Vocal Fold Haemorrhage

Vocal fold haemorrhage is submucosal bleeding from a ruptured vessel in the superficial lamina propria, creating a haematoma that distorts the fold and abolishes vibration.

• Precipitants: vigorous phonation (shouting, singing at high intensity, screaming, forceful coughing), Valsalva manoeuvre, vomiting, upper respiratory infection with cough, and premenstrual hormonal vascular changes.
• Risk factors: pre-existing vocal fold varix or ectatic vessels, anticoagulants (warfarin, DOACs, heparin), antiplatelets (aspirin, clopidogrel), NSAIDs, high dose vitamin E, fish oil, ginkgo, bleeding disorders, hypertension, and chronic reflux.
• It is a vocal emergency in professional voice users because it can cause lasting scarring if mismanaged.
• Healing may leave a polyp, scar, or recurrent varix.

• Sudden loss of voice or severe hoarseness during or immediately after a phonatory event, sometimes with a feeling of a "pop" or giving way.
• Voice is breathy, weak, with loss of the upper register and reduced volume.
• Mild throat discomfort or pain; the patient is otherwise well and the airway is normal.
• Bleeding may be recurrent in the same fold if a varix is present.

• Laryngoscopy shows a red or purple, localised or diffuse swelling of one fold (sometimes both), often involving the entire membranous length, with bruising that may spread to the false fold.
• Videostroboscopy (done once the voice is safe to examine): absent mucosal wave over the haematoma, reduced amplitude, and glottic gap. Stroboscopy should be performed with minimal strain.
• Identify risk factors: medication history including anticoagulants, antiplatelets, and herbal agents, bleeding history, and menstrual timing.
• Investigations when indicated: full blood count, prothrombin time/INR, activated partial thromboplastin time, and a coagulation screen if no mechanical cause is found.
• Differential diagnosis: acute laryngitis, vocal fold polyp with haemorrhage, and, rarely, submucosal tumour.

• Conservative management is first line and most haemorrhages resolve:
  • Strict absolute voice rest (no talking, no whispering) for 7 to 10 days, with written or text communication; the patient should avoid coughing and throat clearing by sipping water or swallowing.
  • Cough suppression if cough is present: dextromethorphan 15 mg to 30 mg orally every 6 to 8 hours or codeine linctus 15 mg orally every 6 hours when necessary.
  • Humidification and hydration of at least 2 litres of water daily.
  • Review and, where safe, stop or adjust aspirin, NSAIDs, and herbal supplements that increase bleeding. Do not stop anticoagulants or antiplatelets for mechanical stents or atrial fibrillation without agreement from the prescribing physician; if anticoagulation continues, keep INR in the lower therapeutic range.
  • Treat reflux with omeprazole 20 mg to 40 mg once daily.
  • Systemic corticosteroids are sometimes given for 3 to 5 days (prednisolone 30 mg to 40 mg orally daily, or 0.5 mg/kg to 1 mg/kg) in professional voice users to limit oedema, although evidence is limited.
  • Avoid performing, singing, and loud speech for 2 to 4 weeks, with graded return only after stroboscopic confirmation of resolution.
• Follow up: stroboscopy at 1 to 2 weeks and again at 4 to 6 weeks to confirm resorption and the return of a mucosal wave. Resolution usually occurs over 1 to 3 weeks.
• Surgical intervention is indicated for a haematoma that persists beyond 4 weeks, recurrent haemorrhage at the same site, a persistent organised lesion (polyp or varix), or progressive stiffness. Procedures include microlaryngoscopic evacuation through a small superficial incision with preservation of the mucosa, excision of a feeding varix, or photoangiolytic laser (pulsed dye or KTP) to ablate abnormal vessels.
• Voice therapy after resolution for return to safe voice use.
• Complications: scar and fibrosis with persistent dysphonia, recurrent haemorrhage, polyp formation, and a vocal fold varix.
• Prevention: voice hygiene, hydration, warm up before performance, treatment of cough and reflux, and avoidance of unnecessary antiplatelet or anticoagulant agents in patients with a known varix.