Acute vocal fold hemorrhage during sensory testing.

A 62-year-old man, an attorney, complained of hoarseness and a progressive loss of vocal volume. An asymmetric gag reflex noted on the physical examination prompted laryngeal sensory testing. Although the patient's sensory threshold to air stimulus was mildly abnormal at 5.5 mm Hg at the arytenoids, he was quite sensitive to the side of the laryngoscope contacting his epiglottis, resulting in violent coughing. During the examination, an area of hemorrhage was noted on the right vocal fold; the hemorrhage slowly dispersed along the superior surface without reaching the vibratory margin (figure). The patient was placed on voice rest for 3 days for his dysphonia. Meanwhile, his hemorrhage resolved completely without sequelae.

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If a patient is not properly prepared, stimulation around the laryngeal inlet during a fiberoptic examination or rigid transoral examination can often result in significant and violent coughing and retching. For most patients, correct patient positioning during sensory examination can limit the amount of contact a scope has with the epiglottis. Having patients sit forward with their elbows on their knees and looking up helps maintain the "sniffing position" and thereby enlarges the amount of available working space in the hypopharynx.

For a minor hemorrhage limited to the superior surface, limited voice rest and close follow-up will usually suffice. More extensive hemorrhages should be managed with voice rest for approximately 1 week and further intervention as necessary. After resolution of an acute hemorrhage, treatment of varicose vessels with the pulsed-dye laser should be considered, especially if the patient has a history of previous hemorrhage or has obvious, prominent varicosities in the area in which the hemorrhage occurred.

Robert Eller, MD; Mary Hawkshaw, BSN, RN, CORLN; Robert T. Sataloff, MD, DMA