Diagnosis: Nodules
To Sing or Not to Sing, A Guide for Teacher and Singers
By Sarah Whitten

Each year many singers are diagnosed with vocal nodules. After such a diagnosis teachers and singers alike may feel unsure as to how to proceed with lessons and performances. This article is intended to educate both singers and teachers about what vocal nodules are and the various treatment options available to help make informed decisions about singing with nodules.

What are Vocal Nodules?
Vocal Nodules are essentially calluses on the vocal folds and are similar to scar tissue on skin after a cut has healed. They typically occur at the intersection of the front and middle thirds of the cords and are the result of either misuse or abuse of the vocal cords. Misuse encompasses behaviors like poor speaking or singing technique or inefficient breathing while abuse encompasses behaviors like excessive yelling, screaming or just talking too much. Current research has shown that vocal hyper-function is almost always an underlying factor in nodules [a] (this refers to an imbalance of muscles in the larynx leading to increased muscle tension and consequently, increased sub-glottal pressure).

When a person has vocal nodules their vocal cords can no longer completely adduct, or, come together. The voice can have a raspy quality, and you may experience the feeling of needing to clear the throat frequently as the body senses a foreign object on the vocal cords. A singer with nodules may find that the voice fatigues easily and the middle voice may have an abnormal, breathy quality.

A treatment model for singers with nodules is a voice care team comprised of the singer, voice teacher, laryngologist, speech language pathologist, manager (if the singer has one) and in the case of a young singer, a parent [b]. The members of this team must work together to develop communication and define the common goal of a healthy voice singer.

Role of the Laryngologist
To accurately diagnose nodules, a singer must visit a laryngologist. At the visit one can expect to give a full medical history, disclosing information about general health as well as the specific voice complaint. It is critical that singers be totally honest with the doctor about their voice use behaviors. During the actual exam doctors may look in the ears and nose as well as the throat. Most singers can expect to have their throat scoped so the doctor can view the structure and function of the larynx. Singers’ larynges will be looked at with either a rigid (through the mouth) or flexible (through the nose) scope. It is likely you will be asked to phonate on the sound /i/, as this brings the epiglottis forward, allowing a clear view of the vocal cords at work. A laryngologist will also be involved if surgery on the vocal cords is necessary.

Role of the Speech-Language Pathologist
Once a diagnosis of nodules is made the singer will move on to meet with a Speech-Language Pathologist (SLP) who will work with the singer to identify and modify the behaviors that contributed to the development of nodules. Singers can expect to do weekly therapy sessions and will need to complete exercises at home in between office visits.

There are several kinds of voice therapy that can be used in the treatment of nodules. The first is called Confidential Therapy (CT). In CT, reduction in nodules is achieved by lowering the volume level and increasing breathiness in the voice, taking the voice down to production level similar to a whisper. In this way, muscular tension in the larynx is reduced, and the force with which the vocal cords are brought together is also reduced. The second kind of therapy, which is popular with singers, is Resonant Voice Therapy (RVT). This therapy involves finding an easily produced sound using vibratory sensations in the bones of the face in the area singers refer to as ‘the mask’ and the voice is usually produced at a normal volume level. Another component of RVT is reducing the tension in the muscles of the upper body and addressing the alignment of the head and neck. Voice teachers and singers may find many similarities between the exercises of RVT and training received in the voice studio to develop balanced resonance.

SLPs may train the singer to do Vocal Function Exercises (VFEs), also called Stemple Exercises. The exercises include sustaining pitches and gliding from top to bottom and bottom to top on different vowel sounds. The purpose of these exercises is to rebalance the muscles in the laryngeal mechanism eliminating hyper- (too much) or hypo- (too little) function. It is and important side note that VFE’s have been shown to improve voice function in healthy voiced singers as well as those who are injured [c]! Additionally, the SLP may work with the singer to develop better vocal hygiene, working to improve hydration and reduce acid reflux.

Role of the Teacher
Any teacher who is going to work with an injured singer (or any singer in this author’s opinion) needs to have a sufficient understanding of the anatomy and physiology of the vocal mechanism. Sataloff recommends that voice teachers speak directly with the SLP. Taking this a step further, he suggests that the teacher should attend a session of voice therapy and the Therapist attend a voice lesson [d]. This sort of interaction furthers the development of common language and allows the team to strategize effectively to develop a healthy regime for the singer. A skilled teacher can offer observations on singing technique to help determine if singing behaviors have contributed to vocal difficulties. Teachers of young singers also need to communicate with parents as they will likely have attended doctor’s appointments with their child.

At a presentation at the Oct 2004 National Center for Voice and Speech conference, Dr. Karen Wicklund presented a paper suggesting a treatment model for vocally injured University level singers. It is reasonable to extract some of her suggestions, as they are applicable to the general population of singers as well. She recommends teachers use exercises that: avoid range extremes, reduce intensity levels, involve messa di voce and vowel equalization, breathing and glissandi as well as body relaxation. In addition, she advocates the use of the Vaccai exercise book and choosing repertoire that has a vocal range of an octave or so.

Role of the Singer
The decision whether a singer continues singing while receiving treatment for vocal nodules must be made on a case-by-case basis. It would not be unusual for singing to be suspended for a few weeks while the assessment of the voice is made and the voice care givers determine the behavior that resulted in the development of nodules. It is critical to determine if singing behaviors contributed to the development of nodules. Therapy may take place over 8-10 weeks, but it can extend longer if the nodules prove difficult to resolve. In many ways the success of voice treatment falls to the shoulders of the singer. He or she must be willing to acknowledge the behaviors that caused nodules and commit to modifying them to achieve success. This is possible when a team of voice care givers work together with the common goal of a healthy voiced singer!

[a]Holmberg, Eva B. et al “Efficacy of Behaviorally Based Voice Therapy Protocol for Vocal Nodules.” Journal of Voice, Vol 15 No 3, 395.

[b]“Role of the Speech-Language Pathologist and Teacher of Singing in Remediation of Signers with Voice Disorders.” The NATS Journal, Vol 49, 1992, 14.

[c]Verdolini, Katherine. National Center for Voice and Speech’s Guide to Vocology.

[d]Sataloff, Robert Thayer, MD, DMA et al “The Role of the Speech Language Pathologist in the Treatment of the Vocally Impaired Singer.” The NATS Journal, Vol 49 1993, 25.

Resources
American Speech-Language Hearing Association & National Association of Teachers of Singing (1992). “Role of the Speech-Language Pathologist and Teacher of Singing in Remediation of Singers With Voice Disorders.” Reprinted from Asha. (1993, January) Vol 35, p 63.

David, Marilee. “Designing a Program of Vocal Hygiene for Singers.” Journal of Singing (1996, September) p 15.

Gregg, Jean Westerman. “From Song to Speech on Laryngeal ‘Bumps’” Journal of Singing. (1993, May) Vol 49, p. 32.

Gregg, Jean Westerman. “On Treatment for Nodules.” Journal of Singing. (1996, November). Vol 33, p.49.
Holmberg, Eva B. et al “Efficacy of Beahviorally Based Voice Therapy Protocol for Nodules” Journal of Voice. (2001) Vol 15 No 3 p.395.

Sataloff, Robert T. et al “The Role of the Speech Language Pathologist in the Treatment of the Vocally Impaired Singer.” NATS Journal. (1993, May) Vol. 49 p. 25.

Verdolini, Katherine. National Center for Voice and Speech’s Guide to Vocology. 1998 National Center for Voice and Speech.

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Editor, Sarah Whitten

Please note that Boston Singers Resource is not endorsing any method, or claiming efficacy of vocal practices as discussed in these pages. The information supplied by the BSR membership is anecdotal and meant to be food for thought. Each singer knows his or her voice best, and should consult with a teacher, ENT or SLP before undertaking any drastic changes.

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