How Common is Hoarseness?

At some point, we all have suffered from a hoarse voice whether from illness or from yelling. However, it was unclear exactly how common this malady is until now... and apparently, the answer is "very common"...

According to a study looking to answer this question, hoarseness affected 17.9 million adults in 2012.   The average age was 49 years old and 63% were women. Overall, 10% saw a health care professional for their hoarseness and 40% were given a diagnosis.

Infectious laryngitis was the most common diagnosis mentioned (685±86 thousand cases, 17.8±2.0%). Gastroesophageal reflux disease was mentioned in 308±54 thousand cases (8.0±1.4%).

33% reported their voice problem to be a significant problem. Bad enough that the mean number of days the hoarseness lasted was about 56 days. Because of the hoarseness, patients missed work about one week in the past year.

A general rule of thumb is to see your local ENT if the hoarseness lasts more than 1 week. Intervention can be performed to minimize the duration of hoarseness as well as to alleviate the morbidity associated with this problem.

Another general rule of thumb is to minimize using your voice if it becomes unexpectedly hoarse.

Reference:
The prevalence of voice problems among adults in the United States. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24740.

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How Long Do Swallowing and Voice Problems Last After C-Spine Surgery ACDF?

I often see patients for swallowing and/or voice difficulties after cervical spine surgery (ACDF). In the vast majority of cases, reassurance that such "side effects" are not uncommon is the only thing I need to provide after a complete exam.

After all, both the voice box and swallowing tube are manipulated and pushed over to one side in order to perform cervical spine surgery from an anterior approach. Check out the video below that illustrates how this happens.

Beyond reassurance, the next question patients have is how long before things go back to normal. Until now, that was a hard question to answer.

A recent report was able to provide some numbers I can now use to help explain to patients. After anterior approaches to cervical spine surgery:

• 60% had a postoperative issue, including 27% with postoperative voice complaint and 48% with postoperative swallowing complaint
• Swallowing complaints that lasted beyond 1 year occurred in 28%
• Voice complaints that lasted over 1 year occurred in 9%
• Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors that significantly resulted in voice and swallowing problems

In certain patients with more extreme swallowing difficulties, barium swallow studies may be ordered. Swallow therapy can be helpful as well.

Should vocal cord paralysis be seen on endoscopy, voice therapy and even vocal cord medialization injections can be performed to alleviate voice problems.

Reference:
Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine. Otolaryngol Head Neck Surg. 2013 Dec 23. [Epub ahead of print]

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Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking. The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

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Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

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Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

Image by Marcin Mycielski from Wikipedia

Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Source:
Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13

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Pop Singer Nathan Sykes Undergoes Vocal Cord Surgery

Nathan Sykes, singer for the boy band The Wanted, underwent vocal cord surgery on April 18, 2013 for a "hemorrhaged nodule" according to media reports.

Rather than a nodule, I am suspecting he actually suffered from a hemorrhagic polyp which makes more medical sense. And along with surgery... he is now on voice rest for an indefinite period of time.

This condition is the same reason Adele underwent vocal cord surgery in 2011 which mandated a several month period of voice rest leading to cancelled concerts.

Typically, a hemorrhagic polyp is treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, much more aggressive approaches can be pursued in order to recover the voice as quickly as possible.

For professional singers like Nathan Sykes and Adele, the desire to have a restored voice as soon as possible is understandable. However, there are always downsides.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Nathan's case (presumably), the vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to phono-trauma or even hormones especially in females. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

It is unknown what exactly happened in Nathan Syke's case.

But, in Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued and probably what happened with Nathan Sykes as well. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Source:
The Wanted's Nathan Sykes Taking 'Unforeseen Hiatus'. MTV News 4/17/13

The Wanted say they 'fear' for Nathan Sykes' voice. BBC News 4/29/13

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Arena Stage 'My Fair Lady' Laid Low by the Flu with Performance Cancellations

It has been an early and bad start to the flu season in the DC metro area. It is just the beginning of the traditional 3 month flu season and flu numbers have already exceeded last year's.

Although professional singers may feel they should have a special exemption from this debilitating illness which also adversely affects the voice, it is not to be...

The flu has literally crippled performances of "My Fair Lady" at the Arena Stage this season with two show cancellations and another possible show cancellation this past Saturday Jan 5, 2013 when both the lead singer AND understudy were unable to perform due to laryngitis. It was not just the lead singer out with the flu, but also 3 other parts which fortunately did have understudy coverage. [more]

However, rather than canceling the show, the show did go on with the lead role being performed by a member of the regular ensemble with script in hand and only a few hours of rehearsal.

Sounds like an episode of the TV show "Smash," but apparently the ensemble singer Hannah Willman did spectacularly well.

I'm also sure Arena Stage breathed a sigh of relief not just for the standing ovation, but also because it was the show's last weekend.

Source:
‘My Fair Lady’ replacement shines at Arena Stage in an unforgettable evening. Washington Post 1/6/13

Flu spreading earlier, faster than usual this season. Washington Post 1/6/13

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Singer Nicki Minaj with Strained Vocal Cords

Media has reported that pop star Nicki Minaj had to cancel upcoming concerts in England due to injured vocal cords.

She apparently saw a doctor who diagnosed "strained vocal cords" after an x-ray and recommended voice rest for a few days.

The singer apparently ignored this advice and sang in New York City on Aug 18 causing her voice to substantially worsen resulting in her decision to cancel her concerts this weekend.

Details of her vocal cord condition are sparse. However, based on the limited information provided, there's a few things I can guess at.

First off, an x-ray can NOT diagnose any type of vocal cord condition. The singer must have undergone a trans-nasal endoscopic procedure which is the ONLY way to visualize the vocal cord and diagnose any vocal problems.

Given the singer was instructed to rest her voice for "a few days," she most likely suffered from a mild acute laryngitis causing inflamed vocal cords. By ignoring advice to rest her voice, she potentially turned a mild laryngitis into a more severe laryngitis. She probably did not suffer from any physical problems on her vocal cords like nodules or polyps which would take weeks if not months to recover (not days) as happened to singers Adele and John Mayer.

Really, at this point, strict voice rest, hydration, acid reflux control, and steroids (ie, prednisone) would enable her to recover her normal voice ASAP.

Here's a picture of a severe laryngitis (left) compared a normal appearing vocal cords (right). Note that the vocal cords are swollen and red compared to normal pearly white and thin appearance.

 

Source:
Nicki Minaj cancels U.K. concerts due to strained vocal cords. NBC News 8/18/12

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Singer Florence Welch Cancels Concerts Due to Vocal Injury

CBS news reported that Florence Welch, the lead singer for British band Florence + The Time Machine, had to cancel two upcoming concerts due to a vocal injury.

Florence Welch (@flo_tweet) herself provided most of the details in a series of tweets today:

July 11, 2012 @ 11:15AM : hello everyone, thankyou so much for all your messages of support, yes its true..it finally happened, I've lost my voice..:(

July 11, 2012 @ 11:18AM : I've sustained a vocal injury and been told i cannot sing for a week.., seriously i felt something snap, it was very frightening.

July 11, 2012 @ 11:20AM : unfortunately this means i will not be able to perform at Benicassim and Optimus alive festival this weekend..i am so so sorry..

Florence used the words "felt something snap" which is pretty classic for a vocal hemorrhage. For those who are Adele fans, something similar happened to her as well in November which mandated a prolonged period of voice rest (months) and even resulted in vocal cord surgery. (read more)

I am guessing that Florence had a blood vessel on her vocal cords that was causing minimal vocal impact. But with the "snap," the blood vessel likely ruptured causing instant vocal decompensation whereby the vocal pitch suddenly becomes much deeper and if bad enough, even complete voice loss as it appears to have happened to Florence.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this which is what Florence's vocal cords prior to the "snap" might have looked like:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. If it is small, the changes may be non-existent. If it is more pronounced, the vocal instability may be noticeable and for a singer, it may make the voice very unpredictable.

When the blood vessel becomes engorged and traumatized (singing forcefully, screaming, coughing), it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle (typically right before period).

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully which increases chance of vocal cord hemorrhage. Rupture (even in the middle of a performance) results in hemorrhage into the vocal lining itself causing a sudden and complete loss of voice (see picture to right). There may even be mild pain associated with this occurrence. This is the "snap" sensation Florence felt.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly. If significant hemorrhage is present, the vocal cord may not even be able to vibrate causing vocal loss.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp if present.

In Florence's case where she was told to be on strict voice rest for only one week, I suspect no polyp is present. Just hemorrhage.

If polyp is present, surgical intervention may be required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

Source:
Florence Welch told not to perform "to avoid permanent damage" to voice.  CBS News 7/11/12

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R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

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TV Show SMASH Portrays Ivy With Vocal Issues

In last night's episode (Episode 106: Chemistry) of the new hit TV drama SMASH, the main character Ivy who plays Marilyn Monroe in the show developed laryngitis that affected her ability to sing clearly, especially in the high registers. However, her speaking voice did sound normal.

To treat this condition, she was given prednisone which did help her voice, but suffered unfortunate side effects of mood lability, hallucinations, insomnia, etc.

Did the show accurately portray what actually happens in real life?

Yes...

Laryngitis

Ivy probably did suffer laryngitis, but more in the sense of pre-nodule formation (otherwise known as vocal cord swelling) from vocal overuse given how much singing she has been doing. With such "pre-nodule" formation, the singer is able to sound perfectly normal when talking, but suffers from pitch breaks and onset delays in the high range, especially when singing quietly. Watch a video and audio demonstrating this phenomenon.

I should also point out that this problem is also under-recognized by medical professionals including ENTs... When such singer/patients with vocal cord swelling present complaining of hoarseness, they sound normal... talk normal... and for all intensive purposes seem to be making up their perceived raspy voice.

A simple test to demonstrate vocal cord swelling is to have the singer sing a song at a high pitch (octave above middle C), but to sing the song very quietly. I typically have patients sing Happy Birthday. Listen for any vocal quality problems.

Even though the vocal issue is only in the high range, for professional (and amateur) singers, such "minor" vocal raspiness is a HUGE problem. Consider this... if this patient is singing a solo for a performance where there's several hundred people in the audience... it's hard enough to sing a solo just from nervousness. Now add the concern that you have no idea what your voice is going to do in that one part of the song where it goes high. Confidence is key to a good performance and with an undependable voice, confidence is lost and the performance overall suffers.

Prednisone

Is prednisone really as good as the show suggests? Yes... including the side effects, though they did stretch the side effects some.

Typically steroids provide almost immediate (within 4-12 hours) resolution of vocal cord swelling and inflammation. Problem is, it only works for a short period of time.

I typically prescribe decadron rather than prednisone as I feel it works faster, better, and more reliably than prednisone. I also prescribe it judiciously.

Judiciously means I prescribe it if there's a single major concert or single audition that is very important to the singer. I typically prescribe a single large dose to be taken the night before.

If it is a singer who is undergoing a series of auditions over a short period of time, I may prescribe a week long course of steroids to maintain its good effects.

The USUAL common side effects are reflux, insomnia, mood lability, and jitteriness. However, for those who are sensitive to medications can suffer many of the side effects experienced by Ivy.

NOW... for the problem with steroids beyond the side effects... Its effects are temporary and the better way of treating vocal cord swelling is behavioral changes as one can't just keep prescribing steroids indefinitely. It is much like giving morphine to a football player to mask the pain of a sprained ankle so he can still keep playing football. MORE vocal injury can occur while taking the steroids!

With steroids, I usually also recommend restricted voice use (strict voice use is even better). What this means is talk ONLY when you MUST talk and with low energy if you do. NO social talking, no whispering, no yelling, no raising voice, etc. Strict voice rest is when you are not even talking at all.

Also, work with a singing voice therapist.

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Adele Speaks About her Vocal Cord Surgery on 60 Minutes

When it was first reported that Adele was undergoing vocal cord surgery in October 2011, there was much speculation regarding what exact vocal cord pathology she suffered from (hemorrhage? polyp?) and what type of vocal cord surgery she underwent for correction (laser? cutting?).

During her 60 Minutes interview with Anderson Cooper which aired on February 12, 2012, many details regarding her vocal cord problems have clarified.

She apparently suffered from a vocal cord polyp with hemorrhage.

Typically, this problem is normally treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, she pursued a much more aggressive approach in order to recover her voice as quickly as possible.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Read the 60 Minutes interview here.

Of note, she later went on to sing a stellar performance at the Grammy Awards debuting her new voice for the first time after her surgery.

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Singer Adele Has Vocal Cord Hemorrhage and to have Surgery

At least that's what the LA Times reported on Oct 28, 2011. And supposedly will be having surgery to treat it in the near future.

Before going any further, the title to the LA Times story was "Adele to have surgery to treat vocal cord hemorrhage. What is it?"

I sincerely hope that whomever her surgeon is knows not to perform surgery when the vocal cord is in the middle of a hemorrhage. You do the surgery when the hemorrhage is gone and the culprit blood vessel is left behind which likely is the reason for the hemorrhage happening in the first place.

What do I mean?

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the LA times story here.

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