The larynx is, of course, a living, moving structure, which consists of muscles, ligaments, membranes and cartilage—all tissues that need blood to function. Blood vessels are everywhere, supplying those structures. You may not see them because they are very small or because they run under the surface—but they are there, bringing food and oxygen and carrying away waste products while your larynx is busy pumping out an aria.
Not uncommonly, some superficial vessels may become visible. Typically, after a performance, and even the following day, the vocal fold may be a little red, as those tiny blood vessels are working away, cleaning up after last night’s concert.
If you have been performing a lot over the years, a blood vessel may remain persistently visible on the upper surface of the vocal fold. Again, not a problem—simply the result of the many miles you’ve put on your larynx. These vessels typically run lengthwise, parallel to the vibrating margin, and are somewhat lateral to the vibrating margin. Apart from taking note, nothing usually needs to be done. But you should be aware, in case a doctor not used to the appearance of your larynx misinterprets this as a new finding. It’s all fine—just a normal variant.
Rarely, some of these vessels become enlarged and stretched. They may appear wider and tortuous, like a small varicose vein. Again, as long as they are away from the vibrating margin, you should be okay—although, sometimes, as they become engorged with prolonged vocal effort, they may change the mass or weight of the vocal fold. Clinically, these singers present with a complaint that the voice is fine when they first start to warm up, but becomes hoarse after 20–30 minutes of singing. The varicose vessel, now distended and filled with blood due to the back pressure created by vocal effort, can affect the vibratory characteristics of the vocal fold. This is less common than the just visible vessel discussed above, but if it becomes a clinical problem, it should be treated.
At times, we see vessels that seem to run not parallel to the long axis of the vocal fold, but perpendicular to it. They seem to originate laterally and run across the fold, toward the free margin. They may show some zigzagging or even branching. These are definitely abnormal and are new vessels that have grown in response to some injury or inflammation on the vibrating edge. Although they may not require any treatment, you should discuss with your doctor how they may have arisen. Neovascularization such as this is always abnormal and should not be ignored.
Now, for those problematic blood vessels. Any vessel, no matter how small, can be a problem if it arises at or near the vibrating edge of the vocal fold. This area, called by some laryngologists “the strike zone,” is the area of repeated contact and microtrauma during phonation. Some of these vessels, especially if they are superficial, may rupture over time, causing a vocal fold hemorrhage and hoarseness. On the other hand, other vessels may remain in this location for years with no bleeding and only minimal hoarseness (when you sing soft and high), due to the slight irregularity in contour of the vibrating vocal fold edge.
So what causes vessels to bleed? Excessive trauma is one trigger. Singing loud and long, especially when you are not adequately hydrated, engorges the vessels—and if the mucous membrane is also dry, the vessel may rupture. The vessels can also be more enlarged when there is increased blood flow to the area, as with an upper respiratory infection. If the blood is thin (meaning not able to properly coagulate), bleeding is again more likely. This occurs during menstruation and also with some anti-inflammatory medications such as aspirin or ibuprofen.
So a “perfect storm” scenario would be that you have an upper respiratory infection but have to push and sing through it. You are also having your period, with cramps, and are taking ibuprofen to control the pain. And you’re not drinking enough water on top of it all! While the coincidence of all these is not common, it does occur, and you need to be careful if you have been diagnosed with a blood vessel—which by virtue of size, location, or other characteristics—is at risk for rupture.
Should blood vessels on the vocal folds be treated? Not always. As you can see, some vessels are harmless and not symptomatic. However, there are specific situations when the vessel should be removed or obliterated.
The following list should give cause for concern:
∙ Large varicose vessels which get engorged and cause hoarseness. The wall of a varicose vein is often not normal and may be thinned, putting you at increased risk for hemorrhage. If you become repeatedly and predictably hoarse after vocal effort, removing such a vessel may be helpful.
∙ Vessels at or near the vibrating margin of the vocal fold. As mentioned above, these are at greater risk for rupture, and proper treatment can eliminate the constant stress of having to worry about oversinging and underhydrating.
∙ Vessels that have ruptured before. If you have a history of recurrent vocal fold hemorrhage, it makes sense to get rid of the cause, especially if this is clearly visible. The confounder in such cases is that the offending vessel is not always visible—it may arise on the undersurface of the vocal fold and (rarely) from underlying deeper tissues.
There are a number of ways of getting rid of blood vessels on the vocal folds, including a variety of lasers and even microdissection, if the vessel is particularly prominent and superficial. The surgeon’s task is to use a highly targeted approach that gets rid of the vessel only, with minimum effect on surrounding healthy tissues. The current trend in this regard is the use of lasers that use light waves with a particular affinity for blood pigment.
In summary, while every blood vessel should be noted, not every blood vessel on every vocal fold needs treatment. Treatment should be limited to situations where the vessel causes problems, has been the source of problems in the past, or has a high likelihood of rupturing in the future. Your best position in this regard is to know the appearance of your larynx when it is “normal” and to continuously monitor your vocal status. If there is a significant change in either, and a cause-and-effect scenario makes sense, that is the time for a discussion with your laryngologist.
