Vocal Nodule Treatment
Treatment for vocal nodules includes both invasive and noninvasive techniques. They may be treated behaviorally, medically, and/or surgically. Since current research indicates that nodules are directly related to vocal use and technique, attention to correcting the underlying causative factors through voice therapy and education is the first line of treatment (Buckmire, 2008). Successful treatment is highly individual and will largely depend on the degree of voice limitation, the specific voice demands of the patient, and the clinical judgment of the speech pathologist and otolaryngologist (“Fact Sheet: Nodules,
”n.d.).
The following are some of the more prevalent treatment options for vocal fold nodules:
> Voice Therapy
> Voice Rest
> Surgical Removal
> Steroid Injections
> Treatment of Comorbid Conditions
> Psychological Support
”n.d.).
The following are some of the more prevalent treatment options for vocal fold nodules:
> Voice Therapy
> Voice Rest
> Surgical Removal
> Steroid Injections
> Treatment of Comorbid Conditions
> Psychological Support
Doctors at Mayo Clinic demonstrate the importance of voice therapy in the treatment of vocal nodules
Voice Therapy
Whether nodules are small and recently acquired or large and long-established, voice therapy should almost always be the first course of treatment. Studies have shown that voice therapy can decrease the severity of dysphonia, decrease nodule size and edema, and in many cases, completely resolve the disorder. For example, a study by Holmberg, Hillman, Hammarberg, Sodersten, and Doyle (2001) demonstrated a significant decrease in the severity of dysphonia in 11 adult women with vocal nodules following behavioral voice therapy (Boone, McFarlane, Von Berg, & Zraik, 2010). Voice therapy involves many different components, including reducing abusive vocal behaviors, teaching good vocal hygiene, and direct treatment to alter loudness, pitch, or respiration for good voicing. Since relaxation is an important factor in optimum vocal production, stress-reduction techniques and relaxation exercises are often taught as well (“Vocal Fold Nodules,” 2011).
Boone’s four-point program for adults with vocal nodules includes the following components (Boone et al., 2010);
1. Identifying vocal abuse/misuse
> Abuses may include; yelling and screaming, coughing and excessive throat clearing, smoking, excessive talking or singing (especially while
having an allergy or upper respiratory infection), speaking in a noisy environment, excessive crying or laughing, and using effortful “grunts” while
weight lifting
> Misuses include; speaking over time at an inappropriate pitch level, speaking with hard glottal attack, excessive singing at the upper or lower end of
one’s vocal range, speaking at intensity levels that are excessive, speaking or singing for very long periods of time, cheerleading, and increasing
loudness by squeezing out the voice at the level of the larynx
2. Reducing the behaviors of abuse/misuse
3. Working with the patient to find facilitating techniques that result in optimal voice production
4. Utilizing the facilitation technique that works best as practice for optimal voice production
Boone suggests several facilitating techniques as being effective in reducing the vocal hyperfunction that is related to nodules. These include relaxation exercises, respiration training, and a number of specific techniques, such as;
> Change of loudness—Often clients will develop vocal nodules when they use excessive voice loudness. Once nodules develop, clients will push for loudness at the level of the larynx when they are unable to produce a loud voice due to a lack of vocal fold approximation. By addressing this symptom of
vocal nodules, the change of loudness technique can reduce a source of vocal hyperfunction.
> Confidential Voice—teaches use of a soft,“confidential” voice in order to reduce hyperfunctional behaviors.
> Open-Mouth approach—reduces hyperfunction by utilizing more oral openness while speaking. It promotes more optimum approximation of the vocal folds and facilitates a louder-sounding voice.
> Yawn—Sigh technique—helps the oral mechanisms assume a more relaxed position by lowering the larynx, moving the tongue anteriorly, and slightly opening the vocal folds.
Boone’s four-point program for adults with vocal nodules includes the following components (Boone et al., 2010);
1. Identifying vocal abuse/misuse
> Abuses may include; yelling and screaming, coughing and excessive throat clearing, smoking, excessive talking or singing (especially while
having an allergy or upper respiratory infection), speaking in a noisy environment, excessive crying or laughing, and using effortful “grunts” while
weight lifting
> Misuses include; speaking over time at an inappropriate pitch level, speaking with hard glottal attack, excessive singing at the upper or lower end of
one’s vocal range, speaking at intensity levels that are excessive, speaking or singing for very long periods of time, cheerleading, and increasing
loudness by squeezing out the voice at the level of the larynx
2. Reducing the behaviors of abuse/misuse
3. Working with the patient to find facilitating techniques that result in optimal voice production
4. Utilizing the facilitation technique that works best as practice for optimal voice production
Boone suggests several facilitating techniques as being effective in reducing the vocal hyperfunction that is related to nodules. These include relaxation exercises, respiration training, and a number of specific techniques, such as;
> Change of loudness—Often clients will develop vocal nodules when they use excessive voice loudness. Once nodules develop, clients will push for loudness at the level of the larynx when they are unable to produce a loud voice due to a lack of vocal fold approximation. By addressing this symptom of
vocal nodules, the change of loudness technique can reduce a source of vocal hyperfunction.
> Confidential Voice—teaches use of a soft,“confidential” voice in order to reduce hyperfunctional behaviors.
> Open-Mouth approach—reduces hyperfunction by utilizing more oral openness while speaking. It promotes more optimum approximation of the vocal folds and facilitates a louder-sounding voice.
> Yawn—Sigh technique—helps the oral mechanisms assume a more relaxed position by lowering the larynx, moving the tongue anteriorly, and slightly opening the vocal folds.
Voice Rest
Voice rest may improve the voice and even shrink the nodules, but will most likely not eliminate them. Voice rest serves to soften and dissolve swelling associated with phonotrauma (Sulica, 2009). It also avoids further injury and facilitates healing. Extreme voice rest may initially involve a period of four to seven days of using the voice no more than 15 minutes in a 24 hour period. After that point, the patient might begin slowly reintroducing voice by keeping his or her speech succinct, avoiding loud voice, keeping phone calls to a minimum and avoiding non-speech voice use such as coughing, throat-clearing, crying, and odd sound effects (Bowen, 1998). Of course, the underlying patterns of vocal abuse or misuse must be changed if the voice is to be restored permanently. Otherwise, the symptoms will simply recur as soon as vocal hyperfunction returns (Sulica, 2009).
Surgical Removal of Nodules
When vocal nodules do not respond to voice therapy alone, surgery is needed. However, surgical removal of nodules is rare, and occurs in fewer than 5% of cases (Buckmire, 2008). Nodules that require surgery are often very large or have existed for a long time. Microlaryngoscopic surgery removes the
accumulated tangle of hardened tissue from the true vocal cord edge under general anesthesia (Sulica, 2009). The goal of surgery is to create a straight
medial true vocal fold edge without any divots or excess tissue remaining, and to do this with minimal disruption of the normal tissue (Buckmire, 2008). Of
course, surgery must be followed by voice therapy in order to remove the underlying hyperfunctional behaviors. Otherwise, nodules will most likely reoccur just several weeks post-surgery. In addition, the risks of surgical scarring must be weighed against the current level of vocal dysfunction, the benefits of the procedure, and the certainty of the diagnosis. Nodules in children will rarely be treated with surgery (Sulica, 2009).
accumulated tangle of hardened tissue from the true vocal cord edge under general anesthesia (Sulica, 2009). The goal of surgery is to create a straight
medial true vocal fold edge without any divots or excess tissue remaining, and to do this with minimal disruption of the normal tissue (Buckmire, 2008). Of
course, surgery must be followed by voice therapy in order to remove the underlying hyperfunctional behaviors. Otherwise, nodules will most likely reoccur just several weeks post-surgery. In addition, the risks of surgical scarring must be weighed against the current level of vocal dysfunction, the benefits of the procedure, and the certainty of the diagnosis. Nodules in children will rarely be treated with surgery (Sulica, 2009).
Steroid Injections
The authors of a 2004 study that appeared in the European Archives Of Oto-Rhino-Laryngology (Tateya, Omori, Kojima, Hirano, Kaneko, & Ito, 2004) suggest that steroid injections directly into the vocal fold using fiberoptic laryngeal surgery (FLS) may be effective in treating vocal nodules that are not responsive to more conservative voice therapy. This study evaluated 28 patients with vocal nodules who underwent steroid injection using FLS under topical anesthesia. Fiberoptic laryngeal surgery involves inserting a fiberscope that is connected to a camera system transnasally, so that a high resolution laryngeal image can be displayed on a monitor. A special curved needle is then inserted orally and the steroid is injected into the site of the lesion. Post-surgery endoscopic findings revealed that nodules disappeared in 17 of the 27 patients and decreased in 10 of the 27 patients. The maximum phonation time increased from 10.9 s before the operation to 13.9 seconds after the operation, representing a significant improvement. In addition, patients’ self-rating of hoarseness showed significant improvement after the injection. The authors stress that this technique must be combined with voice therapy in order to effectively treat vocal nodules.
Treatment of Comorbid Conditions
There are several medical conditions that will contribute to the formation or severity of vocal nodules. These include gastroesophageal reflux diseas (GERD), allergies, and thyroid problems. These must be treated in order to reduce their negative effects on the vocal cords. At times, medical intervention might be needed to help a client stop smoking or reduce their stress, as these also contribute to vocal dysfunction (“Vocal Fold Nodules,” 2011).
Psychological Support
Boone suggests that the clinician will also need to provide psychological support in the treatment of nodules. For young children with vocal nodules, quality of life is often compromised in the social—emotional, and physical—functional domains. Studies have shown that as children get older, their nodules and resulting dysphonia will cause them to suffer more social and emotional handicap (Boone et al., 2010).