Vocal Nodules

Author Credentials 

Original Author:
Gayle Woodson, MD
Professor and Chair
Department of Otolaryngology – Head & Neck Surgery
Southern Illinois University
School of Medicine
PO Box 19662
Springfield, IL 62794-9662

Update by:
Lee M. Akst, MD
Director, Laryngology
Johns Hopkins Department of Otolaryngology – Head and Neck Surgery
601 N Caroline Street, 6th Floor
Baltimore, MD 21287

Module Summary

Vocal nodules are callouses that form on the vocal folds in response to chronic vocal trauma. Treatment requires reduction or elimination of vocally abusive behavior, and voice therapy is the mainstay of treatment. Surgery may be required for recalcitrant nodules, and in this case care must be taken through careful operative technique to preserve vocal fold vibration.

Module Learning Objectives 
  1. Recognize the signs and symptoms of vocal nodules.
  2. Explain the pathophysiology of vocal nodules.
  3. Describe the role of voice therapy in management of vocal nodules.
  4. Summarize the indications for surgical intervention in patients with vocal nodules.
  5. Cite the advantages, disadvantages, and risks of surgical techniques for removing nodules.

Anatomy

Learning Objectives 
  1. Recognize that he term “nodule” is not interchangeable with “lesion”, as nodule has a particular clinical connotation as compared to other laryngeal pathologies such as polyps, cysts, granulomas, etc.
  2. Know that categorization of vocal fold lesions as “nodules” is done on clinical grounds, as histopathologic examination of stromal changes in nodules (for example, epithelial hyperplasia, basement membrane thickening, edema, vascular proliferation, and extracellular fibrin deposition) will overlap with the histopathologic findings of vocal fold polyps
  3. Understand that by clinical consensus, true “vocal nodules” are bilateral lesions
    1. They are on the mid-membranous vocal folds
    2. They need not be completely symmetric
    3. They vocal fold nodules are areas of thickening which accumulates on the subepithelial portion of the vocal fold, just beneath the basement membrane, as a response to repeated trauma from collisions of one vocal fold striking zone against the other
References 
  1. Rosen CA, Lombard LE, Murry T. Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions. Ann Otol Rhinol Laryngol. 2000 Sep;109(9):823-8.
  2. Marcotullio D, Magliulo G, Pietrunti S, Suriano M. Exudative laryngeal diseases of Reinke's space: a clinicohistopathological framing. J Otolaryngol. 2002 Dec;31(6):376-80.
  3. Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, Anthony B, Taxy JB. The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse. Int J Surg Pathol. 2011 Oct;19(5):583-7. 
  4. Rosen CA, Gartner-Schmidt J, Hathaway B, Simpson CB, Postma GN, Courey M, Sataloff RT. A nomenclature paradigm for benign mid-membranous vocal fold lesions. Laryngoscope. 2012 Jun;122(6):1335-41. 

Pathogenesis

Learning Objectives 
  1. Know that vocal nodules are essentially callouses on the vibratory portions of the vocal folds; they are the result of vocal misuse or abuse.
  2. Understand that vocal nodules are caused by excessive collision force during phonation or the impact of repeated collisions over time.
  3. Know that vocal nodules form at the point of maximal impact during vibration: the midpoint of the membranous vocal fold.
  4. Realize that vocal nodules are more common in women
    1. Women’s vocal folds are shorter and force is more concentrated at the midpoint
    2. Vocal pitch is higher in women, with vocal folds colliding at approximately twice the frequency.
  5. Know that vocal behaviors that contribute to nodule formation include:
    1. Shouting and screaming (e.g., cheerleading)
    2. Excessive glottal attack
    3. Loud talking
    4. Inappropriate pitch
  6. Understand that nodules gradually resolve with discontinuation of abusive behavior.
  7. Understand that vocal nodules in young boys generally resolve with laryngeal growth spurt at puberty.
References 
  1. Rosen CA, Lombard LE, Murry T. Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions. Ann Otol Rhinol Laryngol. 2000 Sep;109(9):823-8.
  2. Karkos PD, McCormick M. The etiology of vocal fold nodules in adults. Curr Opin Otolaryngol Head Neck Surg. 2009 Dec;17(6):420-3. 
  3. Rosen CA, Gartner-Schmidt J, Hathaway B, Simpson CB, Postma GN, Courey M, Sataloff RT. A nomenclature paradigm for benign mid-membranous vocal fold lesions. Laryngoscope. 2012 Jun;122(6):1335-41. 
  4. Bastian RW, Thomas JP. Do Talkativeness and Vocal Loudness Correlate With Laryngeal Pathology? A Study of the Vocal Overdoer/Underdoer Continuum. J Voice. 2016 Sep;30(5):557-62. 

Incidence

Learning Objectives 
  1. Understand that prevalence estimates of nodules will depend upon the population being studied
  2. Know that among treatment-seeking patients, nodules are among the most common causes of hoarseness in children
  3. Understand that among adults, nodules are much more common in women than men.
  4. Know that nodules are more common in adults with vocally demanding activities: cheerleaders, schoolteachers, singers, and mothers of small children.
References 
  1. Roy N, Bless DM, Heisey D. Personality and voice disorders: a multitrait-multidisorder analysis. J Voice. 2000 Dec;14(4):521-48.
  2. Cohen SM, Kim J, Roy N, Asche C, Courey M. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012 Feb;122(2):343-8.
  3. Martins RH, do Amaral HA, Tavares EL, Martins MG, Gonçalves TM, Dias NH. Voice Disorders: Etiology and Diagnosis. J Voice. 2016 Nov; 30(6):761.e1-761.e9. 
  4. Benninger MS, Holy CE, Bryson PC, Milstein CF. Prevalence and Occupation of Patients Presenting With Dysphonia in the United States. J Voice. 2017 Apr 13;31(5);594-600.

Patient Evaluation

Learning Objectives 
  1. Recognize that history may offer clues as to nature of the patient’s voice complaints
    1. Onset, duration, severity, and progression are all important factors
    2. Nature of the dysphonia (complaints of roughness vs breathiness vs effort, etc), presence/absence of odynophonia, concurrent swallowing or breathing complaints should all be assessed
  2. Know that history should also include elucidation of the patient’s voice needs and voice use profile
    1. Is voice used professionally?
    2. For speaking or singing? Are there regular abusive voice behaviors – yelling or screaming?
    3. For how many hours each day?
    4. How talkative is the patient?
    5. What degree of quality-of-life handicap is associated with the dysphonia?
  3. Understand that perceptual evaluation may offer insight as to the nature of the patient’s voice complaint
    1. Vocal nodules are most associated with roughness and sense of increased efforts
    2. Voice complaints related to nodules are most often appreciated at high-pitch, especially when trying to sing softly
    3. Vocal nodules are not typically associated with odynophonia, swallowing, or breathing complaints
  4. Recognize the importance of laryngeal exam for vocal nodules
    1. By clinical consensus, vocal nodules are bilateral lesions, on the medial edge of each of the mid-membranous vocal folds
    2. Flexible laryngoscopy with a halogen light source can identify mass lesions.
    3. Examination of vocal fold in motion using stroboscopy, with either flexible or rigid endoscopes, can add information about vocal fold vibration and allow for image-by-image evaluation of the medial edge of the vocal folds during the vibratory cycle, which adds more diagnostic value.
References 
  1. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec;11(6):456-61. Review.
  2. Altman KW. Vocal fold masses. Otolaryngol Clin North Am. 2007 Oct; 40(5):1091-108.
  3. Best SR, Akst LM. Visualizing the Larynx: Indirect and Direct Laryngoscopy. Comprehensive Textbook of Otolaryngology, 2014; eds. Sataloff R, Benninger M. Philadelphia: Jaypee Medical Publishing.

Measurement of Functional Status

Learning Objectives 
  1. Know the minimal requirement to document vocal function is a standardized acoustic recording of the voice.
    1. This is important to document function at presentation and its response to treatment.
    2. An acoustic recording is essential prior to any surgical procedure performed for the purpose of improving the voice.
  2. Know that computerized acoustic analyses of the voice are not essential, and can be performed post-hoc, on the recorded sample.
  3. Understand that aerodynamic tests, such as phonatory airflow and pressure, may be useful.
    1. Vocal breathiness is manifested by increased phonatory airflow
    2. The pressure required to initiate phonation (minimal phonation pressure) is often increased, as patients are unable to speak softly.
References 
  1. Jiang JJ, Titze IR. Measurement of vocal fold intraglottal pressure and impact stress. J Voice. 1994 Jun;8(2):132-44.
  2. Murry T, Woodson GE. A Comparison of Three Methods for the Management of Vocal Fold Nodules. J Voice. 1992;6(3):271-276. 
  3. Rosen CA, Lombard LE, Murry T. Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions. Ann Otol Rhinol Laryngol. 2000 Sep;109(9):823-8.
  4. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec;11(6):456-61. Review.
  5. Altman KW. Vocal fold masses. Otolaryngol Clin North Am. 2007 Oct; 40(5):1091-108.

Imaging

Learning Objectives 
  1. Know that radiologic studies are not indicated or helpful.
  2. Realize that endoscopic photography is very useful to document the lesion and its response to treatment, and to educate the patient about the problem.
  3. Understand that videostroboscopy can demonstrate whether the nodules are soft or firm and can often differentiate nodules from cysts or polyps.
  4. Recognize the further advances may include high-speed imaging.
References 
  1. Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, Granieri E, Hapner ER, Kimball CE, Krouse HJ, McMurray JS, Medina S, O'Brien K, Ouellette DR, Messinger-Rapport BJ, Stachler RJ, Strode S, Thompson DM, Stemple JC, Willging JP, Cowley T, McCoy S, Bernad PG, Patel MM. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009 Sep;141(3 Suppl 2):S1-S31. 
  2. Best SR, Akst LM. Visualizing the Larynx: Indirect and Direct Laryngoscopy. Comprehensive Textbook of Otolaryngology, 2014; eds. Sataloff R, Benninger M. Philadelphia: Jaypee Medical Publishing.
  3. Yamauchi A, Yokonishi H, Imagawa H, Sakakibara K, Nito T, Tayama N, Yamasoba T. Quantification of Vocal Fold Vibration in Various Laryngeal Disorders Using High-Speed Digital Imaging. J Voice. 2016 Mar;30(2):205-14. 

Pathology

Learning Objectives 
  1. Recognize that the histopathologic changes are those of a callous, with epithelial thickening, hyperkeratosis, and subepithelial edema.
  2. Understand that pathologic evaluation is necessary to rule out another pathologic process, but otherwise does not distinguish between vocal fold nodules and polyps as this is a clinical distinction
References 
  1. Marcotullio D, Magliulo G, Pietrunti S, Suriano M. Exudative laryngeal diseases of Reinke's space: a clinicohistopathological framing. J Otolaryngol. 2002 Dec;31(6):376-80. 
  2. Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, Anthony B, Taxy JB. The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse. Int J Surg Pathol. 2011 Oct;19(5):583-7.
  3. Rosen CA, Gartner-Schmidt J, Hathaway B, Simpson CB, Postma GN, Courey M, Sataloff RT. A nomenclature paradigm for benign mid-membranous vocal fold lesions. Laryngoscope. 2012 Jun;122(6):1335-41. 

Treatment

Learning Objectives 

Understand that the treatment is most often behavioral (voice therapy), with phonosurgery reserved as necessary for those patients whose nodules persist despite therapy and whose voice handicap justifies surgery on the basis of risk/benefit analysis of surgical intervention.

Medical Therapies

Learning Objectives 
  1. Know that changing vocal behaviors is the first line of therapy, and can often best be done with a course of voice therapy from a speech language pathologist
  2. Recognize that the goal of therapy is to reduce vocal trauma by reducing number and intensity of collisions between the vocal cords
  3. Understand that some nodules may regress with changes in vocal behavior, while some lesions may persist
  4. Appreciate that even if some fibrovascular fullness persists, patients may better tolerate presence of these nodules if they develop good strategies for vocal technique, vocal prioritization, etc
References 
  1. Leonard R. Voice therapy and vocal nodules in adults. Curr Opin Otolaryngol Head Neck Surg. 2009 Dec;17(6):453-7. 

Surgical Therapies

Learning Objectives 
  1. Know the indications for surgery – generally that lesions persist despite conservative therapies, that voice handicap remains present that is associated with the lesion, and that risk/benefit analysis favors surgery (i.e., potential benefit of vocal improvement outweighs risk of further vocal scarring):
    1. Nodules that do not respond to voice therapy, such as very firm nodules, or those with polypoid degeneration, may need to be excised if they continue to create enough voice handicap for the patient that risk/benefit analysis of surgery favors intervention
    2. In some cases, nodules are so large or firm that normal phonation is not possible, and nodules must be surgically excised before voice therapy can proceed.
    3. Rarely, nodules may be excised before allowing time for complete resolution on voice therapy, if there is a pressing need for the patient to regain voice quickly.
  2. Know the techniques of surgical excision:
    1. Suspension microlaryngoscopy can allow for magnified visualization of the lesions and for bimanual surgery
    2. The goal is removal of the disease with preservation of all adjacent normal tissue, in order to preserve voice
      1. Preservation of superficial lamina propria is paramount
      2. As nodules are subepithelial disease, a microflap approach may be utilized to preserve overlying epithelium
    3. Choice of cold instruments vs laser is based on surgeon preference, and should take into account desire to maintain normal tissue, preserve vibratory capacity of the vocal cords, and limit thermal damage
References 
  1. Murry T, Woodson GE. A Comparison of Three Methods for the Management of Vocal Fold Nodules. J Voice. 6(3):271-276.
  2. Benninger MS. Microdissection or microspot CO2 laser for limited vocal fold benign lesions: a prospective randomized trial. Laryngoscope. 2000 Feb;110(2 Pt 2):1-17.
  3. Zeitels SM. Nodules. In: Atlas of Phonomicrosurgery and Other Endolaryngeal Procedures for Benign and Malignant Disease. San Diego, CA: Singular, 2001:57-68.

Rehabilitation

Learning Objectives 
  1. Understand that voice therapy should be used before considering surgery.
  2. Realize that after surgery, a course of voice therapy is indicated to teach behavioral change that might prevent recurrence.
References 
  1. Leonard R. Voice therapy and vocal nodules in adults. Curr Opin Otolaryngol Head Neck Surg. 2009 Dec;17(6):453-7. 

Case Studies

  1. A 22-year-old student comes to you from a local college, where she is a voice student. She is noticing that while speaking voice remains without complaint, her singing voice is becoming moreeffortful and she cannot sing softly in her highest register. What diagnosis do you suspect in this patient? How would you study vocal function in her? What next steps would you take in treatment of this lesion?
  2. A 37 year-old elementary school teacher presented in the past with complaint of dysphonia, with effortful and rough voice that would get significantly worse as her workday progresses. You diagnosed vocal nodules and referred her for therapy. She was compliant, and returns to you at the completion of therapy noting that voice is better but continues to impact her ability to teach for a full day. What next steps might you take in her care? What risks/benefits do you counsel her regarding the possibility of surgery?

Complications

Learning Objectives 
  1. Realize that surgical excision can result in scarring, with permanent hoarseness.
  2. Know that if abusive vocal habits are not changed, nodules can recur after surgical excision.
  3. While not a complication of surgery, per se, understand that vocal recovery after nodule surgery often requires a period of voice rest and/or modified voice use, with delay in return to prolonged professional voice use (teaching full time, singing on stage, etc) that may be measured in weeks
References 
  1. Zeitels SM. Nodules. In: Atlas of Phonomicrosurgery and Other Endolaryngeal Procedures for Benign and Malignant Disease. San Diego, CA: Singular, 2001: 57-68.
  2. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec;11(6):456-61. 
  3. Altman KW. Vocal fold masses. Otolaryngol Clin North Am. 2007 Oct; 40(5):1091-108, viii. 

Review

Review Questions 
  1. What are the presenting symptoms of vocal nodules?
  2. What factors on history are important to elicit in a patient with vocal nodules?
  3. What is the first step in management of vocal nodules?
  4. What is appropriate surgical technique is nodules are going to be removed?
Resources 

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