Vocal HemorrhageBlood that has leaked into the vocal fold from an injured blood vessel.
What is a vocal hemorrhage?
What does that mean?
Vocal folds are called “folds” because they are not just strings, or cords of tissue. They are many layers thick and contain very fine blood vessels within them. When the voice is used forcefully, the delicate blood vessels in the vocal cord may burst open, and leak blood into the vocal cord. Forceful voice use can include:
- singing aggressive styles (i.e., gospel, rock, etc)
- singing incorrectly (i.e., poor technique, when unwell)
- singing in poor environments (i.e., poor amplification, poor monitors, loud environment, etc)
- throat clearing
After a short time, this leakage stops but the blood remains in the vocal cord.
Imagine what happens when you fall and land on your knees. The force of this impact is significant but does not necessarily result in the tearing of your pants. Your knees, however, have sustained an injury. They turn a dark purplish color within a day of the injury. A week later, as the body heals the bruising, the area turns yellow and then returns to normal. In this scenario, your pants are like the lining of the vocal fold. They absorb some of the impact and do not tear but the delicate tissue underneath is still damaged. It forms a bruise. A vocal hemorrhage is, therefore, like a bruise of the vocal cord.
What are the symptoms?
The symptoms of a vocal hemorrhage vary according to your vocal demands.
If you are a vocational voice user (i.e., someone who uses their voice for their living, such as a singer, actor, voiceover artist, etc), you will possibly notice:
- Hearing two pitches at the same time
- Hearing a flutter in your voice
- Moderate-severe hoarseness in your voice
- Significantly decreased range (no longer hitting higher notes easily)
- Inability to sing quietly
- Inability to hold a pitch steady
- Neck pain
The most significant symptom is an acute loss of voice or vocal range. Singers often describe it as a “curtain” suddenly dropping over their voice. It is rare, if not impossible, to access your full vocal range with a hemorrhage.
Sing a five note scale in the middle of your range as quietly as you can. If this is not extremely easy (even without a warm-up), if the quality is not perfect, if your voice cracks, or if you are intentionally adjusting the notes downwards, you may have a hemorrhage.
If you are an avocational voice user (i.e., someone whose voice is not their livelihood, such as a doctor, teacher, lawyer, etc), you will possibly notice:
- Throat discomfort, pain, or tightness
- Hoarseness in your speaking voice
You will not notice blood in your spit, nor will you cough up blood.
What does a hemorrhage look like?
A hemorrhage is a bruise of the vocal cord. Therefore, there is no blood outside of the vocal cord. The blood is trapped inside. This turns the vocal cord red when it first occurs. The vocal cords should normally be white; however when blood first leaks into the vocal cord, it stains it red. Over time, as the hemorrhage heals, the body will reabsorb the blood in the cord and the color will change to a yellowish tinge and then back to its normal white color. On stroboscopy, the cord will appear stiff and may not vibrate at all. In milder cases, it may vibrate poorly.
How do I know if I have a hemorrhage?
The only way to know if your symptoms are due to a hemorrhage is to have your vocal cords examined. This requires the use of videostroboscopy by a laryngologist.
A general ENT usually cannot see if you have a polyp with the traditional scope. That is because the equipment available to most general ENTs is not sophisticated enough to get a close view of the vocal folds and their vibration.
Complications of a hemorrhage
Complications of a hemorrhage
There are complications of hemorrhages, particularly when the diagnosis is made too late. Complications include:
- Permanent hoarseness
- Painful phonation/voice use
- Loss of vocal range
How can I avoid having a complication?
Early diagnosis is the key to avoiding these complications. This means, especially for a singer, coming in for evaluation as soon as you are hoarse.
Singers incorrectly assume it is okay to be hoarse after a long performance or rehearsal. It is not normal to be hoarse at these times; hoarseness is an indication that something is wrong. Evaluation at this time is critical to ensure reversibility.
Unfortunately, people often ignore hoarseness because when they rest, it goes away. However, that is exactly the time to come in. Hoarseness that goes away usually means your vocal problem is reversible. When you find that your hoarseness never goes away, that may means it is too late and you have an irreversible vocal problem that may need surgery.
Truths & Myths
I hear conflicting things about polpys. What is the truth?
Myth: A hemorrhage means the end of my career.
Truth: Quite the opposite! When diagnosed early, hemorrhages are completely reversible and can leave no permanent injury. Early diagnosis also helps with prevention of future hemorrhages.
Myth: Hemorrhages require surgery.
Truth: Hemorrhages rarely, if ever, require surgery.
Myth: Hemorrhages are not preventable.
Truth: Hemorrhage occurs after voice overuse or misuse. If good vocal hygiene is used, you should be able to prevent a hemorrhage. Having an exam before you have a problem can detect problems with vocal hygiene or blood vessels that are at risk of hemorrhaging. You can then institute measures to prevent having a hemorrhage.
What is the treatment?
Treatment is most effective when a hemorrhage is caught early and diagnosed correctly.
This may seem simple, but without videostroboscopy, it is much more difficult.
How do you handle vocal fold hemorrhage?
The best treatment is accurate diagnosis. Any singer or voice user who notices a sudden change in their voice should seek immediate attention from a laryngologist. Rarely, a severe hemorrhage requires emergent surgery to ensure that the voice is not permanently damaged. However, more commonly, medications and voice rest are all that are required to ensure total resolution of the hemorrhage.
If voice rest is not done or if diagnosis is delayed, the patient risks permanent voice damage.
However, the patient must be evaluated to discover why the problem occurred to help prevent it from happening again.
At the Voice Division at Osborne Head and Neck Institute (OHNI), we understand that your voice is your livelihood. We take the utmost care to prevent poor voice outcomes. Your evaluation at OHNI includes:
•A complete history
•A complete physical exam of the head and neck
•Treatment planning – this usually includes voice therapy with a skilled therapist, trained in the treatment of voice disorders
This comprehensive evaluation results in the best treatment plan for you, that will help prevent you from having future problems.
Can I just see my regular doctor?
Unfortunately, few people are trained to correctly diagnose and treat voice disorders. Most doctors will simply push steroid pills on singers. This will actually make a hemorrhage worse. Each time you are hoarse, you are potentially creating irreversible damage that a regular physician cannot see.
Only a laryngologist can accurately diagnose and treat you, and help prevent you from having a worse problem.
What should I ask my doctor when I see him/her to ensure I’m getting the right treatment?
It is very difficult for a patient to differentiate a qualified voice physician from someone who calls himself a voice doctor simply because their wall is covered in artists’ head shots. Most singers rely on word of mouth, which may not lead to a true laryngologist.
You should ask your voice physician the following questions to ensure you are getting the treatment you deserve:
1.Are you board certified in ENT?
2.Are you fellowship-trained in laryngology/professional voice?
3.Do you perform videostroboscopy?
4.Do you perform the examination on your patients?*
5.When surgery is needed, do you perform the surgery yourself or are there other doctors or doctors-in-training involved?*
6.Do you accept insurance? Are your services covered by insurance?
*Often, laryngologists are located in facilities where residents or fellows (doctors-in-training) perform a large portion of the services.
Does insurance pay for a laryngologist visit?
If the laryngologist accepts insurance, your visit is usually covered. Laryngoscopy with stroboscopy is also usually covered. It is best to ask your doctor’s office billers to clarify insurance issues.