Vocal hemorrhage: stigma and prevention

In the wake of artists like Meghan Trainor and Sam Smith canceling tours, I was asked by the Voice Foundation (www.voicefoundation.org) to write on the topic of the dreaded vocal hemorrhage! If you’re not familiar, a vocal hemorrhage occurs when blood collects within the layers of the vocal fold after a blood vessel bursts (much like a bruise). They can be small and rather insignificant, or they can be very serious and career-altering! One generally notices a very sudden change in voice quality, usually resulting in breathiness and hoarseness. I thought I would share the article I wrote for the Voice Foundation on this much misunderstood topic:

One of the joys of my work is the opportunity to work with a variety of performing artists in a variety of settings: primarily, as a vocal technician, working closely with ENTs and SLPs as part of a rehab team; but also, currently, as a conductor of a Broadway musical. And while it often means that my schedule looks like a game of Jenga, this duality has afforded me an invaluable and intimate perspective on the lives of my clients, and the perfect storm in which vocal pathologies (like hemorrhage) may occur.

The demands on professional performers are extraordinary; not only vocal demands, but also the constraints upon their lives, their relationships, and their sense of self and emotional well-being. And while performers can and do suffer vocal hemorrhage due to inadequate technique, in my experience, the underlying cause is generally more complex and multifaceted than that. From ordinary experiences like excessive stress, throat clearing, coughing, weightlifting, childbirth, or hormonal changes, to more atypical causalities like bulimia or circulatory system anomalies, vascular changes to the folds can originate under a multitude of conditions. Notably, Patti LuPone shared in her memoirs that she suffered a vocal hemorrhage while hiking!

Acknowledging and sharing this information within the industry and the general public will allow the stigmatization of hemorrhage (and other pathologies) to diminish. And the stigma is very real. I was recently in a casting session in which a wonderfully talented actress was being considered for a principal role. The team was mostly in favor of her until someone shared that, years ago, “she had to be replaced in a role due to a vocal hemorrhage”. The unspoken assumption in the room was that technique was to blame. These sorts of casting discussions occur with frequency, and help to explain why actors and singers are terrified to be labeled “unreliable” or “injured”. Even a small and quickly resolving hemorrhage could do great damage to a career if it became common knowledge.

When technical deficiencies are to blame, they often stem from the overwhelming expectations of a particular role or, for a recording artist, living up to the fans’ expectations from their album. Take the infamous role of Elphaba in the megahit “Wicked”: an actress sought rehabilitation because she had suffered a hemorrhage due, in part, to pressed phonation and hyperfunction. As we revisited Elphaba’s songs, we uncovered that her subtext onstage had become “to belt” or “to impress” rather than “to call” or “to celebrate/rage/keen”. The expectations of an audience and producers who knew every word, every recording, every YouTube clip etc. had overwhelmed her ability to tell a story with fidelity.

In terms of prevention, I urge all clients to have a baseline stroboscopy and repeat scopings prior to lengthy runs or major performances. Here, the ENT may be able to catch ectasias and varices before they hemorrhage. If a hemorrhage should occur, establishing a collaborative voice care team is key to provide guidance and prevention of potential recurrences.

For performing artists, the voice is so much a part of who they are and what they do.

Consequently, pathologies like hemorrhage can be exceptionally traumatic and emotional. During rehabilitation, I encourage clients to take a close look at their self-talk in these circumstances. As they think about their condition or circumstance, are they compassionate or are they judgmental in their point of view? For the recovery process, both vocal and psychological, it is imperative that they not view themselves as “damaged goods”, but embrace the experience as a catalyst for growth.

Brannon McAllister