How do vocal nodules form?
Vocal nodules form from repeated forceful vibration, or hyperfunction, of the vocal folds. The delicate lining of one or both vocal folds begins to swell, and over time a callus, or nodule, develops on the epithelium, or protective layer, of the fold. They form on the area of the folds that have the greatest impact with each other, which is generally around the juncture of the anterior and middle third of the vocal folds (Boone et al., 2010; Seikel, Drumright, & Seikel, 2004).
Vocal nodules form from repeated forceful vibration, or hyperfunction, of the vocal folds. The delicate lining of one or both vocal folds begins to swell, and over time a callus, or nodule, develops on the epithelium, or protective layer, of the fold. They form on the area of the folds that have the greatest impact with each other, which is generally around the juncture of the anterior and middle third of the vocal folds (Boone et al., 2010; Seikel, Drumright, & Seikel, 2004).
Healthy vocal folds are white, glossy, and elastic. Each fold is made of five layers: an elastic cover (the superficial epithelium), a gelatinous layer (the superficial lamina propria), an elastic layer (the intermediate lamina propria), a collagenous layer (the deep lamina propria), and a muscular layer (the vocalis muscle) (Boone, et al., 2010;Smith, Underbrink, Quinn, & Quinn, 2013). Each layer works together to perform the delicate balance of healthy, coordinated phonation; they create a unique vibrating quality that is called the "mucosal wave." It can be seen during a laryngostroboscopic examination. Image retrieved from www.neogaf.com
Videostroboscopy of Healthy Vocal Folds
Vocal folds that have been abused will start to swell, decreasing their flexibility and interrupting the mucosal wave. Vocal symptoms will start to appear.
Image retrieved from http://www.fauquierent.net/vocalcordnodule.htm |
With continued abuse, calluses (or nodules) form at the point of greatest impact. As the vocal folds come together, a "chink" is formed from the area where the nodules touch each other, causing incomplete closure (or, adduction) of the vocal folds and the escape of air during phonation (Boone et al., 2010). The classic "hourglass" shape is seen during vibration.
Image retrieved from voicecounseling.blogspot.com |
Who gets vocal nodules?
Vocal nodules are most common among prepubescent boys and adult women. A 2001 study by Pontes, Kyrillos, Behlau, DeBiase, & Pontes, found that an anatomical laryngeal pattern in young women made them more susceptible muscle tension, voice abuse, and vocal nodules. A literature review of vocal nodules in young children by Martins, Branco, Tavares, & Gramuglia (2013) noted that they are the most common cause for dysphonia in children, and that most cases occur in boys ages 7-12.
Image retrieved from commons.wikimedia.org
Vocal nodules are most common among prepubescent boys and adult women. A 2001 study by Pontes, Kyrillos, Behlau, DeBiase, & Pontes, found that an anatomical laryngeal pattern in young women made them more susceptible muscle tension, voice abuse, and vocal nodules. A literature review of vocal nodules in young children by Martins, Branco, Tavares, & Gramuglia (2013) noted that they are the most common cause for dysphonia in children, and that most cases occur in boys ages 7-12.
Image retrieved from commons.wikimedia.org
What are the symptoms of vocal nodules?
The earliest symptoms of vocal nodules are often a change in the quality of voice, hoarseness, breathiness, and a loss of quality and range, particularly on higher pitches (American Academy of Otolaryngology-Head and Neck Surgery, 2014; Boone et al., 2010; Chang, 2014). The symptoms of vocal nodules may change, increase, or decrease, but they will not go away without intervention (American Academy of Otolaryngology-Head and Neck Surgery, 2014).
Image retrieved from www.webmd.com
Other symptoms include:
The earliest symptoms of vocal nodules are often a change in the quality of voice, hoarseness, breathiness, and a loss of quality and range, particularly on higher pitches (American Academy of Otolaryngology-Head and Neck Surgery, 2014; Boone et al., 2010; Chang, 2014). The symptoms of vocal nodules may change, increase, or decrease, but they will not go away without intervention (American Academy of Otolaryngology-Head and Neck Surgery, 2014).
Image retrieved from www.webmd.com
Other symptoms include:
- Pitch breaks
- Neck pain
- Frequent throat clearing
- A "lump in the throat" sensation
- Vocal fatigue
- Deterioration with continued voicing
- Excess mucus on the vocal folds
- A lower-pitched voice
- A breathy, flat-quality voice
- Increased aperiodicity
- The inability to sing soft and high
- Delayed vocal initiation
- A unreliable voice
- The need to use extra force during voicing
- the inability to hold a steady pitch
- Throat discomfort or neck pain
Bilateral Vocal Nodules
For more audio and video samples of voice with vocal nodules, visit http://www.fauquierent.net/voiceupper.htm#nodule2
Implications for the Speech Language Pathologist
Vocal Hygiene
Speech pathologists can help to prevent vocal nodules by educating the public in vocal hygiene. Since vocal nodules are a functional voice disorder, or one that is brought about by behavioral and/or environmental factors, they can be prevented through education and healthy voice technique. The speech pathologist can reach out to those who are at risk for functional voice disorders, such as teachers, cheerleaders, athletes, and singers through workshops, presentations, brochures, or with the internet.
Voice Therapy
Once a qualified laryngologist has diagnosed vocal nodules, the speech pathologist can help to treat them with voice therapy or by referring the patient to another voice professional, like a singing voice specialist or voice teacher.
Vocal Hygiene
Speech pathologists can help to prevent vocal nodules by educating the public in vocal hygiene. Since vocal nodules are a functional voice disorder, or one that is brought about by behavioral and/or environmental factors, they can be prevented through education and healthy voice technique. The speech pathologist can reach out to those who are at risk for functional voice disorders, such as teachers, cheerleaders, athletes, and singers through workshops, presentations, brochures, or with the internet.
Voice Therapy
Once a qualified laryngologist has diagnosed vocal nodules, the speech pathologist can help to treat them with voice therapy or by referring the patient to another voice professional, like a singing voice specialist or voice teacher.
Dr. Dan, Singing Voice Specialist, on Vocal Nodules
This web site compiled by Cathy Carsen, Christina Hammond Cole, Andrea Hanton, and Allie Leino