Vocal Abuse Injury

Vocal abuse injury is damage to the vocal folds caused by excessive, forceful or incorrect use of the voice. It includes vocal fold nodules, polyps, mucosal haemorrhage and traumatic oedema.

• Risk groups are teachers, preachers, singers, vendors, call centre workers and children who shout.
• Contributing factors are poor technique, dehydration, smoking, alcohol, reflux, noisy environments and upper respiratory infection.
• Vocal fold haemorrhage after strain is an emergency for the professional voice.

Hoarse, breathy or strained voice, reduced pitch range, loss of high notes, throat ache, and a sudden voice loss after shouting in haemorrhage.

• Examination with a laryngoscope shows bilateral vocal fold nodules at the junction of the anterior third and middle third, a unilateral polyp, or a red haemorrhagic fold.
• Differential diagnosis: viral laryngitis, laryngopharyngeal reflux, vocal fold cyst, vocal fold paralysis, papilloma, leukoplakia, carcinoma, muscle tension dysphonia, hypothyroidism.
• Complications: chronic hoarseness, vocal fold scarring, fibrosis, permanent dysphonia, occupational loss.

Laryngoscopy confirms the injury.

• Flexible or rigid laryngoscopy, preferably with stroboscopy to assess vibration.
• Voice history, occupation, vocal load, smoking, alcohol and reflux symptoms.
• Biopsy for any white patch or non healing lesion.

Reduce vocal trauma and retrain the voice; surgery is a last step.

• Supportive: complete voice rest for 5 to 7 days after haemorrhage, then graded return; hydration with 2 litres of water daily; steam; avoid whispering, shouting and throat clearing; stop smoking and alcohol; amplification in noisy settings.
• Pharmacological: omeprazole 20 mg twice daily for 8 weeks if reflux is present; prednisolone 30 mg daily for 5 days for acute oedema in a professional voice user with an urgent need, after laryngoscopy; paracetamol for pain. Avoid aspirin and NSAIDs for 2 weeks after haemorrhage.
• Procedures: voice therapy with a speech and language therapist, 6 to 8 sessions over 8 weeks; microlaryngoscopic excision of polyps or persistent nodules after therapy fails.
• Special groups: children, behaviour change and voice therapy, surgery rarely; singers, coaching in technique; pregnancy, avoid systemic steroids.
• Red flags: hoarseness beyond 4 weeks without cause, stridor, haemoptysis, neck mass, a white patch on a fold, dysphagia.
• Follow-up: review at 4 to 6 weeks with repeat laryngoscopy; return to full voice use only after healing.