be examined. Results last best when combined with stopping smoking and voice therapy.

Why does Reinke's edema make a woman's voice sound male?

The swollen vocal cords are heavier, so they vibrate more slowly and produce a lower pitch. A woman's voice can drop into the typical male range, which is why callers may mistake her for a man. Treatment usually raises the pitch again.