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Vocal Nodules and Voice Therapy

Monday, August 24, 2009

Sugarland, a Grammy-winning country music band, has been touring all over the country this year.  When they performed in Washington, D.C., one of my friends went to the concert and was disappointed in the fact that they only played for about an hour.  Her friend pointed out that it might be due to the fact that earlier this summer, Jennifer Nettles, the lead singer for Sugarland, was put on vocal rest, and therefore had to cancel several concerts.  This got me thinking about the importance of good vocal hygiene and wondering if other singers or performers have had similiar concerns, and if so, what therapy they were prescribed for their voice.  After doing some research, I found that in fact many celebrities have had vocal concerns, the most common being vocal nodules.  According to www.wikipedia.org, celebrities such as Justin Timberlake, Mariah Carey, Omarion, Rod Stewart, and Victor Willis, the lead singer of The Village People, have all reportedly had vocal nodules. Rachel Ray reportedly had a successful surgery to remove her vocal nodules.  Julie Andrews had surgery to remove her vocal nodules and the surgery went awry contributing to the loss of her singing voice.  This information led me to think about the different options in treating the voice, especially vocal nodules, and in an effort to help those that have vocal nodules in pop-culture and in the real world, I will explain exactly what vocal nodules are, how they are diagnosed, and the different options to treat them.


One of the most common reasons to receive voice therapy is vocal fold nodules.  Vocal fold nodules are non-cancerous growths on the vocal folds that are typically caused by vocal abuse, which can include yelling, speaking loudly and harshly over an extended period of time, strain or stress on the folds, and excessive throat clearing or coughing.  The nodules are usually found on the anterior and middle two-thirds of the vocal folds where contact of the vocal folds is strongest.  They start out as tiny bumps on the vocal folds and as the abusive vocal behavior continues, these bumps get harder and larger, eventually forming a nodule, which is similiar to a callus.


A change in the voice is the most obvious sign that someone has vocal nodules on their vocal folds.  A person with vocal nodules presents with a voice that can be breathy, harsh, hoarse, rough, or scratchy.  People with vocal nodules also report that at times, they feel like they have a lump in their throat, have a decreased range in their voice, and/or have voice and body fatigue.  If the vocal symptoms persist for more than 2 weeks, consulting a physician and a speech and language pathologist is recommended.


Vocal nodules are diagnosed through a variety of means, which can include an evaluation from a physician, preferably an otolaryngologist (ear, nose, and throat doctor) and a speech and language pathologist.  The evaluation will examine the patient's vocal range, pitch, loudness, and ability to sustain voicing over an extended period of time.  The otolaryngologist could also conduct a nasendoscopy in which a small, flexible camera is inserted through the nose reaching the top of the vocal folds to examine the folds during rest and phonation.  A stroboscope can be attached to the equipment to slow down the image of the folds vibrating giving a clearer picture of the vocal folds.


Vocal nodules can be treated in a variety of ways that include behaviorally and surgically.  Surgery is an option, but is typically reserved for rare occassions when the nodules are large and have been on the folds for an extended period of time.  It is important when working with someone that has vocal nodules that the behavior that contributed to the vocal nodule formation be addressed.  This is when an evaluation and therapy with a speech and language pathologist (SLP) would be necessary.  Therapy is dependent on the client's individual needs, but it would be important to closely examine how the client is using their voice throughout their days, to listen for excessive throat clearing or coughing, and to examine how often they are speaking throughout the day and for how long they are continuously speaking.   There are many different therapy techniques a SLP can do to teach better vocal hygiene and ways to preserve and use the voice more appropriately over time.  Therapy takes time and results may not be as immediate as when the nodules are surgically removed, but it is important to know that surgery is not always necessary to remove vocal nodules.  Teaching proper speaking techniques, vocal hygiene, and relaxation techniques, along with continued practice by the client can most often eliminate the nodule without surgery.  After the new speaking behaviors are learned, it is up to the client to continue practicing the good vocal habits to prohibit the vocal nodules from returning.

It is important to remember that vocal nodules are most often caused by abusive vocal behavior and if the behavior is not removed or changed, the nodules will likely remain or will continue to form after being removed.  Speech therapy with a certified speech and language pathologist is a great option for treating and eliminating vocal nodules and the behaviors that contribute to their formation.  If you have questions about vocal nodules or think you or a loved one has them, please contact your ENT and SLP for further evaluation.  Let's hope that our favorite performers have good vocal hygiene and behaviors so that we can continue to enjoy their music for many years to come!