Phonotrauma, the physical stresses of the vibrating vocal cords, can sometimes cause hemorrhage or bleeding within the vocal cord. The vocal folds are very small and it does not take much blood collecting under the surface to cause hoarseness. Bleeding under the surface may be associated with small polyps, varices (weak areas and blood vessels) or normal vocal folds. This can be a serious event for professional voice users. There is usually no pain associated with hemorrhage and because bleeding occurs just under the surface there is no blood cough up.

Hemorrhage usually involve involves immediate voice rest. Often this is all that is needed for a single event. Repeated vocal hemorrhage always has a harmful voice behavior associated with it and voice therapy is useful and identifying and preventing future problems. Sometimes, microscopic laryngeal surgery is needed to remove or repair blood vessels problem to bleed and to remove small polyps or changes in the surface of the vocal fold contributing to hoarseness. Considerable experience and expertise is needed to treat this problem.