Vocal Fold Nodules

Overview:

Vocal fold nodules are benign, growths on the surface of the true vocal folds. It is commonly believed that they are result of vocal trauma. Nodules are located bilaterally, or on each of the two vocal folds, commonly at the junction of the anterior and middle third of the vocal fold, or the midpoint of the membranous vocal fold. A unilateral mass is not a nodule. 

Vocal fold nodules are most often observed in women aged 20-50 years, but they are also found commonly in children, both male and female. It has been suggested that laryngeal size may be a factor that predisposes women and pre-adolescent boys and girls (who have smaller larynxes than adult men) to nodule formation. As vocal fold nodules are rare in men, bilateral vocal fold lesions should be examined carefully. An adult male who is diagnosed with vocal fold nodules should be careful in accepting a diagnosis of nodules without a thorough diagnostic examination. See "Diagnosis" for more information on the diagnostic process for vocal fold nodules.

Vocal fold nodules are a well-known problem in singers, both amateur and professional, possible due to the singing style of the singers or simple their increased amount of vocal use in general.

Nodules are symmetric or nearly symmetric and can vary in size. (Note: bilateral masses that are not symmetric should be examined very carefully, as they most likely are cysts or polyps that have damaged the opposite vocal fold, causing swelling. This swelling may resemble a second mass and therefor may be mistaken for a pair of nodules.) They resemble a mound of tissue and will stand out from the edge of the vocal folds. Unlike polyps, vocal fold nodules are the same color as the rest of the vocal fold. They will not significantly grow in size, however with time they may swell due to repeated trauma from vocal use. 

Cause:

Vocal Abuse:

Vocal fold nodules are thought to be caused by vocal trauma, or more specifically, phonotrauma. Vocal trauma can be caused by vocal abuse, vocal misuse, and  vocal overuse. Vocal abuse refers to vocal behaviors that are done under circumstances that lead to trauma of the mucosa of the larynx. Vocally abusive behaviors include the following:

• Excessive talking
• Prolonged and excessive loudness
• Use of inappropriate pitch
• Excessive cough
• Throat clearing

Vocal misuse involves abnormal vocal behaviors that cause stress or trauma to the larynx. Vocal misuse includes the following behaviors:

• The use of excessive tension and effort while phoning
• Hard glottal attacks
• Ventricular phonation

It is important that your physician take a complete history to identify any potential contributing factors including:

• Thyroid disease
• Smoking history
• Caffeine use
• Use of prescription or over-the-counter (OTC) medications
• Patterns of vocal behavior (including occupational use and recreational and social behaviors)
• This may provide clues to contributing vocal overuse, vocal misuse, and vocal abuse

Symptoms:

Symptoms of vocal fold nodules include the following:

• Hoarse sounding speech
• Hoarseness worsens with vocal use and during a cold or sore throat
• Hoarseness improves with vocal rest
• Painful speech production
• Frequent vocal breaks
• Reduced vocal range
• Breathiness
• Vocal fatigue
• Inability to produce voice with soft volume

Diagnosis:

Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared with other indirect laryngoscopy techniques because of it can detect subtle differences in the appearance, pliability, and mucosal wave characteristics of the true vocal fold.

Treatment:

Vocal Rest

Vocal rest is often prescribes for cases of hoarseness. It is a temporary fix as it improves the condition somewhat, but is not likely to make the nodules go away. Vocal rest may improve the hoarse quality of the voice, decrease the size of the nodules, and reduce the swelling due to phonotrauma. However, these improvements will reoccur the next time the voice is strenuously used. 

Medication

Steroids, which are anti-inflammatory medications, are often prescribed to reduce swelling caused by the phonotrauma and vocal fold nodules. However, steroids will not address the main issue: the nodules themselves.

Voice Therapy

Voice therapy from a speech and language pathologist is the most prominently used treatment for vocal fold nodules. The goal of therapy is to make the person aware of the habits that have led to their problem and teach them strategies to use their voice more efficiently so as to not lead to these problems again. The poor vocal habits to be addressed and mediated in therapy include:

• Excessive talking
• Prolonged and excessive loudness
• Use of inappropriate pitch
• Excessive cough
• Throat clearing
• The use of excessive tension and effort while phoning
• Hard glottal attacks
• Ventricular phonation

Voice therapy will make vocal fold nodules more soft and flexible, therefore improving the quality of the patient's voice. It is important to note, however, that voice therapy usually does not make vocal fold nodules disappear as other factors such as the anatomy play a role in their formation and existence.

Surgery

Due to the fact that vocal fold nodules are the result of poor vocal habits, surgery is usually not recommended, as these vocal habits will most likely return after surgery, causing those nodules to reform. However, for vocal fold nodules that are a result of long-standing and repeated damage and are so well-formed that no amount of voice therapy can improve the voice, microlaryngoscopic surgery is considered. During this procedure, an endoscope and special microlaryngeal instruments are used to remove the nodules. 

Following surgery, your physician will follow-up with the patient to use videostroboscopic technology to examine the vocal folds for the presence of mucosal waves, which should be present once again.

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes, which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view.

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

Scarring should be monitored, as it can interfere with the movement of the vocal folds and present symptoms similar to the vocal fold nodules themselves.

Complications:

Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may result in the following:

• Numbness of the tongue
• Altered taste
• Oro-pharyngeal, mucosal, or dental injuries

Deep-plane dissection or exposure of the vocal ligament can result in the following:

• Scarring of the mucosa
• Fibrosis of the mucosa
• Loss of mucosal wave
• Glottal insufficiency

References:

Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The Clinicopathologic Spectrum of Benign Mass Lesions of the Vocal Fold due to Vocal Abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.[Medline].


Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol. Sep 1995;104(9 Pt 1):698-703. [Medline].


Hogikyan ND, Appel S, Guinn LW, et al. Vocal fold nodules in adult singers: regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing. J Voice. Mar 1999;13(1):128-42. [Medline].

Gray SD, Titze I, Lusk RP. Electron microscopy of hyperphonated canine vocal cords. J Voice. 1987;1(1):109-115.


Kuhn J, Toohill RJ, Ulualp SO, et al. Pharyngeal acid reflux events in patients with vocal cord nodules.Laryngoscope. Aug 1998;108(8 Pt 1):1146-9. [Medline].


Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of Vocal Fold Polyps With Conservative Treatment. J Voice. Nov 12 2011;[Medline].

Ragab SM, Elsheikh MN, Saafan ME, et al. Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol. Dec 2005;119(12):961-6. [Medline].

http://www.otolaryngology.com/vocalnodule.html

http://www.bbivar.com/vp_vocal_nodules.php

http://www.voiceproblem.org/disorders/vflesions/understanding.php