What is the cause of unilateral vocal cord swelling in an opera singer, potentially secondary to trauma?

Unilateral Vocal Cord Swelling in an Opera Singer

Unilateral vocal cord swelling in an opera singer is most commonly secondary to phonotrauma (functional vocal trauma from excessive or improper voice use), manifesting as contact edema, vocal nodules, polyps, or vocal fold hemorrhage. 1, 2

Primary Etiology: Functional Vocal Trauma

The swelling you're observing is likely phonotrauma-related, not accidental trauma, unless there's a clear history of external injury or recent intubation. Here's the algorithmic approach:

Most Common Causes in Professional Singers:

Phonotrauma-induced lesions (in order of likelihood):

• Contact edema or "nodule-like" lesions: Result from vascular disorders secondary to overstrain of the vocal apparatus during phonation and disorders of vegetative innervation 1
• Vocal fold hemorrhage: Can occur from phonotrauma alone or be exacerbated by anticoagulants (Coumadin, aspirin, NSAIDs), phosphodiesterase-5 inhibitors 3, 4
• Polyps: Develop from excessive and improper voice use with specific histologic features 2
• Vocal nodules (singer's nodules): Typically bilateral but can appear asymmetric initially, most common in 20-50 year-old singers 1

Key Distinguishing Features to Assess:

History elements that point to phonotrauma:

• Recent increase in vocal load (performances, rehearsals, additional concert/pedagogical work) 5
• Singing parts that don't match the singer's technical capacity or voice type 5
• Improper vocal technique or voice abuse patterns 6
• Age 20-50 years with 3-26 years singing history 1

History elements that point to other trauma:

• Recent intubation or laryngoscopy (94% develop laryngeal injury including edema and ulceration after >4 days intubation) 7
• Recent head, neck, or chest surgery 3
• Medications: anticoagulants, antiplatelet agents 3, 4
• Smoking history (increases risk of polypoid lesions and malignancy) 3

Critical Pitfall to Avoid

Do not assume benign etiology without expedited laryngeal examination. The American Academy of Otolaryngology-Head and Neck Surgery mandates that professional voice users warrant early evaluation because delay in diagnosis has significant psychological and economic ramifications 3. Even if phonotrauma seems obvious, you must rule out:

• Malignancy: Especially if the singer smokes (2-3 fold increased risk) or has concurrent neck mass 3
• Vocal fold paralysis: Can present as apparent "swelling" due to immobility 3
• Hemorrhage: Particularly if on anticoagulation 4

Management Algorithm

Step 1: Immediate laryngoscopy (flexible or rigid videostroboscopy)

• Direct visualization is the gold standard; CT has limited utility for small mucosal lesions 8
• Assess for true edema vs. hemorrhage vs. mass lesion vs. paralysis 2

Step 2: If phonotrauma confirmed (contact edema, nodules, polyps):

• Primary treatment is voice therapy, NOT surgery 1, 6
• Combine: psychotherapy, anti-inflammatory medications (phlogenzym allows avoidance of voice rest and surgery), physiotherapy, and phonopedia 1
• Voice therapy success rate: 71-100% for contact granulomas and similar lesions 6
• Surgery only indicated for: suspected malignancy, benign lesions failing conservative therapy, or glottic insufficiency 3

Step 3: If vocal fold hemorrhage:

• Immediate voice rest
• Consider discontinuing anticoagulation if medically safe (discuss alternative therapies for conditions requiring anticoagulation) 4
• This can be career-ending if not managed properly 4

Step 4: Address contributing factors:

• Evaluate correspondence of vocal parts to singer's technical capacity 5
• Assess distribution of vocal load throughout the month/season 5
• Review comorbidities affecting vocal apparatus 5

The pattern of vocal apparatus disease depends on voice type and nervous system status, so individualized assessment of these factors reduces incidence by 15-20% 5.