Vocal Fold Hemorrhage

Overview:

The vocal folds are composed of many layers of thick tissue which contain blood vessels within them. A vocal fold hemorrhage is when the superficial lamina propria, or the layer of the vocal fold under the mucosa that makes the vocal folds pliable and able to vibrate well, suffers a bleed. When the voice if used forcefully, blood vessels in the superficial lamina propria may burst open and cause blood to leak into the vocal fold. As the superficial lamina propris is made of a network of fibers that are arranged loosely, blood spreads throughout this layer quickly and affects it greatly. This causes swelling. The result of a vocal fold hemorrhage is that the vocal fold will not vibrate as well as before the bleed. 

A vocal fold hemorrhage is not life-threatening, as it does not require a large amount of blood to cause it. The leakage of blood will stop after a short period of time, but the blood will remain the the vocal fold longer due to the fact that the bleeding has taken place under the mucosa and therefore has no way out of the vocal fold.

Normally, the vocal fold should be a white color. With a vocal fold hemorrhage, however, the blood can turn patches of the vocal fold red. Additionally, the red color may extend throughout the whole fold. Over time, as the blood resorbs, it undergoes the vocal fold will experience the same changes as a bruise, turning darker red to brown. Eventually it will fade and return to the white color. However, repeated hemorrhages often leave a yellowish tint to the vocal folds due to the by-products of blood resorption.

Cause:

A vocal fold hemorrhage is caused from phonotrauma, or the physical stresses caused by using the voice, often inappropriately. Phonotrauma can result from the following behaviors:

• Singing aggressive styles of music, e.g., gospel & rock
• Singing incorrectly, e.g., with poor technique or when one is sick
• Singing in poor environments, e.g., with poor amplification or in a loud environment that may cause the singer to use an excessively loud volume
• Throat clearing
• Excessive coughing
• Shouting

The small blood vessels of the vocal fold endure this stress and may rupture after loud voicing or sustained voicing. This may also occur when the blood vessels are more fragile than normal, as when they are swollen during laryngitis. Small irregularities, like tiny polyps or weak areas in the blood vessel wall called varices, may also predispose someone to vocal fold hemorrhages.

Hemorrhage may be a one-time event, or it may recur. In situations of repeated bleeding, the vocal folds should be examined very carefully for other abnormalities.

Symptoms:

Hemorrhage causes hoarseness which usually develops over a very short period of time, typically as a result of a specific event that required strenuous voice use, e.g.,  a musical performance, speaking over the noise at a party, or cheering at a baseball game. The hoarseness may range in severity: it may be obvious in the speaking voice, or it may be more subtle, and only be evident in the person's singing voice. Additionally, one may experience vocal fatigue.

People who use their voice for a living, such as a singer or actor may experience the following symptoms:

• Diplophonia, or producing two pitches at the same time
• Hearing a flutter in the voice
• Significantly decreased range of pitch
• Inability to speak or sing quietly
• Inability to hold a steady pitch, or frequent pitch breaks
• Neck pain

The following symptoms are not associated with a vocal fold hemorrhage:

• Pain
• Difficulty swallowing
• Difficulty breathing 
• Blood in your saliva
• Coughing up blood

If you have been diagnosed with a vocal fold hemorrhage and experience any of these symptoms, speak with your doctor, as you may need to be re-evaluated to examine other possibilities. 

Diagnosis:

If you are experiencing symptoms that suggest a vocal fold hemorrhage, your vocal folds must be examined using videostroboscopy by a laryngologist.

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view. 

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

The laryngologist will look for the following signs of a vocal fold hemorrhage:

• Patches of red on the vocal fold
• Entire vocal fold that is red in color
• Yellow-ish tint of the vocal folds due to the by-products of blood resorption 
• Reduced or no vocal fold vibration

It should be noted that a general Ear, Nose, and Throat doctor (ENT) cannot determine the cause of your symptoms, as their traditional scope is not sophisticated enough to get a close-up view of the vocal folds and their vibrations.

Treatment:

Medical:

Anticoagulant medications may be prescribed in instances where the bleeding has not yet stopped, as the bleeding itself should be a short-term problem. Any conditions which may have predisposed a patient to vocal fold hemorrhage, such as excessive cough or reflux disease, should be treated with the appropriate medications.

Vocal Rest:

Vocal rest is a basic behavior change which gives the vocal folds some time off from phonation in order to allow for healing of a temporary condition like vocal fold hemorrhage to occur. It should be noted, however, that vocal rest does not address the underlying problems that may be causing the vocal fold hemorrhage.

Vocal rest can range in terms of the amount of voice use that is allowed. Total vocal rest refers to no voice use at all, including whispering. Relative vocal rest refers to voice use that may be limited in terms of amount, volume, or under what conditions one may speak (e.g., not in noisy environments where increased volume is often necessitated).

Vocal rest is beneficial when it is used for a period of 1-2 weeks. Longer periods of vocal rest do not provide any additional benefit and may in fact only mask the problem and delay the start of potentially-beneficial treatment.

Voice Therapy:

Because vocal fold hemorrhages are often caused by phonotrauma, voice therapy with a speech and language pathologist is important to modify the vocal behaviors that caused that phonotrauma in the first place. Voice therapy may target the following vocal behaviors:

• Avoid hard glottal attacks
• Use easy-onset vocal patterns
• This includes using a reduced rate of speech, coordinated breathing and phonation, light articulatory contacts, and easy & relaxed phonation 

Surgery:

Surgery is only recommended for the following reasons:

• Hemorrhages that are recurrent
• Enlargement of the lesion
• Development of an associated mass
• Intolerable dysphonia
• Acute hemorrhages that may result in the formation of a hemorrhagic polyp

Preoperative:

Patients should be evaluated by indirect laryngoscopy and videostroboscopy. During this examination, the following will be examined:

• Vocal fold mobility
• Glottic closure
• The presence, amplitude, and symmetry of the mucosal wave. 

Any concurrent medical conditions that may affect the voice such as reflux disease, laryngitis, and allergic rhinitis should be evaluated and treated prior to surgical intervention. In addition, the stage of the menstrual cycle in women is important in order to gauge the severity and timing of intervention. This is because the size of the blood vessels in the vocal folds often increase and become more fragile in the premenstrual period: approximately 5 days prior to menstruation.

All known sources of mechanical trauma should be reduced prior to considering surgical therapy to determine reversibility of the vocal fold hemorrhage and to hopefully prevent recurrence post-surgery. This is accomplished in part by medical and speech therapy. See the Medical and Voice Therapy sections for more information. Surgery is reserved for vocal fold hemorrhages that show no reversibility with exhaustive medical and speech therapy.

Intraoperative:

Surgical technique begins by identifying the feeding and emptying vessels, which are then photocoagulated sequentially with a laser. Some lasers that are typically used are: 

• Carbon dioxide lasers
• Specific photoangiolytic lasers
• A KTP (potassium titanyl phosphate)
• A 585 nm pulsed dye laser 

At this point, depending on the size of the primary lesion, it is either removed using a microflap approach or photocoagulated to stop the bleeding. If it is removed, the goal is to preserve the mucosal layer of the vocal fold with minimal disruption to the underlying tissue. Scar formation should not be a factor in many instances. The use of iced saline and/or a topical epinephrine solution can be beneficial in controlling the hemorrhage limiting the spread of thermal injury beyond the immediate area being treated surgically.

Another surgical option is the direct excision of the hemorrhage by using cold steel phonomicrosurgical techniques and instruments.

Postoperative:

Patients will be placed on strict vocal rest for 2 weeks after microflap surgery. Patients with more extensive excisions may be placed on a short course of corticosteroids to reduce swelling. All patients receive antibiotics and a mild narcotic for pain relief. 

Patients with symptoms or findings of laryngopharyngeal reflux are treated medically. 

Aspirin and nonsteroidal anti-inflammatory agents should be avoided during the first 2 weeks following surgery.

Follow-Up:

Reexamine patients at 2, 4, 8, and 12 weeks following surgery. At the 2-week postoperative visit, videostroboscopy will be performed to examine the vocal folds and evaluate the patient's progress. At the two-week mark, the patient resumes therapy with a speech pathologist. The physician will discuss a plan to gradually return to vocal use with the patient, and this typically occurs over the first few weeks following surgery. Singers may begin to work with a singing coach after 1 month. 

Most patients can expect 90% of their functional surgical result after approximately 3 months.

Complications:

Complications of vocal fold hemorrhages typically arise when a diagnosis is made too late, and can include the following:

• Permanent hoarseness
• Scarring
• Pain during phonation
• Loss of vocal range

To ensure that these complications are avoided, early diagnosis is imminent, especially if you use your voice for your occupation, e.g., singers. Often times, singers assume that hoarseness is to be expected following intense vocal usage, however this is not normal and is an indication that something is wrong. Further more, hoarseness usually resolves following vocal rest, making it seem insignificant. However, it is important that a singer see their doctor at this time, as temporary hoarseness is an indication that the vocal problem is reversible. Once one realizes that their hoarseness is not going away, it may mean that an irreversible vocal problem is present which may require surgical intervention. 


Some complications can arise from surgical intervention. These may include the following:

• Tongue numbness
• Altered taste
• Oropharyngeal, mucosal, and dental injuries
• Loss of mucosal wave 
• Glottal insufficiency. 

References:

Postma GN, Courey MS, Ossoff RH. Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol. Jun 1998;107(6):472-6. 


Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.


Hochman I, Sataloff RT, Hillman RE, et al. Ectasias and varices of the vocal fold: clearing the striking zone.Ann Otol Rhinol Laryngol. Jan 1999;108(1):10-6. 


Ivey CM, Woo P, Altman KW, et al. Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study. Ann Otol Rhinol Laryngol. May 2008;117(5):353-8. 


Burns JA, Friedman AD, Lutch MJ, Zeitels SM. Subepithelial vocal fold infusion: a useful diagnostic and therapeutic technique. Ann Otol Rhinol Laryngol. Apr 2012;121(4):224-30. 


Franz P, Aharinejad S. The microvasculature of the larynx: a scanning electron microscopic study.Scanning Microsc. Mar 1994;8(1):125-30; discussion 131. 


Frenzel H, Kleinsasser O. Ultrastructural study on the small blood vessels of human vocal cords. Arch Otorhinolaryngol. 1982;236(2):147-60. 


Hsiung MW, Kang BH, Su WF, et al. Clearing microvascular lesions of the true vocal fold with the KTP/532 laser. Ann Otol Rhinol Laryngol. Jun 2003;112(6):534-9. 


Lin P, Stern JC, Gould WJ. Risk factors and management of vocal fold hemorrhages. J Voice. 1991;5:74-7.

http://www.rightdiagnosis.com/v/vocal_cord_hemorrhage/intro.htm

http://www.voicemedicine.com/hemorrhage.htm

http://www.gbmc.org/home_voicecenter.cfm?id=1564