Obstructed at the Cords: Reinke Edema Leading to Post-Extubation Respiratory Failure

Introduction: Reinke’s edema is a rare, benign, inflammatory vocal folds disorder with a prevalence of less than 1%. Though classically presenting with dysphonia, its presence can profoundly complicate airway management, predisposing patients to post-extubation laryngeal edema and potential respiratory failure.


Description: A 64-year-old female with gastroesophageal reflux disease (GERD) and an extensive smoking history was admitted with multiple rib fractures after a mechanical fall, complicated by progressive hypoxia requiring intubation. On hospital day three, she was extubated but rapidly decompensated with stridor and agonal breathing, unresponsive to racemic epinephrine and dexamethasone, necessitating urgent reintubation with a smaller endotracheal tube (ETT). Given difficult extubation with concern for airway edema, bedside flexible fiberoptic laryngoscopy by ENT revealed polypoid swelling of the true vocal cords with incomplete closure, intra-arytenoid and false cord edema, and supraglottic inflammation. These findings, in the setting of chronic GERD and smoking, raised suspicion for Reinke’s edema as a contributing factor. She was continued on steroids with gradual clinical improvement and successful extubation with follow-up laryngoscopy confirming resolving edema, improved supraglottic appearance, and near-complete vocal cord closure.


Discussion: Reinke’s edema, a known risk factor for post-extubation laryngeal edema manifesting as stridor and rapidly progressing to respiratory failure, is often underdiagnosed until airway management becomes challenging. Although linked to smoking, phonotrauma, and laryngopharyngeal reflux, smoking remains the most significant risk factor. Increased awareness of Reinke’s edema in high-risk patients, particularly chronic smokers, can guide preventive strategies such as the use of smaller ETT, performing pre-extubation airway assessment via direct visualization or cuff leak testing, and administering intravenous corticosteroids. These measures, along with optimized airway management, can help mitigate peri-extubation complications. In cases where post-extubation respiratory failure develops, definitive airway management with prompt reintubation, systemic steroids, and nebulized epinephrine administration remains the standard of care.