Last month, we discussed what vocal fold nodules were and how they develop. While nodules can certainly be treated, the best treatment is prevention. Nodules do not form after one episode of voice abuse, although they may start that way. They are the result of months or years of faulty vocal habits that bring the edges of the vocal folds together with excessive pressure. These habits can include singing with inadequate support and too much laryngeal “squeeze,” singing with a high larynx, belting, and habitual use of glottal attack with either the speaking or singing voice. The first two of these causes usually occur in inadequately trained singers. Every month I see several young singers who typically began singing in high school musicals or choir without adequate classical training; consequently, they squeeze and push the voice out. They lack the ability to float the voice, and by using excessive muscle power actually constrict the resonating cavities of the pharynx, further decreasing the volume of sound. They try to compensate by pushing even more. As they increase the air pressure pushed through the larynx, they need to constrict the glottis even more, increasing the trauma to the edges of the vocal folds. Inadequate training compounds itself when the young singer tries to imitate recordings, which represent an electronically modified sound which may not be attainable.
Even reasonably trained singers can develop nodules if they belt excessively. The belted sound, along with the covered but husky stage whisper voice, are the stock-in-trade of the musical theater performer. The usual belt involves pushing chest register up into head range, a process that involves excessive muscular tension in the larynx and rubs the vocal folds together. Among classical singers, nodules usually develop for a different reason. If the performer has to sing excessively through a series of rehearsals and performances, the vocal folds may become slightly swollen. This is normal, and, if recognized, can be remedied with vocal rest. If, however, the singer must continue to perform without giving the vocal folds time to recover, the edema eventually organizes along the edge of the folds, usually at the point of maximum vibration and contact. Singing a role which may be too demanding, or singing with excessive tension due to emotional stress (such as may be engendered by inadequate preparation or an unreasonable director), can also lead to excessive laryngeal pressure.
While nodules usually develop in the higher voices, I have seen them also in mezzos. Regardless of the cause, once nodules develop, the singer starts to notice difficulties in the upper part of the voice. It becomes undependable and breathy, and some notes may not sound, or sound only after an initial hiss of air. This is because as the damaged vocal folds come together, the nodules meet first, allowing air to continue to escape around them. The laryngeal opening has an hourglass appearance, with the nodules representing the constriction, and the leaky laryngeal opening in front and behind the nodules the two wider parts of the hourglass. Only with increased glottic pressure can the nodules sometimes be effaced and the folds brought together along their entire length.
The second part of the nodule story is how they continue to exist and even grow. Singers will compensate, either consciously or unconsciously, for the difficulty. If this compensation involves grabbing, squeezing and glottally attacking notes, the condition will not only persist, but may worsen. If the nodules are soft, they can be initially squeezed and flattened. The voice may be a bit harder, more metallic, but the range will not be affected. Later on, the top notes become unreliable or disappear completely.
Prevention of nodules obviously involves singing with good support, a low larynx, and minimal glottic pressure. It also requires that the singer avoid repertoire that is in the wrong range. Belting, while harmful, can be done safely, although this is not normally an issue for the classical singer. Two general measures applicable to all types of voices are drinking lots of water to keep the larynx lubricated, and resting the voice after excessive rehearsal or performances. And that includes the speaking voice also!
Treatment for nodules begins, first and foremost, with identifying the cause and correcting it. Faulty vocal habits must be eliminated. The details of this cannot be covered in this brief overview. Medical treatment such as cortisone will not permanently remove vocal nodules, although it may temporarily reduce (not eliminate) the swelling associated with them. I perform surgery (microscopic removal) only in selected cases. In my opinion, nodules are most accurately removed using microscopic instruments rather than the laser, but not unless the cause has been identified and addressed. If the singer is inadequately prepared to alter her vocal habits, the nodules may return even after the most skillful surgery.
