Nodules of the vocal folds are the bane of a singer’s existence. No day goes by without a patient (often several patients) asking the question: Do I have nodules?
In most cases, the answer is, thankfully, no. But there are many singers with hoarseness whose larynx demonstrates irritation or swelling along the edge of the vocal folds. These are early warning signs that the process that may eventually lead to nodules has already started, and needs to be addressed.
For most singers with hoarseness—especially classical singers—the issue is not how to treat nodules but how to prevent their formation. Here are some common sense thoughts.
Vocal nodules, unlike other benign masses (such as cysts or polyps), are the result of chronic and repetitive trauma to the vibrating edge of the vocal folds. They will not result from a single episode of vocal abuse, from hemorrhage, traumatic intubation, or any of the other injuries that the larynx may suffer. Chronic and repetitive trauma affects the region of the vocal folds where there is maximum vibration and contact between the folds.
If you look at the length of the fold, this area, called by some “the strike zone,” is one third of the way back from the anterior commissure. Symmetrical swellings of the two folds in this location, then, are either nodules or nodule precursors. Swellings that affect only one fold, or are markedly asymmetric, are most likely something else.
Here is how nodules begin. Repetitive or excessive trauma to the vocal folds causes irritation and edema in this location. That trauma may certainly be the result of inappropriate singing, but also other vocal abuse—in children, they used to be called “screamer’s nodules.” This means that, while you may be singing with a well supported and healthy technique, your non-singing vocal behavior may still result in nodules. Over the years I have seen a number of trained professional singers who become school teachers. Within a year, many of these patients develop nodules—not from singing but from trying to project their voice for hours a day across a noisy classroom.
The warning signs of such swelling manifest as hoarseness in the upper range. Singing softly, using the upper octave or topmost five notes of your voice should reveal this difficulty. Singing a very soft glissando going up, without crescendo or vibrato, should also show the problem: the voice breaks up, either showing breathiness or simply a loss of the top notes. When you test this range of your voice, remember to sing pp and float the voice on the breath—no vibrato or squeezing. If the swellings are more substantial, you may hear a delay in the onset of the voice as you try to initiate those high notes or, at times, a double pitch.
When there is swelling, especially after a particular episode of vocal overdoing, it is essential to rest the voice to allow the swelling to subside. The damage at this point is usually mild and fully reversible. You can compare it to the temporary period of ringing in the ears that you experience after going to a loud concert—if you give your ears a break, the ringing typically resolves in a day or two.
There are situations, however, where vocal rest is not possible. Whether it is a noisy and demanding day job or a taxing rehearsal or performance schedule, a singer may decide to ignore these early warning signs and try to sing through. This usually means using increased effort to force the vocal folds together in an attempt to flatten the swellings and, by sheer muscle effort, approximating the folds to produce a voice. This muscling may occur consciously, when performing, or unconsciously, when using the larynx in a non-singing way.
While you may be able to “sing” in this way, such muscling has numerous harmful consequences in the intermediate and long term. It increases muscle effort in the chest and abdomen, since more effort is needed to push air past the glottis. Generally, heightened muscle tone also causes the larynx to rise in the neck, reducing vocal power and resonance and causing abnormal discomfort in the throat after vocal effort. And, from the nodule point of view, it increases the extent and degree of trauma to the vibrating margins of the vocal folds.
Consider that edema that comes with injury is protective: it has the effect of immobilizing and splinting the injured area. The body, in its wisdom, is trying to rest the injured structure. This is true whether you have edema after wrenching your ankle or traumatizing your vocal fold. If you circumvent this natural protection by further trauma, the body also needs to up its defenses: it starts to lay down a callus—connective tissue that forms a protective cushion.
The analogy I often use here is a corn on your toe. Corns develop when the shoe is too tight and keeps traumatizing your toe. Removing the corn and then putting on the same shoe simply means that the corn will regrow. You need to change your shoe! In the same way, once a nodule starts to form, any kind of treatment—medical or surgical—that does not address the continuing trauma that has caused the nodule to form in the first place is doomed to fail.
Vocalizing at this stage may show a complete loss of notes at the upper end of the range, but will typically also reveal difficulties in the primo passaggio: evidence of the chronic excessive muscle effort that the singer has employed to try to push past the earlier soft swellings. You simply cannot squeeze those calluses flat any more. And, further, you have also acquired some poor compensatory vocal habits that need to be identified and unlearned. The triad of options now becomes voice therapy, medication and, possibly, surgery.
Nodules come in many forms: small and large, protruding and more diffuse, hard and soft. The size, shape, and consistency are not directly related to the amount and kind of vocal trauma. It is also not clear at what point they become irreversible with voice therapy. But one thing is clear—prevention is superior to treatment.
So, how to prevent this from happening? The first step, already alluded to above, is to globally examine how you use your voice—as a singer, a teacher, a parent, a restaurant server, or a party animal. It’s all the same larynx, my friend! The two suggestions here are to minimize any unnecessary and potentially damaging vocal activity and to use your good vocal technique to manage unavoidable vocal tasks. In the case of the school teacher, then, consider better support, more resonance, speaking in head voice (if appropriate), and using environmental modification to allow your voice to do its job. For young singers, look at your summer job—are you a camp counselor to a bunch of rowdy teenagers?
Assuming you are well trained, consider your current singing activities. New teacher, new technique, moving into a new repertoire, pushing to expand your range are all areas of possible concern. Look also at how much you actually sing. Is it eight shows a week in a musical or simply a grueling schedule of rehearsals with inadequate rest between?
Hydration is also important here. Water is a lubricant which covers the vocal folds. If the folds are dry, vibratory trauma may cause more damage. Dry folds may also need more muscle pressure to adequately adduct, further increasing the forces acting on those edges. So drink, steam, and even nebulize to keep the folds moist and pliant.
But, most importantly, be ever vigilant about the state of your voice. If you develop difficulties, even mild ones, in the absence of an infection or other obvious external cause, consider the possibility of edema and early swelling. Good vocal technique in all of your laryngeal activities, good hydration, and constant monitoring are the keys to avoiding vocal fold nodules.
