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Hemorrhage

Hemorrhage

What is vocal fold hemorrhage?

“Hemorrhage” means bleeding. In the vocal fold, hemorrhage refers to bleeding into the superficial lamina propria, the layer that guarantees the pliability of the vocal fold for vibration (see Normal Voice Function). Because this layer is made up of a network of loosely-arranged of fibers, blood spreads throughout it quickly and affects it so that the vocal fold does not vibrate as well. It does not take a lot of blood to cause a vocal fold hemorrhage, so this kind of bleeding is in no way a risk to a person’s overall health or life.

Hemorrhage is the result of phonotrauma, the physical stresses caused by voicing, upon the tiny blood vessels of the vocal fold. These may rupture and bleed after loud voicing, after sustained voicing, or when they 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 (the singular is varix) may also predispose to hemorrhage.

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.

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Figure 1: The whole left vocal fold (right in the picture) has turned deep red from a hemorrhage.

What are the symptoms of vocal fold hemorrhage?

Hemorrhage causes hoarseness which usually develops over a very short period of time. It is typical for a hemorrhage to happen as a result of a specific event that required strenuous voice use, like a musical performance, or speaking over the noise at a party or cheering at a baseball game. The hoarseness may be obvious in the speaking voice, or it may be more subtle, and cause only a change in the singing voice. There is no pain associated with a hemorrhage, and no difficulty swallowing or breathing.

What does vocal fold hemorrhage look like?

Because the bleeding takes place under the mucosa , the blood has no way out of the vocal fold and spreads throughout the loose tissue layer of the superficial lamina propria. The blood can turn patches of the vocal fold red, or extend throughout the whole fold. Over time, as the blood resorbs, it undergoes the same changes as a bruise, turning darker red to brown and eventually fading. Repeat bleeds often leave a yellowish hue to the vocal folds from by-products of blood resorption.

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Figure 2: This image shows a resolving vocal fold hemorrhage on the left vocal fold (right in the picture), visible as a darker blush of resorbing blood, in a patient with bilateral pseudocysts. A varix (the red dot), or dilated blood vessel, is visible in the pseudocyst and is probably the source of the bleeding.

A small polyp or a dilated blood vessel – known as a varix – may be visible, and give a clue as to the reason for repeat hemorrhage.

How is vocal fold hemorrhage treated?

A hemorrhage which involves the entire vocal fold should be treated with immediate voice rest. Voice use should be limited or entirely suspended for several days. The exact length of time can be determined by repeat examinations. Steroids should not be used to “mask” the effects of a hemorrhage in order to press ahead with a performance, for instance. It is an invitation to further injury.

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Figure 3: This woman lost her voice after an amateur musical theater performance 1 week before being seen. Her hemorrhage resolved entirely after voice rest. She had no further difficulty.

Voice rest alone is adequate treatment for a single, isolated hemorrhage. Repeated hemorrhage, on the other hand, always has an underlying cause, be it a harmful voice behavior or an irregularity on the vocal fold. In the first case, voice therapy may be useful, and in the second, microlaryngoscopy may be necessary to remove or repair any small irregularities or blood vessels prone to bleeding. This is among the more delicate surgeries in laryngology.

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