A Singer's Notes: Preventing Vocal Nodules

Teresa Radomski, MM

"Do I have nodules?!" This is one of the questions most often asked by singers who have been having problems with their vocal production. Repeated hoarseness, breathy or "husky" tone (especially in the middle register), difficulty singing in the upper register (especially the inability to sing high notes pianissimo), the need to use greater-than-normal breath pressure to sustain the voice, thereby increased the overall effort of singing -- these are danger signals that indicate the possibility of nodules on the vocal cords. What are vocal nodules? Normal vocal cords have smooth, white mucosal surfaces without any irregularities on the vibrating borders. Excessive tension or force used when singing or speaking often "overloads" the vibration of the vocal cords, resulting in too much friction. A hematoma, or bruise on the vibrating edge develops, generally occurring at the anterior one-third of the vocal cord, which is the point of maximal contact during phonation. Later, fibrous tissue replaces the hematoma, becomes larger, and eventually appears as a soft or hard white nodule. Typically, two nodules are present; they appear opposite each other on each vocal fold, indicating the place of excessive friction and/or impact. How are nodules treated? Once vocal nodules have been diagnosed, treatment usually begins with complete vocal rest followed by a careful regimen of speech therapy and/or appropriate singing exercises. If the nodules are large, surgical removal may be necessary. However, regardless of how the nodules are treated, it is imperative that destructive singing or speaking patterns be corrected -- if the singer returns to his or her old habits of voice production, the nodules will return. How can nodules be prevented? Proper vocal technique and a sensible lifestyle, which includes necessary rest and relaxation, aerobic exercise, and a healthy diet, are sufficient to prevent vocal nodules! Recent studies of the laryngeal biomechanics of singers at the Center For Voice Disorders have shown that excessive muscle tension patterns in the larynx are greatly reduced in singers with vocal training, as compared to singers who have never studied voice. See "Laryngeal Biomechanics of the Singing Voice" Singers need to learn how they can be both relaxed and energetic in their vocal production -- a delicate "balance" that is accomplished gradually through increased kinesthetic awareness. Breath support must be appropriate; too much breath pressure can result in excessive laryngeal tension. The vocal cords must be protected from overexertion: for example, through the avoidance of a hard "glottal attack." Learning to "open up" pharyngeal space with a loose jaw, tongue, and soft palate increases resonance and enhances vocal production without "forcing" or "pushing." Careful development of the registers of the voice safeguards against vocal strain; for example, the "blending" of the male falsetto voice or the female "head" voice with the "chest" register aids in appropriate vocal cord vibration. Appropriate voice classification is essential to ease in singing; singing out of range (in the wrong tessitura) is asking for vocal trouble. Likewise, singers should use care in developing the extremes of their range, and should avoid singing too many high (or low) notes during a practice period. Singers

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should also be aware that the "correct technique" applies not only to their singing voice, but also to their speaking voice. Misuse of the speaking voice, usually by forcing it to a lower pitch, causes problems for singers, including the possibility of developing nodules. (See "BogartBacall Syndrome.") Once proper vocal technique has been learned, it remains the responsibility of the singer to maintain optimal vocal performance through a sensible regimen of daily practice, including a careful warm-up before all rehearsals and performances. No athlete would attempt to compete without warming-up, yet singers frequently neglect to prepare themselves adequately for the physical intricacies of singing! Certain types of singing are much more prone to the development of vocal nodules: rock, jazz, gospel, and most popular styles, for example, in which the technique resembles shouting or screaming, greatly "overload" vocal cord vibration. Performing for long hours in the smoky, dusty, and noisy environment of nightclubs further aggravates a tendency toward vocal abuse. The prevalence of nodules among popular singers is often evidenced by the typical "husky," or "breathy" tone quality -- a characteristic sound that can become a personal "vocal trademark." Indeed, many pop singers diagnosed with nodes do not wish to treat them, for fear of losing their "persona"! Such singers should be aware, however, that continued vocal abuse (singing with nodules), combined with smoking, alcohol, or drug abuse can lead to serious laryngeal disease, including cancer. The fact that many popular singers are untrained also increases their chances of vocal disorders. In the aforementioned recent study of laryngeal biomechanics at the Center For Voice Disorders, two female popular singers were examined, by transnasal fiberoptic laryngoscopy. The two singers were about the same age, and sang a similar repertoire, but one had never studied voice, while the other had had many years of "classical" voice study. The untrained singer had vocal nodules, with a resulting breathy tone, and exhibited a great deal of muscle tension while performing. The trained singer showed a healthy larynx with little muscle tension, and sang with a clear, strong tone -- evidence that vocal study benefits popular as well as "classical" singers. Most professional "classical" singers are very protective of their voices, occasionally to the extent of hypochondria. Nonetheless, their best intentions to preserve their voices may be undermined by overly-demanding rehearsal/performance schedules, often combined with the fatigue of travel (usually on dry, dusty, and noisy airplanes), and the necessity to fulfill their performance contract obligations, regardless of whether they are healthy or ill. Aspiring young singers often allow themselves to be overworked during the early stages of their careers, a time when they should instead be carefully developing and nurturing a healthy technique that will enable them to perform well for many years. Would-be professional singers, in their desire for "experience", often accept roles that are out of their optimal vocal range. Unfortunately, the demands of today's high-pressured professional world have resulted in the "early retirement" of many of these singers. The importance of maintaining one's general health as a contributing factor to one's vocal hygiene cannot be overestimated. Regardless of the style of singing, rest and relaxation are essential as antidotes to the rigors of extensive vocal use, nervous tension, and performance stress. Proper diet is important, especially since many voice disorders result from gastroesophageal reflux disease, in which stomach acid backs up into the larynx, causing irritation of the vocal cords. (See "Medicine in the Vocal Arts"). Overuse of alcohol adversely affects the voice through its drying effect on the tissues of the vocal tract. The damaging effects of cigarette smoke, including "secondhand smoke," are well known, and obviously should be avoided by singers. Any drug that is inhaled, swallowed or injected may affect the muscles of vocal production, aside from the obvious dangers of being an addict on substances. Commonly used drugs such as antihistamines can irritate the vocal cords through over-drying

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of the mucosa, and aspirin can increase the tendency to hemorrhage. Finally, a routine of aerobic exercise, yoga, and/or meditation, can greatly help to relieve stress and tension, thereby enhancing the singer's overall well-being. References: 1. Bunch, Meribeth: Dynamics of the Singing Voice, Springer-Verlag, New York, 1982. 2. Punt, NA: The Singer's and Actor's Throat, William Heinemann Medical Books Ltd., London, 1979. 3. Saunders, WA: The Larynx, CIBA Pharmaceutical Company, Summit, N.J., 1964.

Radomski.T, A Singer's Notes: Preventing Vocal Nodules, Center For Voice Disorders of Wake Forest University, Medical Center Boulevard 2004.

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Vocal Cord Disorders
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What Is It? Symptoms Diagnosis Expected Duration Prevention

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Treatment When To Call A Professional Prognosis Additional Info

What Is It?
Vocal cords are two bands of elastic muscle tissue located side by side in the voice box (larynx) just above the windpipe (trachea). When you are silent, the cords remain open, creating an airway through which you breathe. When you speak, the air you exhale from your lungs is forced through the closed vocal cords, causing them to vibrate — faster for higher-pitched sounds, slower for lower-pitched sounds. Like other tissues in the body, vocal cords can be strained and damaged. But unlike a strained arm or leg muscle, strained vocal cords generally aren't noticed until the problem becomes severe. People who use their voices for a living or who shout or scream frequently are at particular risk. This group includes lawyers, teachers, singers, cheerleaders, actors and clergy. People who work in noisy environments, such as airports or racetracks, that require shouting to communicate are also at risk. Vocal cords are also subject to infections, tumors and trauma. Common vocal cord disorders include: • Vocal cord nodules are small, hard, callus-like growths caused by vocal abuse. They occur in pairs, with one nodule on each vocal cord at the site of greatest irritation. They sometimes are called singer's, screamer's or teacher's nodules. • Vocal cord polyps are small, soft growths that usually appear alone on a vocal cord. They are caused most often by vocal abuse or long-term exposure to irritants, such as chemical fumes or cigarette smoke. • Contact ulcers, a less common disorder, are erosions and sores on the vocal cords of people who consistently use great force when beginning to speak, instead of gradually increasing force and loudness. Contact ulcers may affect people who work as public speakers, physical education teachers and people who work in noisy environments. Ulcers also can be caused by gastroesophageal reflux (GERD) or heartburn, occurring when highly acidic stomach contents flow back up the esophagus and irritate the larynx. • Laryngitis is swelling of the vocal cords caused by inflammation or infection. Swollen vocal cords vibrate differently than usual, changing the typical sound of your voice. You can lose your voice if the inflammation is so severe that you can't make a sound. Laryngitis can be caused by vocal abuse, allergies, viral infection, reflux of stomach acids or exposure to irritating substances, such as cigarette smoke or too much alcohol. • Vocal cord tumors, which can be cancerous (malignant) or not cancerous (benign), occur most often in men aged 60 or older. Benign tumors can be caused by a virus or may be unusual growths of body tissue that will cause voice problems. Cancerous tumors are most likely to occur in smokers and people who drink too much alcohol. Cancerous tumors are life threatening if not caught and treated early. Rarely, tuberculosis bacteria can form a vocal cord lump that looks similar to cancer.

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• Vocal cord paresis occurs when one or both vocal cords don't open and close properly, changing voice quality. When one or both vocal cords don't move at all, this is called vocal cord paralysis. If both vocal cords are paralyzed and remain in the closed position, breathing can be difficult. Vocal cord paresis and paralysis can have several causes, including: o Surgical trauma, most often from thyroid surgery, but also from any neck or chest surgery o Head or neck trauma o Trauma during birth o A neurological disease (such as Parkinson's disease or multiple sclerosis) o Stroke o A tumor o A viral infection o Some debilitating diseases, such as myasthenia gravis

Paresis also can be the result of weakened vocal cord muscles. Vocal cord muscles can be weakened temporarily as a side effect of inhaled corticosteroid medicine sprays, or because of extended treatment with an artificial respirator (ventilator) in an intensive care unit.

Symptoms
Symptoms can vary, depending on the vocal cord disorder: • Vocal cord nodules — Hoarseness, low-pitched voice, breathy voice. Singers may notice a loss of vocal range. • Vocal cord polyps — Hoarseness, low-pitched voice, breathy voice • Contact ulcers — Some throat pain while talking, possible hoarseness, a voice that tires easily • Laryngitis — A change in the sound of the voice, from hoarseness to croaking or complete loss of voice and, if due to an infection, also fever, throat pain, malaise and a feeling of having to clear your throat • Vocal cord tumors — Hoarseness and, with large tumors, possibly trouble breathing or swallowing • Vocal cord paresis — Changes in the voice (hoarse, breathy, change of pitch, unable to get louder), discomfort from the strain of trying to move paralyzed cords, and possible breathing difficulties.

Diagnosis
Your doctor will ask about your medical history. The doctor will listen to the quality of your voice and then inspect your vocal cords, usually by holding a small mirror at the back of your mouth. To get a better view, the doctor may use a fiberoptic laryngoscope, which is a small, flexible lighted tube with a camera at the end that is inserted through the nose to the larynx. You will need to make certain sounds so your doctor can see your vocal cords in action. The examination may be videotaped so your doctor can analyze it later. This is all that is needed to diagnose most cases of laryngitis, vocal cord nodules and polyps.

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In some cases, your doctor may recommend an acoustic analysis, which is a series of tests that measure the quality of your voice, including its pitch stability, range and intensity. Often, these tests are used when vocal cords are paralyzed or if a growth must be removed surgically. Using the test results, doctors and voice therapists can judge the amount of improvement after treatment. Cancer of the larynx can look similar to a noncancerous growth or a contact ulcer. If an abnormality is found on the vocal cords, your doctor may do a biopsy, which involves removing a tiny sample of the affected vocal cord tissue so it can be examined in a laboratory under a microscope. Additional tests, such as computed tomography (CT) scans, may be required in some cases of vocal cord paralysis or cancer.

Expected Duration
• Vocal cord nodules — If you don't do anything to change your vocal cord abuse, nodules can last a lifetime, and even can come back after they are surgically removed. With proper voice training with a certified therapist, nodules can disappear within six to 12 weeks. • Vocal cord polyps — With rest, some vocal cord polyps will go away on their own within a few weeks. Most, however, have to be removed surgically. • Contact ulcers — It can take a long time for contact ulcers to heal. Some doctors recommend resting your voice for a minimum of six weeks. If the ulcers are caused by acid reflux, the reflux problem must be treated to keep your vocal cords healthy. • Laryngitis — Laryngitis caused by a viral infection usually goes away within one to three weeks. Laryngitis from vocal abuse usually goes away on its own in a few days with voice rest. • Vocal cord tumors — Noncancerous (benign) tumors generally do not go away; they must be removed surgically. Cancerous (malignant) tumors must be treated immediately to prevent the cancer from spreading. Untreated cancer of the larynx leads to death. • Vocal cord paresis or paralysis — In some cases, the voice returns on its own within a year. If not, the condition is likely to be permanent. Surgery may be done to try to improve speech.

Prevention
To prevent disorders caused by vocal abuse (including laryngitis, vocal cord nodes and polyps, and contact ulcers), consult a voice therapist who can teach you how to talk without straining your vocal cords. Look for a licensed and certified speech-language pathologist who specializes in voice. To prevent disorders related to gastroesophageal reflux (including contact ulcers and laryngitis), see your doctor to treat the reflux. Medications, including antacids, histamine (H2) blockers and proton pump inhibitors, can help to control stomach acid. Lifestyle changes also help some people. Changes include: • Eating smaller meals to avoid overfilling the stomach • Not eating or snacking three to four hours before sleeping to make sure all food is well digested before you lie flat • Raising the head of your bed a few inches to keep your head and upper chest higher than your stomach

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• Avoiding alcohol, caffeine, fatty foods, chocolate and peppermint, which may trigger heartburn To help prevent vocal cord disorders caused by irritation (including laryngitis and vocal cord polyps), avoid smoking, drinking or inhaling chemical irritants. To help prevent vocal cord cancer, quit smoking and limit your consumption of alcoholic beverages. If you use an inhaled corticosteroid medicine to treat asthma or other lung disease, you may be able to prevent vocal cord muscle weakness by using a spacer device that catches large medicine droplets too heavy to be carried deep into your lung airways. These large droplets can otherwise settle in your throat and trachea, where they can cause side effects. If you have viral laryngitis, cover your mouth when coughing and wash your hands often to prevent others from getting your infection.

Treatment
For vocal cord disorders resulting from vocal abuse, there are two main treatments: • For short-term relief, rest your voice — Speak or make sounds only when absolutely necessary. Try not to talk or whisper at all for a couple of days. • For long-term relief, voice therapy — Learn the proper way to speak to avoid straining your vocal cords. If rest and therapy don't resolve the disorder, other treatments are available, based on the type of disorder: • Vocal cord nodules may require surgical removal. • Most vocal cord polyps require surgical removal. • A contact ulcer may require surgical removal if it does not go away on its own after a minimum of six weeks of voice rest. You also may need voice therapy and treatment for gastroesophageal reflux. • Laryngitis caused by a virus needs rest and fluids. Antibiotics are not helpful to treat routine infections. • Vocal cord tumors require surgical removal if they are noncancerous (benign), and generally will not return. Treating cancerous tumors depends on the extent of the cancer. In the early stages, radiation, chemotherapy, surgery to remove a portion of the larynx or a combination of treatments may be needed. Some voice will remain after these procedures. In later stages of cancer, the entire larynx, including the vocal cords, must be removed (laryngectomy). You will need to learn a new speech method, using a special valve inserted surgically between the trachea and the esophagus, which allows air to be sent up the esophagus, creating enough vibrations for understandable speech. • People with vocal cord paresis or paralysis may be able to learn how to speak in different ways through voice therapy. If improvement is not satisfactory, surgery may be recommended to change the position of the affected vocal cord or to add bulk by injecting it with Teflon, collagen, silicone, body fat or some other substance. These types of procedures are recommended more often when one of the vocal cords is paralyzed. Both techniques bring the paralyzed cord closer to the cord that is not paralyzed, which then allows the cords to vibrate enough to make sounds. For people with two paralyzed vocal cords, the goal of treatment is to improve breathing. The

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most common procedure, a tracheotomy, creates a hole in the neck below the level of the vocal cords, and a breathing tube is placed into the hole. • Vocal cord muscle weakness due to inhaled corticosteroids may require a change in medicines, if using a spacer device does not prevent symptoms.

When To Call A Professional
See your doctor if you: • Lose your voice for more than two days • Are hoarse for more than two weeks • Have hoarseness accompanied by difficulty swallowing, a lump in the throat, unexplained pain or are coughing up blood

Prognosis
• Vocal cord nodules — Whether they disappear with voice rest and voice therapy or are surgically removed, nodules can come back if vocal abuse continues. • Vocal cord polyps — Even if polyps are removed successfully with surgery, polyps can return if you don't have voice therapy and don't stop inhaling irritating substances. • Contact ulcers — With rest, treatment of reflux and retraining the voice, most contact ulcers go away without complications in weeks or months. • Laryngitis — Most cases of laryngitis go away within a few days to a few weeks, depending on their cause. • Vocal cord tumors — Noncancerous (benign) tumors usually do not return after they are surgical removed, and you usually regain your normal voice. Cancerous tumors can be very serious, but the earlier they are detected and treated, the better the likelihood of survival and cure. Your voice may change dramatically, depending upon the extent of the cancer and the type of treatment. • Vocal cord paresis — Many instances of vocal cord weakness improve over time, which may take many months. • Vocal cord paralysis — Although some cases go away within a year on their own, many people require surgery to restore their voice, and many need voice therapy. With proper treatment, most people with one-sided vocal cord paralysis will regain good voice quality and control. People with two-sided vocal cord paralysis must relearn how to use their voices after they have had surgery to assist their breathing.

Additional Info
National Institute on Deafness and Other Communication Disorders NIDCD Information Clearinghouse 1 Communication Ave. Bethesda, MD 20892 Phone: (301) 496-7243 Toll-Free: (800) 241-1044 Fax: (301) 402-0018 TTY: (301) 402-0252 E-Mail: nidcdinfo@nidcd.nih.gov http://www.nidcd.nih.gov/

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Vocal Cord Contact Ulcers
Contact ulcers are raw sores on the mucous membrane covering the cartilage to which the vocal cords are attached. Contact ulcers are usually caused by abusing the voice with forceful speech, particularly as a person starts to speak. These ulcers typically occur in teachers, preachers, sales representatives, lawyers, and other people whose occupation requires them to talk a lot. Smoking, persistent coughing, and backflow (reflux) of stomach acid also may cause contact ulcers. Symptoms include mild pain while speaking or swallowing and varying degrees of hoarseness. A doctor makes the diagnosis by examining the vocal cords with a thin, flexible viewing tube. Occasionally, a small tissue sample is removed and examined under a microscope (biopsy) to make sure that the ulcers are not cancerous. Treatment involves resting the voice by talking as little as possible for at least 6 weeks so that the ulcers can heal. To avoid recurrences, people who develop contact ulcers need voice therapy to learn how to use the voice properly. A speech therapist can provide such instruction. If the person has acid reflux, treatment includes taking antacids, not eating within 2 hours of retiring for the night, and keeping the head elevated while sleeping. Last reviewed/revised February 1, 2003

Vocal cord nodules and polyps
Definition Vocal cord nodules and polyps are noncancerous growths on the vocal cords that affect the voice. Description The vocal cords, located in the voice box in the middle of the neck, are two tough, fibrous bands that vibrate to produce sound. They are covered with a layer of tissue that is similar to skin. With use, this layer thickens. With heavy use, the thickening may localize, producing a nodule. Unlike skin, heavy usage over a short time may also produce polyps. A polyp is a soft, smooth lump containing mostly blood and blood vessels. A nodule is similar to a polyp, but tends to be firmer. Causes and symptoms 9

Chronic infections caused by allergies and inhalation of irritants, such as cigarette smoke, may produce these lesions, but extensive use of the voice is the most common cause of vocal nodules and polyps. Nodules and polyps are more common in male children, female adolescents, and female adults. This may be due in part to the faster speed at which the cords vibrate to produce higherpitched voices. Voice alterations are most apparent in singers, who may notice the higher registers are the first to change. Hoarseness causes others to seek medical attention. Diagnosis The head and neck surgeon (otorhinolaryngologist) must see the vocal cords to diagnose these lesions. It is also important to confirm that there are not other problems instead of or in addition to these benign lumps. Other causes of hoarseness include throat cancers, vocal cord paralysis, and simple laryngitis. The cords can usually be seen using a mirror placed at the back of the tongue. More elaborate scopes, including a videostroboscope, allow better views while the cords are producing sounds. A biopsy of a nodule or polyp will ensure they are not cancerous. Treatment Nodules usually only require voice therapy; less than 5% of nodules require surgery. Small polyps can be treated with voice therapy, but typically they are surgically removed. Prognosis Continued overuse of the voice will cause these lesions to regrow. Prevention Careful use of the voice will prevent most vocal cord nodules and polyps. Avoiding inhaled irritants, may also prevent nodules and polyps from forming. Key Terms Laryngitis Inflammation of the larynx (voice box). Lesion A wound or injury. Otorhinolaryngologist A physician specializing in ear, nose, and throat diseases. Also known as otolaryngologist. For Your Information Resources Books 10

Ballenger, John Jacob. Disorders of the Nose, Throat, Ear, Head, and Neck. Philadelphia: Lea & Febiger, 1991.

Source: Gale Encyclopedia of Medicine, Published December, 2002 by the Gale Group The Essay Author is Polsdorfer.J.R., Vocal cord nodules and polyps, Http.WWW.HealthAtoZ.com

Vocal Cord Nodules And Polyps
• • • • • • • • Definition of Vocal Cord Nodules And Polyps Description of Vocal Cord Nodules And Polyps Causes and Risk Factors of Vocal Cord Nodules And Polyps Symptoms of Vocal Cord Nodules And Polyps Diagnosis of Vocal Cord Nodules And Polyps Treatment of Vocal Cord Nodules And Polyps Prevention of Vocal Cord Nodules And Polyps Questions To Ask Your Doctor About Vocal Cord Nodules And Polyps

Definition of Vocal Cord Nodules And Polyps Vocal cord nodules and polyps are small growths that develop on the vocal cords of some people. Description of Vocal Cord Nodules And Polyps

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The vocal cords are the folds of mucous membrane in the larynx. The superior pair are called the false, and the inferior pair are the true vocal cords. These thin, reed-like bands vibrate to make vocal sounds during speaking and are capable of producing a vast range of sounds. One end of each cord is attached to the front wall of the larynx. The opposite ends are connected to two tiny cartilages near the back wall of the larynx. A vocal cord nodule is a small, inflammatory or fibrous growth that develops on the vocal cords of people who constantly strain their voices. These are also called screamer's nodule, singer's nodule and teacher's nodule. A vocal cord polyp is a small swelling in the mucous membranes covering the vocal cords. As they grow, they take on a rounded shape. They may run the whole length of the vocal cords or be localized. Causes and Risk Factors of Vocal Cord Nodules And Polyps People who use their voices a great deal, such as professional singers, teachers, auctioneers, lecturers, and members of the clergy, are prone to have nodules on their vocal cords. Like polyps, nodules may develop as a result of excessive use of the voice. A nodule differs from a polyp in that it is a growth of the epithelium that covers the mucous membrane, not of the mucous membrane itself. Thus, it has a structural resemblance to a corn on a toe or a callus on the hand. If one has vocal cord nodules, the voice will become breathy and hoarse. Polyps are lesions that develop from voice abuse, chronic laryngeal allergic reactions and chronic inhalation of irritants, such as industrial fumes and cigarette smoke. It may also be seen in hypothyroidism. Symptoms of Vocal Cord Nodules And Polyps Polyps can make the voice become breathy-sounding and harsh. The person may complain of hoarseness. Diagnosis of Vocal Cord Nodules And Polyps It is important to rule out squamous cell carcinoma of the larynx. Your physician may recommend indirect laryngoscopy to visualize the vocal cords. Treatment of Vocal Cord Nodules And Polyps Treatment requires modification of voice habits, and referral to a speech therapist may be indicated. Resting the vocal cords by allowing little or no speaking for several weeks may permit the nodules to shrink. Children occasionally have screamer's voice nodules and these can be treated by voice therapy alone. Inhaled steroid spray may be helpful. Sometimes biopsy and surgical removal are necessary. They can be removed during the course of a special examination (a laryngoscopy) in which a metal tube with a light on the end is passed through the mouth and into the throat. A small, sharp, cup-shaped punch is threaded through the tube and used to clip off the polyps. Biopsy of the polyp may be performed in order to be certain that there is no cancer. Removal of a polyp should be followed by voice therapy to correct the underlying cause. Prevention of Vocal Cord Nodules And Polyps

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Good • • • • •

preventive practices include: Properly using the voice to eliminate strain Avoiding screaming and loud talking Speaking in a normal range that is comfortable Not whispering or speaking at a higher or lower pitch than is natural Releasing neck tension by gently tipping the head forward and to each side while keeping the shoulders down.

Questions To Ask Your Doctor About Vocal Cord Nodules And Polyps Do any tests need to be done to establish the cause? How severe is the condition? What is the prognosis? What treatment do you recommend? How effective is this treatment for the condition? How long will it take for relief of symptoms? If conservative treatment fails, is surgery necessary? What can be done to prevent this from recurring? Do you recommend speech therapy?
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Vocal Cord Nodules and Polyps
Vocal cord nodules and polyps are noncancerous growths that produce hoarseness.

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Vocal Cord Problems

When relaxed, the vocal coards normally form a V-shaped opening that allows air to pass freely through to the trachea. The cords open during speech and close during swallowing. Holding a mirror in the back of a person's mouth, a specially trained doctor can often see the vocal cords and check for problems, such as contact ulcers, polyps, nodules, paralysis, and cancer, all of which affect the voice. Paralysis may affect one (one-sided) or both vocal cords (two-sided—not shown).

Vocal cord nodules and polyps are similar conditions that develop mainly from abuse of the voice (prolonged singing or shouting). Chronic irritation of the larynx, such as occurs with inhalation of cigarette smoke or industrial fumes, or backflow (reflux) of stomach acid at night may also cause a nodule or polyp to form. The growths are similar, but polyps tend to be larger and protrude somewhat more than nodules. Symptoms include chronic hoarseness and a breathy voice, which tend to develop over days to weeks. A doctor makes the diagnosis by examining the vocal cords with a thin, flexible viewing tube. Sometimes the doctor removes a small piece of tissue for examination under a microscope (biopsy) to make sure the growth is not cancerous. Treatment is to avoid whatever is irritating the larynx and rest the voice. If abuse of the voice is the cause, voice therapy conducted by a speech therapist may be needed to teach the person how to speak or sing without straining the vocal cords. Most nodules go away with this treatment, but most polyps must be surgically removed to restore the person's normal voice.

Last reviewed/revised February 1, 2003

Vocal Cord Paralysis
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Vocal cord paralysis is the inability to move the muscles that control the vocal cords. Vocal cord paralysis may affect one or both vocal cords. Paralysis can result from brain disorders, such as brain tumors, strokes, and demyelinating diseases (see Multiple Sclerosis and Related Disorders: Introduction), or damage to the nerves that lead to the larynx. Nerve damage may be caused by noncancerous and cancerous tumors; injury; a viral infection of the nerves; or neurotoxins (substances that poison or destroy nerve tissue), such as lead or the toxins produced in diphtheria.

Symptoms and Diagnosis
Vocal cord paralysis may affect speaking, breathing, and swallowing. Paralysis may allow food and fluids to be inhaled into the windpipe (trachea) and lungs. If only one vocal cord is paralyzed, the voice is hoarse and breathy. Usually, the airway is not obstructed because the normal cord on the other side opens sufficiently. When both vocal cords are paralyzed, the voice is reduced in strength but otherwise sounds normal. However, the space between the paralyzed cords is very small, and the airway is inadequate so that even moderate exercise causes difficulty in breathing and a harsh, high-pitched sound with each breath. A doctor tries to find the cause of the paralysis. Examination of the larynx, bronchial tubes, or esophagus with a thin, flexible viewing tube may be performed. Magnetic resonance imaging (MRI) or computed tomography (CT) of the head, neck, chest, and thyroid gland and x-rays of the esophagus also may be needed.

Treatment
The first goal of treatment is to prevent closure of the airway from the paralyzed cord. If only one side is paralyzed, an operation called a thyroplasty can be performed to move the paralyzed vocal cord to the best position for more normal speech. When both sides are paralyzed, keeping the airway open adequately is difficult. A tracheostomy (surgery to create an opening into the trachea through the neck) may be needed. The tracheostomy opening may be permanent or may be used only when the person has an upper respiratory tract infection. In another procedure, called an arytenoidectomy, the vocal cords are permanently separated, thus widening the airway. However, this procedure may worsen voice quality.

Last reviewed/revised February 1, 2003

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Vocal Cord Paralysis
What are the vocal cords? The vocal cords (or folds) are two small muscles located within the larynx (voice box) that are responsible for voice production. They are found at about the level of the Adam's apple (thyroid cartilage) in the neck. The vocal cords are very small (about 18mm in length for males and 11mm in length for females). How is voice/speech produced? Most of the time the vocal cords lie apart, forming a "V" shaped opening. During speech, the vocal cords come together and produce sound by vibrating. Movement of the lips and tongue change this sound to create individual speech sounds. What is vocal cord paralysis? Each vocal cord muscle is moved by a nerve called the recurrent laryngeal nerve (one on each side). If the nerve does not function properly, the attached vocal cord cannot move. This is vocal cord paralysis. This paralysis can result in either breathing or speech problems. Damage to one vocal cord causes a "breathy" voice, but rarely any breathing problems. Damage to both vocal cords causes severe noisy breathing (stridor), but the voice remains strong. What are vocal cord nodules? Vocal cord nodules are callous-like bumps on the vocal cords. They can form on one or both of the cords. They usually are located on the front 1/3 of the vocal cord, and range in size from a pinhead to a split pea. During normal speech, the vocal cords should press firmly together. However, if nodules are present the cords cannot close completely. Therefore, extra air escapes and the voice sounds hoarse and breathy as a result. Are vocal cord nodules always the cause of a hoarse voice? No, although vocal cord nodules are a common cause of persistent HOARSENESS, they are not the only cause. It is important to be evaluated by your doctor for any hoarseness present for more than four months. What causes vocal cord nodules? Any one or more of the following can contribute to the development of vocal cord nodules: 1) Misuse of the voice • • • The use of an incorrect pitch, volume, or quality Inadequate breath support Excessive tension in the neck muscles when speaking

2) Abuse of the voice (the most common cause of vocal nodules in children) • • • Excessive shouting, screaming cheering or crying Strained vocalizations (for example, sounds used to imitate animal noises or motors) Excessive loud talking

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• •

Hard vocal attacks (starting words abruptly) Excessive coughing or throat clearing

3) Other factors • • • • • • • Chronic (long standing) upper respiratory infections or allergies Exposure to smoking Reflux (stomach acid coming up the swallowing tube) Endocrine or Hormonal imbalance Fatigue Allergies Personality or general adjustment of the child

How do vocal cord nodules develop? Vocal abuse and misuse cause the vocal cords to close with excessive force (i.e. bang together). This may result in the formation of vocal nodules at the point of maximum contact. As the nodules begin to form, a slight reddening can be noted on the margin of the cord. This reddening is soon followed by a localized swelling or thickening on the edge of the cord. Finally, a definite nodule or bump develops and becomes harder and more fibrotic with time, just like a callous can form on your hand if you use a shovel without gloves. Is there any pain associated with the development of vocal cord nodules? At no time during the development of the nodules is there pain associated. The most common symptom of the presence of nodules is the breathy and hoarse quality of the voice. If you have pain, you should consult your doctor immediately. How are vocal cord nodules treated? The treatment of vocal nodules usually includes voice (or speech) therapy. This is best performed for at least 6months in twice-weekly 30 minute sessions. Why is surgical removal alone usually not recommended? It is important to understand that unless the causes of the vocal cord nodules are eliminated, the vocal cord nodules will most likely return no matter how often they are surgically removed. Surgery is not advisable for children with vocal cord nodules. (with rare exception) What is the purpose of voice therapy? The purpose of voice therapy is to reduce the vocal abuse or eliminate vocal misuse. It helps eliminate the causes of the nodules and teaches the child more efficient use of his/her voice. What is involved with voice therapy? The first step is to identify how the child uses his/her voice. The child must then be aware of these habits in order that they may be eliminated. It may be necessary to establish a new set of rules regarding the way in which the child may use his/her voice, and can include the following: • Limit screaming, yelling, shouting, and long periods of singing

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• • • • •

Encourage the child to walk to where you can hear him rather than shout Replace abusive motor or animal sounds with less abusive sounds (sounds made with the lips for example, and not the voice) Replace throat clearing and dry coughing with hard swallowing and drinks of water (increase in fluid intake in general is helpful) Limit trying to talk over loud noises Rest the voice after loud periods occur, involving the child in a quiet, non-talking activity (for example, coloring)

How important is the family in the process? Although continued follow-up by the otolaryngologist and speech pathologist are essential components of your child's overall therapy program, the family's participation and encouragement can mean the difference between success and failure in the treatment of vocal nodules. What are some ways the family and people in the child's environment can help? These people can help to enforce the child's new vocal behaviors with consistency. It is also important that the people in the child's environment work to set a good example for the child. How should these new vocal behaviors or "rules" be enforced? Positive reinforcement is usually the most effective way. Praise him/her whenever you notice him practicing a new rule. Try not to nag about the bad habits; instead, point out the correct way to do it if you notice a slip. The child must learn that appropriate behavior gets good.

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Dysphonia (voice disorder) Written by Dr Michael SW Lee, specialist registrar in otolaryngology, Ninewells Hospital, Dundee What is dysphonia? Dysphonia is a descriptive medical term meaning disorder (dys- ) of voice (-phonia). There are many causes of dysphonia. Fortunately more than half of people with voice complaints have a benign (non-cancerous) cause. How is voice normally produced? The generation of voice requires a sound-producing ('phonatory') system, a control centre and a network connecting the two. Phonatory system The larynx (voice box) has a framework of cartilage with muscles attached to different structures. It also has a pair of vocal cords which move apart on breathing in (inspiration) and come closer together on breathing out (expiration). The vocal cords resemble two small blinds that can be drawn across from the side of the larynx in to the middle, thus causing a variable restriction in the amount of air that can pass through. According to how tightly the muscles tense the edges of the vocal cords and how much breath pressure is applied, the frequency of vibration of the cords can be changed very rapidly, which generates the tone of the sound being produced. The pharynx (area at the back of the throat) and oral cavity act together as a sound resonator. Understandable voice is produced by co-ordinated movements of the tongue, lower jaw and soft palate the flexible part of the roof of the mouth. This process is called articulation. Clearly it is a complex system, depending for its success on sophisticated control. Control centre The brain acts as a control centre which receives and sends out signals to different parts of the body including the diaphragm, muscles of the chest wall, abdomen, larynx, pharynx, oral cavity, tongue, soft palate and lower jaw and co-ordinates their movements. Connecting network The crucial nerves that carry the brain's signals to the muscles of phonation are the laryngeal nerves, which are themselves branches of the 10th cranial nerve the 'vagus' nerve. As with the other cranial nerves, (which all exist in pairs) the vagus arises directly from the brain, rather than from the spinal cord, and travels through a specific opening in the skull to reach its location. What symptoms do people with dysphonia have? People with dysphonia may present with hoarseness and a sore or dry throat. A singer may notice that he or she is no longer able to sing in the upper range. There may be other associated symptoms such as a continuous drip at the back of the throat (nasal catarrh) and heartburn <./000419.html>. When should a patient seek treatment? Any person who has been hoarse for four weeks or more should seek medical attention from their family doctor. They may require to be seen by an ear, nose and throat specialist for further examination including inspection of the larynx. This can be done quite easily (by the specialist!) using an angled mirror, or flexible fibre-optic 'telescope'.

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Persistent hoarseness, difficulty in swallowing, sore throat <./000190.html>, choking when swallowing (especially fluids), persistent earache <./000402.html>, coughing up blood, weight loss and loss of appetite may indicate a more serious condition and should always be taken seriously. Causes of dysphonia Inflammation of the larynx (voice box) over a short (acute) or long (chronic) period of time. Lumps (nodules) on the vocal cords (eg singer's nodules). Underactive thyroid gland hypothyroidism <./000062.html>. Trauma - any kind of trauma, including surgery, to the vocal cords will inevitably cause scarring and hence affect the vocal fold function. The risk of permanent voice change therefore needs to be discussed prior to surgery on the larynx. Vocal cord paralysis some other surgical operations including removal of the thyroid gland and heart or lung surgery can damage the nerves to the larynx causing either temporary or permanent vocal cord paralysis (palsy). Reinke's oedema of the larynx. Psychological - voice changes are not uncommon when people are under stress either at work or at home. The voice may be lost suddenly, usually overnight or following a cold. It is important to identify and remove the underlying stress. Speech therapy is very useful for this cause. The above conditions are commonly seen in ENT (ear, nose and throat) specialist clinics but there are many other relatively uncommon and rare diseases not mentioned here. How is dysphonia treated? Each condition has its own specific treatment, and the treatment should also be tailor-made to each individual. The general principles of management are described below. Conservative therapy Every attempt should be made to identify and eliminate causative factors such as stress, smoking, and alcohol. Drink plenty of clear fluid to avoid a dry throat. Rest the voice completely for two to three days. No talking or whispering is allowed. Communicate to others by writing everything down on a note pad. Speech therapy The speech therapist plays an important role in the assessment and treatment of patients with voice disorders, eg Reinke's oedema, vocal cord nodules and voice misuse. The therapy will take some weeks or months before any improvements are noticed and so the patient must be highly motivated. Medical therapy Upper respiratory tract infections, eg acute laryngitis <./003187.html>, are commonly caused by viral infections. Bed rest, regular paracetamol and saline or soluble aspirin gargles are often adequate. Antibiotics are only indicated when there is bacterial infection. Inhaled sprays such as Beconase are used to treat patients who suffer from chronic inflammation of the sinuses and nasal lining and who get catarrh dripping down the back of the throat. Medications to reduce acid secretion by the stomach are used to treat patients with gastro-oesophageal reflux <./000136.html>. Surgery Surgery is indicated for diagnosis (eg tissue biopsies <./000214.html>) and treatment (eg removal of tumours and laser surgery). The operation is performed with a fibre-optic viewing 'telescope' (endoscope) under general anaesthesia. The view of the larynx is magnified with a microscope so that delicate operations can be carried out. The procedure is known as 'microlaryngoscopy' or 'endolaryngeal microsurgery'. Surgical management of non-cancerous causes of voice disorders is only indicated when all the other measures have failed.

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These small vocal cord elevations or nodules have a tiny capillary in the one on the right. They impair the singers voice on soft singing above note G5 up through C6.

These vocal cord elevations are fairly discrete. The left one has a small capillary within it.

A muscle tension often develops holding the cords slightly apart with nodules. They must be held slightly apart during vibrations or they will stop vibrating because the nodules dampen the cords when they touch.

This is the prephonation position just before blowing air through the vocal cords. Notice a gap in front of and behind the central vocal elevations or nodules.

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