Vocal fold hemorrhage.

A 27-year-old woman--a singer--was evaluated for a 6-week history of hoarseness that had been severe since its onset. Other complaints included cough, globus, vocal fatigue, loss of range, and an inability to sing. The patient was a trained soprano, and she had sung competitively in college. Prior to her presentation, she had been performing regularly on weekends. She usually became hoarse only once or twice a year. She took medication for reflux occasionally; she had not been taking any anticoagulants or birth control pills.

On examination, the patient's speaking voice was slightly rough and breathy, and there were breaks in pitch on sustained phonation that were worse at the higher end of her range. Videostroboscopy detected a large hemorrhage of the right true vocal fold that extended from the anterior commissure to the vocal process of the arytenoids (figure, A). The hemorrhage involved the vibratory margin. The right fold was stiff, and there was a complete loss of mucosal wave amplitude and waveform. The left fold was mildly stiff, and the mucosal wave patterns were irregular. Bilateral hemorrhagic masses were seen along the midportion of the striking zone, but no ectasias or varices were evident. Glottal closure was complete, and mild supraglottic hyperfunction was noted.

[FIGURE A OMITTED]

The patient was placed on complete voice rest for 1 week, a tapering course of prednisone, and a daily proton-pump inhibitor. After 1 week, she was allowed to speak, but not sing, under the guidance of our voice therapist. During voice therapy, she worked on decreasing excessive muscle tension, developing better voice technique for speaking, vocal hygiene, and permanent behavioral changes at home and at work that were identified as abusive.

Videostroboscopy 2 weeks after her initial visit demonstrated a complete resolution of the hemorrhage (figure, B). No stiffness was seen, and mucosal wave amplitude and periodicity were regular and symmetrical. The mass on the right showed near-complete resolution, but the left-sided mass appeared to be consistent with a small hemorrhagic polyp. The patient's speaking voice was more clear, and she continued to work with the voice therapist. She did not return to singing until the polyp was removed.

[FIGURE B OMITTED]

A rapid onset of hoarseness should raise a suspicion of vocal fold hemorrhage. Predisposing factors include traumatic vocal habits, use of anticoagulants, and hormonal issues. The voice is usually poor, and some patients are aphonic. Videostroboscopy usually identifies the hemorrhage, vocal fold stiffness, and loss of mucosal wave amplitude and waveform. Vocal fold masses and varices may also be seen.

Treatment involves complete voice rest, usually for 1 week. Many patients will spontaneously stop singing and limit their voice use because of the severity of the dysphonia. Control of predisposing factors and treatment of reflux disease, cough, or respiratory infection is also important. After 1 week, patients may undergo voice therapy and return to speaking and singing under the supervision of the voice therapist. It may take several weeks before a patient can resume singing, depending on examination findings, the effectiveness of voice therapy, and the individual patient's vocal demands. Follow-up videostroboscopy is useful in determining the effectiveness of therapy, the speed of resolution of the hemorrhage, guidelines for voice use, and the need for further intervention, including surgery. (1)

Avocal fold hemorrhage can cause fibrosis and permanent dysphonia. Early diagnosis, aggressive treatment, and possibly surgery are needed to improve the voice and prevent recurrences. Videostroboscopy is essential in the diagnosis, follow-up, and treatment of vocal fold hemorrhage.

Reference

(1.) Spiegel JR, Sataloff RT, Hawkshaw M, Rosen DC. Vocal fold hemorrhage. Ear Nose Throat J 1996;75:784-9.