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Vocal Cord Bruising (Hemorrhage)

Vocal cord bruising is caused by the rupture of one or more capillaries in the vocal cords, so that blood leaks into the tissue. This 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 cord margin; within a few days, the voice recovers. If the vessel is a few cell layers deeper into the cord, then a small “puddle” of blood like a micro-hematoma may collect and create a kind of “blood blister.”

Treatment

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.

A Vocal Cord Bruise that Could Happen to Anyone

While capillary ectasia (as seen in other photo series here) markedly increases vulnerability to vocal cord bruising, every human vocal cord has capillaries on its service, and even normal capillaries can leak and cause a bruise with sufficient vocal trauma.  In this person, with an aggressive cough, her normal capillaries are the source of the bruise.

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Bruised Vocal Cord

Bruised Vocal Cord (1 of 2)

View from a distance, showing a bruise of the right cord. But is there a vulnerable (ectatic) capillary that explain this bruise?
Bruised Vocal Cord

Bruised Vocal Cord (2 of 2)

At closer range, the normal capillaries are seen; there is no dilated capillary to explain the bruise. This bruise could happen to anyone, with sufficient vibratory (loud voice) or cough trauma.

Vocal Cord Bruises (Hemorrhage) often Initially Obscure the Ectatic Capillary “Culprit”

A person can experience sudden hoarseness at a time of sustained heavy voice use, or even immediately following a “scream,” or even a loud sneeze. The explanation might be a bruise of a vocal cord. This can happen to anyone but is far more likely if the person has underlying capillary ectasia.

When a bruised vocal cord is seen, therefore, the question is: “Is this a fluke bruise that can happen to anyone, or is it one explained by capillary ectasia?” In this instance, the answer is yes to capillary ectasia.

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Bruised Vocal Cord

Singer’s Bruised Vocal Cord (1 of 8)

In this singer, bilateral margin swellings are seen, but the right cord (left of photo) is bruised. Sometimes we must wait to see the culprit capillary or capillaries. Here, we can already suspect that this is the explanation (from following photos) since the bruise is a few weeks old and the blood in tissue partially resorbed.
Bruised Vocal cord under Strobe Light

Bruise under Strobe Light (2 of 8)

Strobe views (giving us apparent slow-motion vibration) help us see the margin elevations more clearly.
Abnormal Capillary

Abnormal capillary (3 of 8)

At very close range, the suspicion of an abnormal capillary is confirmed. But will it be there when the bruise is completely gone?
Bruise is gone

Bruise is gone (4 of 8)

Several weeks later, the bruise is indeed gone, and the vulnerability-inducing capillaries are seen clearly in this distant view.
Capillaries under narrow band light

Capillaries under narrow band light (5 of 8)

At close range under narrow band light, the capillaries come into full view. Notice one small capillary also on the left cord margin (right of photo).
Capillaries touch during phonation

Capillaries touch during phonation (6 of 8)

Phonatory view again reveals the margin swellings bilaterally, but with the ectatic capillaries in the point of maximum vibratory contact, where they increase the risk of another bruise.
Post-surgical repair

Post-surgical repair (7 of 8)

After surgical repair of the ectasia and margin swellings (distant view), open for breathing.
Margins match

Margins match (8 of 8)

Also after repair, voicing position showing again absence of the capillary ectasia and much better match of the margins. Upper voice is restored; vibratory flexibility is normal even at very high pitch.

Vocal Cord Bruise / Hemorrhage, Before and After Rest and Surgery

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Vocal cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (1 of 4)

Bruise, right vocal cord (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 cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (2 of 4)

Same patient, during phonation.
Vocal cord bruise / hemorrhage, after rest and surgery

Vocal cord bruise / hemorrhage, after rest and surgery (3 of 4)

Bruise was allowed to resolve, and then patient underwent vocal cord microsurgery one week prior to this examination.
Vocal cord bruise / hemorrhage, after rest and surgery

Vocal cord 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 cords, as though the vocal cords “remember” the early contact that used to require separation during voicing. This gap can be lessened through expert speech (voice) therapy.

Vocal Cord Bruise / Hemorrhage

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Vocal cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (1 of 2)

Bruise, left vocal cord (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 cord, indicating residual hemosiderin (breakdown products of blood in tissue).
Vocal cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (2 of 2)

Same patient during phonation under standard light.

Vocal Cord Bruise / Hemorrhage, Before and After Rest

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Vocal cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (1 of 6)

Breathing position, standard light. Notice a superficial bruise of the left cord (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-cord, 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 cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (2 of 6)

Prephonatory instant, standard light, shows that the margin of the left cord (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 cord bruise / hemorrhage

Vocal cord bruise / hemorrhage (3 of 6)

Closer phonatory view, strobe light, also shows subtle elevation of the right cord (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 cord shows a darker linear bruise (larger arrow). After the bruising clears, perhaps it will become evident that this is in fact the ectatic capillary.
after 2 weeks of rest

Vocal cord 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.
after 2 weeks of rest

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.
After 2 weeks of rest

After 2 weeks of rest (6 of 6)

Strobe light, closed phase, shows small margin swellings, greater on the left cord (right of image) than on the right cord. 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 Cough

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Closer view of bruise

Bruise caused by violent coughing (1 of 2)

Closer view of bruise, with small collection of white mucus in the middle.
Bruise caused by violent coughing

Closer view of bruise (2 of 2)

A person with violent sensory neuropathic coughing may injure the vocal cords, as illustrated by this bruise, right vocal cord (left of photo).

Bruising from Sensory Neuropathic Cough

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subglottic bruise

Bruising from SNC (1 of 1)

This individual occasionally coughs to the point of hoarseness. Particularly noteworthy is the subglottic bruise (arrow, dotted line) caused by profound Valsalva-retching kind of coughing. The rest of the right cord (left of photo) is also bruised.

Vocal Cord Bruising From Coughing

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bruising over the vocal processes

Bruise from coughing (1 of 3)

This man had an episode of aggressive coughing a week earlier. Note the bruising over the vocal processes, which receive the major collisional force during coughing.
Pre-phonatory instant

Pre-phonatory instant (2 of 3)

The vocal processes are approaching the point of touching (contact would occur gently with onset of talking and more aggressively with coughing).
moderately-severe vocal cord bowing

Phonation (3 of 3)

Vocal cords are now in full contact. Note the unrelated moderately-severe vocal cord bowing.

The Evolution of Vocal Cord Bruising and Emergence of a Vulnerable Capillary

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Margin swelling and bruising

Margin swelling and bruising (1 of 2)

This professional woman is extraordinarily dynamic and intense, and must talk all day to do her work. Here, the right vocal cord (left of photo) is bruised due to vibratory trauma. The margin swelling on the right causes her hoarseness more than the bruising, however.
Six weeks later

Six weeks later (2 of 2)

Six weeks later, the bruise is mostly resolved. The capillary that “leaked” blood to form the bruise is now seen more clearly (long arrow). This ectatic capillary can be seen easily now when looking back at photo 1. The short arrows indicate the residual “smudges” of discoloration caused by breakdown products of the bruise. The last evidence of widespread vocal cord bruising is always in these two locations.

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Vocal nodules & other voice injuries YT Thumbnail

Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated

This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.

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