Pathology of the Head and Neck

208 N. Gale · A. Cardesa · N. Zidar7abFig. 7.5. Reinke’s oedema. a Diffuse oedematous swelling in theentire length of both vocal cords. b Diffusely oedematous, bluecolouredsubepithelial stroma is lined with hyperplastic squamousepithelium with thickened basement membrane. Epitheliumshows hyperplasia of basal and parabasal cells7.5.1.1 Reinke’s OedemaReinke’s oedema is a chronic, diffuse, mainly bilateral,oedematous swelling of the membranous part of thevocal cords [177]. Several synonyms for RO have beenused, such as polypoid vocal fold, polypoid degeneration,chronic polypoid chorditis and chronic oedematous hypertrophy[320]. The specific morphologic features ofReinke’s space , such as sparse lymphatic drainage andits sharply demarcated borders, except the lateral one,contribute to the development of RO [158, 177, 179, 308,309]. Various mechanical and chemical aetiologic factorsare related to the development of RO , including overuseor abuse of the voice, and cigarette smoking . The role ofconstitutional and hormonal disturbances such as hypothyroidism,remains uncertain [32, 177, 308, 395]. Thelesion appears most commonly in women of 20–40 yearsof age with hoarseness as the leading symptom.Laryngoscopically, the surface of the swollen vocalcords along their entire length is smooth, translucentand jelly-like, with a clearly visible capillary network.Incision yields a characteristic yellowish or gelatinousfluid (Fig. 7.5a) [177, 226].Histologically, an excessive accumulation of oedemais a leading microscopic feature. Increased thickness ofthe walls of the teleangiectatic blood vessels, and thickeningof the epithelial basement membrane completethe classical triad of morphologic changes. The sulphatedglycosaminoglycans are probably responsible for thecharacteristic blue-coloured abundant amorphous materialin the subepithelial stroma in haematoxylin andeosin (H&E)-stained slides (Fig. 7.5b) [238]. Fragilityand alterations in the walls of blood vessels, such asthin endothelium with many fenestrae and vesicles, andthickened basement membrane, revealed by electronmicroscopy, are considered important in the developmentof RO [320]. Connective tissue proliferation, especiallywith aging of the lesion, makes the lesion irreversibleunless surgical removal is provided. Changes in thecovering squamous epithelium of all three exudative lesionsare expected to be only reactive (squamous cell hyperplasia,basal and parabasal cell hyperplasia) and mayturn with aging and enlargement of the lesions into atrophicepithelium. Exceptionally, 12 (1.7%) patients withpotentially malignant lesions (atypical hyperplasia, andLIN I and II) were found in a review of two comprehensivestudies. No malignant alteration was reported withinthese two studies [177, 226].In the early stage, only voice rehabilitation and avoidanceof irritating factors should be attempted. However,microlaryngoscopic excision is required in the great majorityof cases. Following surgery, voice therapy is oftenindicated [32, 177, 386].7.5.1.2 Vocal Cord Polypand NoduleVocal cord polyp (VCP) and vocal cord nodule (VCN)are fairly common benign reactive lesions, causally relatedto phonotrauma and vocal abuse [85, 175, 177, 181,194, 308]. The distinction between a VCP and VCN is