Shakira and vocal hemorrhage: when does the hoarseness of someone who works with their voice need to be investigated?

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

On 14 November 2017, Shakira posted a statement about her voice on social media. The El Dorado tour, which was to have opened days earlier in Cologne, Germany, was postponed in its entirety to 2018. According to El País’s report, the promoter Live Nation announced the postponement on medical advice, because of a hemorrhage of the vocal cords (the right one, according to the newspaper), and the singer herself wrote that the hemorrhage “seems not to have been reabsorbed yet” and that she was in a “very tough battle” to recover. The tour resumed in June 2018, in Hamburg. In July of that year, in Barranquilla, according to El País, she called that period “the hardest months” of her life and said: “I never thought I could end up losing my voice”.

The account ends there. Tests, cause and treatment were not disclosed, and nothing is said here about her doctors, the services involved or her clinical choices; nor is it claimed that her work caused the hemorrhage, which can have many origins. The episode serves as a starting point for a question that matters to millions of Brazilians who make a living with their voice, such as teachers, call-center operators, singers, salespeople, religious ministers, lawyers and community health workers: when hoarseness stops being fatigue and calls for an examination of the larynx, and what Brazilian law recognizes when a voice disorder is related to work. The article covers what science has measured, what the guidelines say, what the SUS (Brazil’s public health system), health plans and Social Security provide, how other countries treat the voice as an occupational disease, and where delay can turn into liability.

Hoarseness is not a diagnosis

Hoarseness, or dysphonia, is a change in the quality, pitch, loudness or effort of the voice that impairs communication or quality of life. It is a symptom, not a disease: it may stem from a respiratory infection, irritation, benign lesions such as nodules and polyps, neurological changes, side effects of medication, heavy use of the voice and, in a minority of cases, cancer. The guideline of the American Academy of Otolaryngology (Stachler and colleagues, Otolaryngology–Head and Neck Surgery, 2018) estimates that dysphonia affects “nearly one-third of the population” at some point in life. Vocal fold hemorrhage is a specific diagnosis, which cannot be recognized by listening to someone speak; a person who becomes hoarse after a class or a performance should not conclude that they have the condition Shakira described.

Science has been measuring the weight of the voice as a working tool for two decades. In the landmark study by Roy and colleagues (Journal of Speech, Language, and Hearing Research, 2004), with 2,531 randomly selected people in Iowa and Utah, 11% of teachers reported a voice problem at the time of the interview, against 6.2% of non-teachers, and lifetime prevalence was 57.7% against 28.8%. Women had more chronic disorders, lasting more than four weeks. In a second article by the same group, the authors showed that teachers missed more work because of their voice and more often considered changing profession. In Brazil, the study by Medeiros, Barreto and Assunção (Journal of Voice, 2008) of 2,103 female public-school teachers in Belo Horizonte found probable dysphonia in 15% and possible dysphonia in 52%; only one-third reported no vocal symptom in the previous fifteen days. High noise (odds ratio 2.55) and poor classroom ventilation (2.00) were among the associated factors, alongside recent airway problems and a current mental disorder.

The Ministry of Health protocol on the subject, from 2018, brings together the national figures. It cites a review that found a prevalence of voice disorders of 20% to 50% among teachers, against 6% to 15% in the general population; a case-control study of female municipal teachers in São Paulo in which those with a voice disorder were eight times more likely to have lost work capacity; and a survey by the medical examination service of Rio de Janeiro City Hall according to which, in 2007, 41.7% of the teachers reassigned to other duties had been reassigned because of dysphonia, equivalent to 1% of all teachers in the municipal system. The same document records that “there are no epidemiological data on the magnitude of this condition in the databases” of the SUS, and it is this gap that notification seeks to fill.

There is one more reason not to treat persistent hoarseness as a “tired throat”. INCA (Brazil’s National Cancer Institute) lists voice change and hoarseness among the warning signs of head and neck cancer, and smoking weighs especially on the larynx. In an analysis by the international INHANCE consortium published in 2026 (de Abreu and colleagues, International Journal of Cancer), with 2,143 cases and 5,799 controls among former smokers, the risk of laryngeal cancer was 2.6 times higher in those who had smoked more than 50 pack-years than in those who had smoked fewer than 10, and quitting after age 55 tripled the risk compared with quitting by age 45; the authors conclude that alcohol weighs more in tumors of the mouth and oropharynx and that tobacco is “more strongly associated” with laryngeal cancer. Most people with hoarseness do not have cancer. The point is that it is persistence, not pain, that calls for investigation.

Shortness of breath, noisy breathing, progressive difficulty swallowing, blood, a lump in the neck or rapid worsening warrant urgent assessment, with no waiting period. A sudden loss of voice while singing or speaking intensely also calls for early medical contact; continuing to force the voice until the end of the schedule hampers the assessment. When persistent hoarseness is treated for months as fatigue and the diagnosis of a laryngeal tumor comes late, the law measures that delay as the loss of a chance, a topic the firm has examined in the diagnosis missed in a ten-minute consultation and in late diagnosis and the loss of a chance (both in Portuguese).

Four weeks: what the guidelines require

The guideline of the American Academy of Otolaryngology–Head and Neck Surgery, updated in 2018, has a central rule: the clinician should perform laryngoscopy, or refer the patient to someone who can, “when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected”. Among the factors that call for expedited evaluation of the larynx, the guideline lists recent surgery of the head, neck or chest, recent intubation, a neck mass, respiratory distress, a history of smoking and being a professional voice user. Four weeks is the outer limit for those with none of these signs, not a mandatory waiting period.

The same guideline says what not to do before looking at the larynx: not to order CT or MRI as the first response to a voice complaint, not to prescribe anti-reflux medication for isolated dysphonia based on symptoms alone, not to prescribe corticosteroids routinely and not to use antibiotics routinely. It also calls for diagnostic laryngoscopy before voice therapy is prescribed, and for the result to be communicated to the speech-language pathologist. The order makes sense: voice therapy is effective for many causes, but the right technique for a nodule is not the same as for a paralysis, and an acute hemorrhage is not treated with a “vocal hygiene” leaflet. Voice rest, its degree and its duration are individual clinical decisions.

The 2018 Brazilian protocol follows the same logic. For the diagnosis of work-related voice disorder, it provides for a medical assessment “with visualization of the laryngopharyngeal region, preferably performed by an otorhinolaryngologist”, and a speech-language assessment. Speech-language pathology assesses voice production, speaking demands and the possibilities of rehabilitation; it does not replace the medical examination of the larynx, and the two professionals need to exchange information.

The voice as a working tool: DVRT in Brazilian law

The Ministry of Health protocol on Distúrbio de Voz Relacionado ao Trabalho (DVRT, work-related voice disorder) defines the condition as “any form of vocal deviation related to professional activity that reduces, compromises or prevents the worker’s performance or communication, whether or not there is an organic change in the larynx”. It proposes reconstructing the clinical and occupational history: working hours, amount of speaking, breaks, noise, dust, temperature, pressure for productivity and changes in the organization of work. Working with the voice does not, on its own, prove that the work caused the problem; a teacher may also have an allergy or an infection unrelated to the classroom. But the protocol is clear about the other side: “The disease must be related to work even when there are other factors or comorbidities unrelated to the work activity”. This is the principle of concurrent causation (concausalidade), and the document, citing the literature, places voice disorders in the groups in which work is a contributing factor or an aggravating factor of a pre-existing condition.

The voice is named on the official list. Portaria GM/MS nº 1.999 of 27 November 2023 (an ordinance of the Ministry of Health), which updated the Ministry of Health’s List of Work-Related Diseases, includes codes R49 (voice disturbances), J38 (diseases of the vocal cords and larynx) and J38.2 (nodules of the vocal cords), associated with “work involving vocal overload” aggravated by factors such as long working hours, accumulation of duties, sound pressure above comfort levels, unfavorable acoustics, inadequate ventilation and “difficulty of access to hydration and toilets”. As for notification in Sinan (the national information system for notifiable diseases), the 2018 protocol recorded that DVRT was not among the conditions subject to compulsory national notification and that states and municipalities could include it, with code R49. The referral network is that of Cerest (Reference Centers for Workers’ Health), which integrates workers’ health into the SUS, and Technical Note nº 21/2025 of the Ministry of Health now guides DVRT surveillance.

In social security law, Lei 8.213/1991 (the Social Security Benefits Act) treats as equivalent to a work accident the occupational disease and the work-related disease included in the Social Security list (art. 20, I and II), and § 2 of the same article requires a disease outside the list to be considered a work accident when it “resulted from the special conditions in which the work is performed and is directly related to it”. Art. 21, I, accepts concurrent causation: it is enough that the work, “although not the sole cause”, contributed directly to the reduction or loss of capacity. The medical examination of the INSS (the National Social Security Institute) establishes the accident-related nature of the condition when it finds the technical epidemiological link (nexo técnico epidemiológico) between the activity and the condition (art. 21-A). The company must issue the Comunicação de Acidente de Trabalho (CAT, the work accident report) by the next working day (art. 22); if it does not, the worker, the union or the treating physician may file it (art. 22, § 2), which the DVRT protocol repeats. Once the accident is recognized, there is a twelve-month job guarantee after the accident-related sickness benefit ends (art. 118). The Constitution completes the picture: accident insurance does not exclude the compensation the employer owes “when it acts with intent or fault” (art. 7, XXVIII). The firm followed the same path in noise-induced hearing loss at work (in Portuguese).

Access in the SUS and under health plans

In the SUS, the entry point is primary care, which should record the onset and duration of the hoarseness, examine the associated signs and refer the patient to otorhinolaryngology and speech-language pathology according to the clinical picture and the organization of the local network. If professional activity is being affected, this needs to be written in the medical record: how many hours of speaking per day, which tasks the person can no longer perform, whether the worsening occurs during or after the working day. That information weighs on clinical priority and is the first link in the occupational causal chain. The Estatuto dos Direitos do Paciente (Patients’ Rights Statute), Lei 15.378/2026, guarantees care “in a timely manner” (art. 8), and Lei 8.080/1990 (the SUS Organic Law) ensures comprehensive care (art. 7, II); two months of hoarseness without a scheduled laryngoscopy is a fact that can be documented and pursued, administratively or in court.

For health plans, RN ANS 566/2022 (a resolution of ANS, the federal health plan regulator) sets maximum waiting times: up to 14 working days for a consultation with a specialist, such as an otorhinolaryngologist (art. 3, II), and up to 10 working days for other outpatient tests and therapies (art. 3, XI); the official ANS page on maximum waiting times also sets 10 working days for speech therapy. If the operator does not guarantee care and the beneficiary pays outside the network, reimbursement is full, within 30 days (art. 10). Since 1 August 2022, ANS has stated that there is no numerical limit on consultations and sessions of speech therapy, psychology, occupational therapy and physiotherapy, which does not dispense with an individual indication. Coverage of the laryngeal examination and of the therapy should be checked procedure by procedure in the Rol da ANS (the ANS list of mandatory coverage), taking into account the plan’s segment and the contract. An article on this site about speech therapy in another clinical context (in Portuguese) explains the difference between indication, place of care and coverage. If there is a refusal or a delay, keep the medical request, the exact name of the test or therapy, the reference numbers of your contacts and the written reply; a refusal without the applicable rule in writing is not an answer, it is the beginning of the claim.

Comparative law: three ways of treating a voice that falls ill at work

Recognizing voice disorders as an occupational disease is not a Brazilian invention, but legal systems follow different paths. The three examples below were read in the official sources or in a scientific review and range from full recognition to a narrow door.

1. European Union: the voice on the waiting list

Commission Recommendation 2003/670/EC of 19 September 2003, which establishes the European schedule of occupational diseases, included in Annex II, item 2.503, “nodules of the vocal cords caused by sustained work-related vocal effort”. Annex II brings together the diseases suspected of being occupational in origin, which should be notified and which may later be moved to the main list. It is a recommendation, without binding force, and it shows the stage of the European consensus: the link between voice and work is recognized, but left to each Member State.

2. Poland: the most frequently certified occupational disease

Poland went further. Occupational voice disorders are recognized as an occupational disease and, according to the review by Niebudek-Bogusz and Śliwińska-Kowalska (International Journal of Occupational Medicine and Environmental Health, 2013), they are the most frequently certified category of occupational disease in the country, about 20% of all cases. The same review describes the medico-legal certification procedure, the objective measurement of vocal load and the prevention programs aimed at teachers. The text of the Polish regulation was not read for this research; the figure comes from the review.

3. Germany: off the list, with an exception door

The German list of occupational diseases (Annex 1 to the Berufskrankheiten-Verordnung, the Occupational Diseases Ordinance) has no entry for voice disorders; the larynx appears in item 4104, which recognizes laryngeal cancer associated with asbestos exposure. For the German teacher or singer, what remains is the opening clause in § 9(2) of Book VII of the Social Code, which requires an unlisted illness to be recognized “as an occupational disease” when, according to new findings of medical science, the requirements for adding it to the list are met. It is a narrower door than the Brazilian one, which already names R49 in the Ministry of Health list and allows, under Lei 8.213, recognition outside the list.

From delay to liability

Two different legal questions may arise from persistent hoarseness, and they should not be confused. The first concerns care: should someone have examined the larynx earlier? The Código de Ética Médica (the Brazilian Code of Medical Ethics) forbids physicians to fail to use all scientifically recognized diagnostic means available to them (art. 32) and to fail to inform the patient of the diagnosis, prognosis and risks (art. 34), and requires a medical record with dated entries (arts. 87 and 88). Lei 15.378/2026 guarantees sufficient information to make decisions (art. 12, § 1), a second opinion at any stage (art. 18) and access to the medical record without having to give reasons (art. 19). The liability of the hospital, the clinic or the plan operator is strict as regards the services that are their own (CDC, the Consumer Protection Code, art. 14); when the defect lies in the physician’s act, proof of fault is required (art. 14, § 4), and it is the comparison between the medical record and the four-week rule that decides it.

When delay takes away a serious and real possibility of earlier treatment, the Superior Tribunal de Justiça (STJ, Brazil’s highest court for non-constitutional matters) allows compensation for the loss of a chance. The leading precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, decided on 4 December 2012), a case of inadequate treatment of breast cancer, not of hoarseness, whose headnote states: “The chance, however, can never reach the value of the asset lost”. What is compensated is the opportunity taken away, not the cure. In laryngeal cancer, the evidence, in each case, is expert evidence and depends on what the clinical picture would have been on the date the examination should have been performed.

The second question is occupational: did the work cause or aggravate the disorder? Here the path runs through the DVRT protocol, the 2023 list, the CAT and the INSS medical examination and, if the employer is at fault, through the compensation provided for in the Constitution. An employer who keeps overcrowded classes, noisy rooms, working hours without breaks and no access to water, after repeated voice complaints, produces precisely the factors the official list describes. For civil servants, such as most public-school teachers, the rule is that of each government entity’s own scheme, and the functional reassignment the protocol records in Rio de Janeiro shows that the problem is also one of public management.

Before deciding

In my view, Brazil has enough rules for the voice that falls ill and little practice in using them: the Ministry of Health list, in its 2023 version, names voice disorder, Lei 8.213 accepts concurrent causation, and yet a teacher’s hoarseness is usually treated as fatigue until it turns into sick leave. Those who live by their voice have three steps to take, in this order. If the hoarseness has lasted more than four weeks, or sooner if there is a warning sign, ask for the examination of the larynx and for the complaint and the professional use of the voice to be written in the medical record. Note when the voice changed, the working hours, the noise, the breaks and what you can no longer do, because it is this timeline that supports both the clinical urgency and the link with work. And keep the requests, reports, reference numbers and replies from the SUS, the plan and the employer. If the hoarseness was investigated late, if the plan refused the test or the therapy, or if work is at stake and no one is willing to recognize the causal link, get in touch with the firm: the analysis begins with the medical reports, the chronology and the records of the working hours, and does not replace a medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).