How Does Vocal Injury Happen?

To judge by the news, it would seem that singers are getting injured more frequently than ever. We regularly hear of performers cancelling shows, or even tours, due to injury. Why is this happening? There may be two factors at play here: Increased demand, Improved ability to detect injury.

Demand
There is no question that demand on the professional singer has increased. Starting baseball pitchers are given a relief during a game and often several days off between games. In contrast, the touring singer, who is using their instrument no less rigorously, does an entire show, followed by several others, moves to another city, and does it again. The opportunity to rest has vanished, and with it has gone a singer’s chance to recover.

How does demand cause injury?
When demand on the vocal folds increases, blood supply increases. As the instrument is pushed, the chance of one of these vessels bursting increases. When high demand is compounded by a small issue, like a cold or smoking, the risk of a burst vessel is even higher. This is called a vocal hemorrhage, and it may be small or large. When large, there will be a sudden change in the voice that will make even the speaking voice sound hoarse.

When bruise is small, it will result in hoarseness that the singer feels they can “work around.” The voice from a small hemorrhage is only slight, and so it is common for the singer to ignore it and proceed with singing.
Historically, this post-performance hoarseness may be seen a badge of honor or a necessary evil after a performance. Teas, lozenges, scarves, and steroid shots were band-aids that allowed the singer to push the next day again.

However, now knowing that hoarseness may be due to a small hemorrhage, we understand how dangerous “pushing through” is. Continued voice use despite the hoarseness from a hemorrhage (small or large) leads to injuries, including nodules, polyps, and cysts.

Improved ability to detect injury
Modern voice medicine is far different to what has been practiced in the past. It used to be that a flexible scope would be inserted into the nose, providing a low-resolution image of the vocal folds. The advent of videostroboscopy has revolutionized voice medicine, allowing for the detection of small hemorrhages and minute injuries. This procedure involves a larger, rigid scope that is positioned through the mouth, while audio and video recording are simultaneous achieved. A slow motion, high-definition view of the vocal folds vibrating is achieved. This allows for detection of microscopic injuries and more careful management.
These factors are the likely explanation for why more singers are found to have injuries. To prevent yourself from being of these injured singers, you should seek out:

Control issues that risk the vocal cords, including allergies, smoking, excessive/loud speaking, reflux, etc. Implement voice rest while touring as often as possible and book days off between whenever possible. Look for a “board-certified, fellowship-trained laryngologist”; being a “voice doctor” is not enough as this term does not guarantee rigorous training in voice medicine. A voice team: a laryngologist, a vocal therapist, and a vocal coach
Videostroboscopy: a rigid camera inserted into the mouth. Mirrors in the mouth and flexible scopes in the nose are inadequate to find early injury. A screening exam (videostroboscopy) when healthy and vocal therapy when demand is high, before injury has occurred.