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Voice case of the Week: Prolonged Vocal Hemorrhage from Herbal Supplements
The patient is a 43 year old female who presented with occasional hoarseness for the past year. She noted her voice was normal at times. Her most recent episode of hoarseness, however, started 3 weeks ago and had not improved at all. She denied any associated symptoms, such as would be consistent with an illness. The patient is a lawyer and uses her voice frequently at work but does not shout or use her voice forcefully. She has no known medical problems and does not take any medications regularly. She takes an herbal supplement provided by her acupuncturist to promote vocal health.
Her general ENT exam was within normal limits. Videostroboscopy was performed.
Stroboscopy demonstrates a severe right vocal fold hemorrhage. Even more concerning is that there appears to be the beginning of a mass formation on the vibratory margin of the right vocal fold.
Strict voice rest was recommended and she followed up one week later. Stroboscopy was again performed:
The lack of significant resolution was extremely concerning. Typically, hemorrhages are nearly resolved after one week of strict voice rest. The patient confirmed she had been compliant with voice rest. Therefore, particularly out of concern for the impending mass formation, another week of voice rest was recommended.
After two more weeks, stroboscopy was performed again.
While this strobe is markedly improved, it is an excellent case study of how vocal polyps may develop. In this case, the patient presented for evaluation after several weeks of symptoms. It is easy to see how, if she had not been seen and had been non-compliant with voice rest, the mass that was beginning to appear would have formed a polyp. Even with 3 weeks of voice rest, there is some concern for polyp formation.
Blood acts as an irritant and inflammatory masses, such as polyps, may easily form when there is blood in the vocal fold.
The prolonged time of wound healing required we look into her history for the cause. She did note that she bruises easily. The hemorrhage was not timed close to her menses, at which time woman are prone to bruising. After much questioning, we realized that her herbal “vocal health” supplement had several components that thinned the blood, including garlic and ginger. There are actually many herbals that may thin the blood. It is vital that we appreciate how risky all medications, including herbal, may be for vocal health. Often we interpret “natural” as healthy; however, vitamin C, gingko, and many other natural things, when taken in excess, promote bleeding. Be very cautious when taking any herbal supplements. It is important to partner with your laryngologist to determine if the vocal risk of any treatment is outweighed by a health benefit. Three weeks of vocal rest, with incomplete resolution, would be devastating to a working performer and, in this case, could have been limited (or simply 1 week) had she not been taking blood-thinning supplements.Blood acts as an irritant and inflammatory masses, such as polyps, may easily form when there is blood in the vocal fold.
Mon, Sep 29, 2014 @ 6:25 AM MDT
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