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Small Hemorrhages: So Now What?

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

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About Amy Chapman

Amy Chapman MA, CCC-SLP is a vocal therapist and performance specialist in the Division of Voice and Laryngology at the Osborne Head and Neck Institute in Los Angeles, CA. Amy is a board-certified Speech & Language Pathologist who has dedicated her career to helping the professional voice user improve and optimize their voice.

In a prior article, we discussed how small undetected hemorrhages will eventually lead to a larger vocal injury. The overarching question here, though, is now what? How do we use this information to change our behavior?

Technique

There is no question that good speaking and singing technique will reduce the risk of vocal injury. A good vocal coach and vocal therapist will help to guide you along this road. Your vocal coach will help with singing technique and a good vocal therapist will make adjustments to speaking and singing technique as well as address muscular issues.

Management of medical problems

Early evaluation by a laryngologist ensures vocal risk factors are addressed. Most importantly, vocal fold varices (dilated blood vessels) that form due to overuse or misuse can be identified with videostroboscopy. These will often produce no symptoms but are the precursors to small hemorrhages that may eventually lead to nodules, polyps, cysts, or other vocal injuries.

Early treatment of varices

When varices are identified, these can be treated before they hemorrhage. Varices usually occur on the edges of the vocal folds, at the points of contact, because this is where the majority of voice use force occurs. Therefore, they are at highest risk to rupture because they will get repeatedly hit during voice use.

vocal-hemorrhage-treatment

When a small hemorrhage is identified, or even before it occurs, a safe procedure can be performed to eliminate the varices. The recovery is short and easy and this is a low-risk procedure. This is in direct contrast to the procedure that would be required for nodules, polyp, or cyst removal. The recovery here is longer and the procedure itself is riskier. This is a simple equation of prevention rather than cure and the old aphorism holds true: An ounce of prevention is worth a pound of cure.

Figure: This opera singer noted vocal fatigue. Screening stroboscopy demonstrated a varix that had not formed a lesion but was very dilated. We opted for preventative laser treatment. Two weeks later, the vessel is gone and fatigue is resolved.
Figure: This opera singer noted vocal fatigue. Screening stroboscopy demonstrated a varix that had not formed a lesion but was very dilated. We opted for preventative laser treatment. Two weeks later, the vessel is gone and fatigue is resolved.

The road to eventual surgery for nodules, a polyp, or a cyst is what has been seen for artists such as Meghan Trainor, Adele, and Sam Smith. There is a series of missed engagements and cancelled shows before the micro-hemorrhages lead to a larger injury. The surgery for the larger injury results in a longer recovery. The less risky, preventative route allows for a predictable time course and fewer (if any) missed engagements.

Figure: Varices that lead to a large polyp due to repeated small hemorrhages that were not detected with a scope in the nose by a prior ENT.
Figure: Varices that lead to a large polyp due to repeated small hemorrhages that were not detected with a scope in the nose by a prior ENT.

The road to vocal success for a performer is strenuous and it is unfair to attribute injury to technique issues or health issues alone. Back-to-back performances in multiple cities will cause strain. A simple cold may be all that it takes to push a performer into forming a small hemorrhage. Worse still, this hemorrhage may be impossible for the singer to sense. The only symptoms may be fatigue, which is also a natural occurrence when touring or performing heavily.

Being realistic about the toll that demand takes on the voice is the first step to effective treatment. When we focus on the preventative side of vocal injury, with an early check with a laryngologist, early intervention for problems, and rehabilitation, the outcomes are improved and the downtime is lessened. These steps may be the best way we know how to help singers manage the intense demands of a successful career.

To learn more about Dr. Reena Gupta or voice evaluation and treatment, please visit www.voicedoctorla.com.

Contact a Physician at Osborne Head & Neck Institute

If you would like to speak with one of our physicians regarding this issue or another ear, nose, throat problem; or have other questions or concerns, please complete the contact form below or call us at 310-657-0123.

Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.
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