The rupture of one or more capillaries in the vocal folds, so that blood leaks into the tissue. This vocal fold bruising occurs as a result of excessively vigorous mucosal oscillation, usually during extensive or vigorous voice use, aggressive coughing, or even a very loud sneeze, and it can make the voice hoarse or otherwise limited.
If the ruptured capillary is extremely superficial, like the capillaries seen on the white of the eye, then a “thin suffusion” kind of bruise occurs, and there is no deformity of the vocal fold margin; within a few days, the voice recovers. If the vessel is a few cell layers deeper into the fold, then a small “puddle” of blood like a micro-hematoma may collect and create a kind of “blood blister.” Although a superficial bruise resolves quickly and doesn’t seem to cause permanent damage, the “blood blister” type can become a hemorrhagic polyp and require surgery; with state-of-the-art surgery, however, the voice can virtually always be restored to its original capabilities.
Vocal fold bruise / hemorrhage (1 of 4)
Bruise, right vocal fold (left of image), estimated one week old, in combination with large polypoid vocal nodules. Note the yellowish discoloration, indicating partial breakdown of the hemoglobin (source of red color of blood) into hemosiderin as bruise is beginning to be cleared away.
Vocal fold bruise / hemorrhage, after rest and surgery (3 of 4)
Bruise was allowed to resolve, and then patient underwent vocal fold microsurgery one week prior to this examination.
Vocal fold bruise / hemorrhage, after rest and surgery (4 of 4)
Same patient, during phonation. Note the patient’s tendency to phonate with a gap between the folds, as though the vocal folds “remember” the early contact that used to require separation during voicing. This gap can be lessened through expert speech (voice) therapy.
Vocal fold bruise / hemorrhage (1 of 2)
Bruise, left vocal fold (right of image), estimated three weeks old, in combination with vocal nodules, capillary ectasia. There is likely an ectatic capillary also on the same side, within the nodule, that is the source of the leaking of blood into the tissues. When the bruise first occurred, it would have been most evident in the area of the nodule. As time passes, the central part of the bruise typically resolves first, with the last area to disappear anterior and posterior, as shown here. Note also the faint yellowish discoloration of the left fold, indicating residual hemosiderin (breakdown products of blood in tissue).
Vocal fold bruise / hemorrhage (1 of 6)
Breathing position, standard light. Notice a superficial bruise of the left fold (right of image), still very bright red. The source vessel cannot be identified with certainty here, but would be expected to be in the mid-fold, where the bruising is least evident. This is because mucosal oscillation tends to "massage" the bruise anteriorly and posteriorly, when the bruise is a thin-suffusion "wet pavement" type rather than a pocket or "puddle" of blood.
Vocal fold bruise / hemorrhage (2 of 6)
Prephonatory instant, standard light, shows that the margin of the left fold (right of image) is relatively straight. This suggests that the bruising is a very thin layer, and not a pocket of blood (as mentioned in photo 1).
Vocal fold bruise / hemorrhage (3 of 6)
Closer phonatory view, strobe light, also shows subtle elevation of the right fold (left of image), and a tiny ectatic capillary (small arrow), both of which can suggest that this person has been using the voice a lot. Left fold shows a darker linear bruise (larger arrow). After the bruising clears, perhaps it will become evident that this is in fact the ectatic capillary.
Vocal fold bruise / hemorrhage: after 2 weeks of rest (4 of 6)
After two weeks of relative voice rest, standard light. Notice the yellowish discoloration, which represents the breakdown products of hemoglobin. No obvious culprit capillary is seen. The last blood to resorb is always at the periphery from the point of origin.
Vocal fold bruise / hemorrhage: after 2 weeks of rest (5 of 6)
Strobe light, open phase of vibration. No obvious ectatic vessel is seen, except for the vessel on the non-bruised side (at arrow) that was seen in photo 3.
Vocal fold bruise / hemorrhage: after 2 weeks of rest (6 of 6)
Strobe light, closed phase, shows small margin swellings, greater on the left fold (right of image) than on the right fold. This swelling is being addressed by ongoing mild voice conservation, “on the fly” – i.e., while the person carries on with her work.
Bruise caused by violent coughing (1 of 2)
A person with violent sensory neuropathic coughing may injure the vocal folds, as illustrated by this bruise, right vocal fold (left of photo).
Closer view of bruise (2 of 2)
Closer view of bruise, with small collection of white mucus in the middle.