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 therapyprior 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.
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.
In the same spirit of a recent TEDMED talk by Nate Bell and re-published on CNN Jan 12, 2012 whereby he performed various beatboxing noises while stroboscopy was performed, I decided to record a similar video with a person performing various unusual human vocalizations to see what happens.
For those who don’t know what stroboscopy is, click here.
Such vocalizations recorded included various types of human screams and a yodel.
Researchers in Iowa have discovered what makes a lion or tiger roar so effectively. Apparently, there is a layer of fat within large feline vocal cords that makes the vocal cords especially prone to vibrate easily with minimal exhalation effort.
What import does this have to humans?
Well, there are patients who have a very weak voice due to vocal cord atrophy as well as vocal cord paralysis. Standard interventions include voice therapy as well as surgical procedures using an implant or injectable material in order to “bulk” up the vocal cord.
In fact… one such injectable material that has been used to inject into vocal cords is fat, typically taken from the belly of the patient!
Two points to keep in mind however…
Just like in lions and tigers, it DOES improve the vocal strength and volume to a patient who previously had a weak voice, may now have a much stronger voice after the procedure.
However, the second point is that by making the vocal cord “bulkier” you are making it thicker which can decrease the vocal pitch… just like a violin string where the thicker the string, the lower the pitch.
On another related note… human infants have fat within their vocal cords… that may be why something so small with tiny lungs can produce such a terrific loud cry!
Read a story in the NYT regarding this research here.
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.
Here is a picture of a vocal cord hemorrhage. Note the entire vocal cord on the left (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). Another type of laser that may be used is a KTP laser.
Read more about laser treatment of vocal cord pathology here.
In September 2011, grammy-award winning singer John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.
Last week on Thurs, Oct 20, 2011, he underwent surgery to remove the granuloma and is now on strict voice rest for several weeks.
Though removal sounds like a great idea, vocal cord granulomas are notoriously difficult to eliminate completely as they have a high risk of recurrence. Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential. However, it is not unusual that steroid injections to the granuloma site as well as even botox injection to partially and temporarily paralyze the vocal cord may need to be pursued for complete resolution.
Surgical removal of the granuloma may have looked something like this video…
There are MANY theories as to how vocal cord cysts, polyps, and nodules form. However, one theory that seems to make the most sense to me deals with how the vocal cord heals after a traumatic event (ie, screaming, yelling, coughing, etc).
With a cyst, the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the vocal cord lining. Vocal cord nodule for comparison’s sake is just callous thickening of the vocal cord lining that occurs over time.
To use human skin as an analogy…
A vocal cord cyst is like a sebaceous cyst that commonly occurs under the skin of the face or neck (a pimple, but no opening to the surface).
A vocal cord polyp is like a blister that forms on the hand if you shovel dirt too much.
A vocal cord nodule is like a callous that forms after prolonged repetitive skin trauma (like callous on the hands after shoveling dirt for years).
A new webpage has been uploaded to our practice website describing the evaluation and management of a thyroid mass. Surgical removal is discussed along with risks involved.
Given the sudden interest patients have expressed in vocal cord granulomas ever since singer John Mayer announced a hiatus in concerts due to his voicebox granuloma, a new webpage has been developed to describe this unusual mass as well as treatment options.
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?).
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.
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.
