Vocal injury in singers can trigger a great deal of fear and uncertainty. A sudden change in the voice during or after a performance may raise the specter of a career-ending injury in the mind of the singer, and a voice that does not recover in due time can directly impact a singer’s livelihood. Much of the misgivings surrounding vocal injuries are attributable to a lack of accurate medical information on the nature of vocal injuries, how they are treated, and real-world outcomes. Several papers in the recent scientific voice literature shed light on these issues and may alleviate the singer’s concerns.

Vocal injury can consist of acute or chronic vocal fold hemorrhage or take the form of lesions that develop due to voice trauma (phonotraumatic vocal fold lesions). In the past, vocal fold hemorrhage was regarded as unforgiving for a singer’s career prospects. While seeing blood on the vocal folds of a singer is understandably anxiety-provoking, evidence contradicts the conventional association of hemorrhage with catastrophe. Kerwin et al. showed that while singers with hemorrhage were more likely to miss days of work due to the voice problem compared to those without hemorrhage, hemorrhage had no significant long-term impact in singers and should be considered a temporary problem that can be managed with conservative measures.

Phonotraumatic vocal fold lesions can take the form of nodules, polyps, pseudocysts, and some types of cysts. Nodules are bilateral nearly-symmetric opaque lesions in the mid-vocal folds and occur more commonly in females than males. Most nodules will respond to voice therapy, and surgery is rarely necessary. Polyps can be translucent or hemorrhagic and vascular. They occur more in men than in women, and large ones can cause severe dysphonia. Pseudocysts are thin, blister-like lesions on the vocal fold edge. They are most often only found in female singers and rarely in men. Cysts are the most rare form of phonotraumatic lesions. In fact, there is uncertainty as to whether they are actually caused by voice trauma.

A question of great concern to a singer with a vocal injury is whether surgery will be necessary. Some recall the story of the much beloved Julie Andrews, whose legendary singing career ended with an ill-fated vocal surgery that would not be considered medically appropriate today. Modern microsurgical techniques for phonotraumatic vocal fold lesions are meant to maximally preserve the precious vocal fold vibratory tissue (vocal fold cover) that surround or underlie the lesions. While no surgery can guarantee perfect restoration of a singing voice, most singers do recover and return to performance, often with the help of a voice therapist with the appropriate expertise and experience working with singers.

The Childs et al. study provides another reassuring statistic. In one of the largest studies of its kind, Childs et al. showed that in over 400 singers with phonotraumatic injuries, only 1 out of 7 injured singers required surgery. About half of the singers who developed polyps eventually underwent surgery, 37% of those with cysts, and 22% of those with pseudocysts. The percentage of singers with pseudocysts who underwent surgery was higher in a different study by Estes and Sulica, at 37%. The take-home message is the same: Most injured singers will recover with the appropriate voice therapy without the need for surgery.

These findings can be used for evidence-based counseling and guidance for the injured singer, the treating laryngologist, and the voice therapist in a concerted treatment program.

References

Childs LF, Rao A, Mau T. Profile of Injured Singers: Expectations and Insights. Laryngoscope. 2022 Nov;132(11):2180-2186. doi: 10.1002/lary.30015. 
Estes C, Sulica L. Vocal Fold Pseudocyst: Results of 46 Cases Undergoing a Uniform Treatment Algorithm. Laryngoscope. 2014 May;124(5):1180-6. doi: 10.1002/lary.24451. 
Kerwin LJ, Estes C, Oromendia C, Christos P, Sulica L. Long-term consequences of vocal fold hemorrhage. Laryngoscope. 2017 Apr;127(4):900-906. doi: 10.1002/lary.26302