Among the various occupational hazards of singing, nodules have acquired almost mythical status; they are the nightmare of every singer. Most new voice patients I see need this one question answered: “Do I have nodules?” It is important therefore to discuss (in more than one column) what nodules are. And what they are not.
What nodules ARE:
Nodules are small bumps or calluses that form on the vibrating edge of the vocal folds as a result of excessive voice use. I often compare them to corns or calluses that may form on your toes if you wear shoes that don’t fit your foot. Nodules are vocal fold corns that come from “wearing” a voice that doesn’t fit your larynx. They are a benign reaction, and represent evidence of inadequate or inappropriate vocal technique. The common symptoms of nodules are hoarseness and breathiness, particularly in the high voice, along with an inability to sustain. There is a direct cause and effect relationship between inappropriate singing and nodules.
What nodules are NOT:
First and foremost, they are not the end of your career. An old professor of mine, who, as a young man, examined Bing Crosby’s throat, told me that Crosby had nodules “with an estimated value of 1 million dollars each”. The late Dr. Wilbur Gould once told me that in his practice 17% of sopranos had some degree of nodule formation. While I don’t keep such statistics, it is my own experience that some of the finest singers working the international opera circuit today have full careers despite nodules. Depending on the voice and the kind of singing required, nodules might not be an impairment at all, but add a quality to the voice which is acceptable. This is particularly true for popular music, where a certain husky, sexy quality may be actually desirable. (Hence, the estimated monetary value placed upon Bing Crosby’s nodules.)
Secondly, nodules are not some unexplained blight that needs but to be surgically removed, and will then be gone forever. They are the result of excessive trauma to the edges of the vocal folds. Unless the cause (inadequate technique or inappropriate repertoire) is addressed, the effect nodules will return. The “disease,” therefore, is not the nodule but rather the technique which caused it to form. Nodules do not form after a one-time vocal indiscretion. They form gradually, over months or even years of repeated vocal abuse. One or two episodes of voice misuse may certainly cause edema of the vocal folds, but this resolves itself without a trace over the next few days of voice rest. If, however, vocal abuse continues over weeks and months, the edema consolidates into an area of swelling which persists. The situation is analogous to the temporary hearing loss or ringing in the ears which you may experience after a rock concert. Initially, this will disappear over a day or two, but after repeated episodes you may be left with some permanent damage. This moment, when the edema of normal vocal fold tissue is replaced by the deposition of new tissue, is the moment of nodule formation. The exact time of this cannot be predicted, any more than one can predict how many rock concerts it takes for temporary hearing loss to become permanent. The new tissue that forms may be thought of a protective mechanism, a kind of “bumper” formed by the body to reduce further trauma to the edge of the vocal fold. Concep-tually, the nodule tissue has two components: an acute edema component, which responds to voice rest or cortisone, and a chronic component, consisting of deposition of new tissue. Voice rest, no matter how prolonged, will NOT dissolve this tissue. If the singer returns to his faulty technique, even after prolonged vocal rest, the symptoms of hoarseness and breathiness will quickly recur. Clearly, voice rest alone is not the answer. Neither is cortisone; while this may give temporary improvement, the condition will recur as the trauma of the folds rubbing together is reapplied. It is particularly important to understand the cortisone issue. We often see singers (popular as well as classical) on tour, who go from doctor to doctor, forging a long and harmful chain of cortisone shots link by link. The problem is always acute, always a one-time emergency: “I have to sing tonight!” Two days later, in another city, the scenario repeats. Everyone patient, doctor and management is standing too close to the trees to see the forest.
The complete management of nodules involves an understanding of why they form, and how this formation can be prevented, and definitively treated. And these issues, dear reader, will be addressed next month.
