Vocal Cord Nodules: Symptoms, Diagnosis and Treatment

01Nodules

What vocal fold nodules are

The NIDCD explains that the voice is produced by vibration of the vocal folds, two bands of smooth muscle tissue in the larynx (voice box) that come together as air from the lungs passes between them. Vocal nodules are benign growths along the vocal folds. They form in pairs, on opposite sides of the folds, as a result of too much pressure or friction, much as a callus forms on the foot from a shoe that is too tight.

The British Voice Association (BVA) sheet describes how small swellings at the site of trauma, often called “soft nodules”, interfere with how the vocal folds close and vibrate, causing hoarseness. If they are ignored and the strain continues, fibrous scar tissue may develop, producing what are known as “hard nodules”. Nodules usually affect only the outer covering of the vocal fold, which is one reason why they generally respond well to treatment.

02Voice load

How voice load can contribute

The NIDCD notes that nodules are sometimes called “singer’s nodes” because they are a frequent problem among professional singers. More generally, it lists cheering at sporting events, speaking loudly in noisy places, talking for too long without resting the voice, singing loudly and speaking at a pitch that is too high or too low as ways of overusing the voice. People whose jobs depend on their voices, such as teachers, singers and public speakers, may develop hoarseness that does not go away.

The BVA sheet stresses that nodules are not a crime and not necessarily the result of “bad technique”: it compares them with an injury a marathon runner might get in training. Understanding how much and how you use your voice helps treatment, but nodules are not a reason for blame.

03Symptoms

Hoarseness, fatigue and voice breaks

The BVA sheet describes how symptoms often develop over time:

• at first, the voice may become slightly husky (“cloudy”) and less responsive over certain pitches, losing clarity and brightness
• the voice is slow to warm up and may sound deeper, breathy and weak, particularly at higher pitches
• over time, the speaking voice may become noticeably hoarse and breathy
• the voice may cut out on certain notes, causing voice breaks that are most obvious when speaking or singing quietly

The NIDCD describes hoarseness more generally as a voice that sounds breathy, raspy or strained, softer or lower in pitch, sometimes with a scratchy throat. These symptoms are not specific to nodules. Our guides on hoarseness and a raspy voice cover other causes.

04Differences

Nodules versus polyps and cysts

Nodules, polyps and cysts are all benign growths on the vocal folds, but they differ. The NIDCD explains that nodules form in pairs on opposite sides, a polyp typically occurs on only one side, and a cyst is a hard mass of tissue enclosed in a membrane sac inside the vocal fold.

The BVA sheet warns that other conditions can look similar to nodules and make diagnosis more difficult, that some of them respond less well to voice therapy and may need more complex surgery, and that the terms used for vocal fold swellings vary between clinicians. You cannot tell which one you have from the sound of your voice; if you are unsure of your diagnosis, ask your specialist to explain it.

05When to get help

When voice changes need assessment

The NIDCD advises seeing a doctor if your voice has been hoarse for more than three weeks, especially if you have not had a cold or flu. You should also see a doctor if you:

• cough up blood
• have difficulty swallowing or breathing
• feel a lump in your neck
• have pain when speaking or swallowing
• lose your voice completely for more than a few days

The NIDCD explains that hoarseness is occasionally a symptom of laryngeal cancer, which is why persistent hoarseness should always be checked. Nodules themselves are benign. If you lose your voice suddenly while shouting or singing hard, the NIDCD notes this may be a bleed in the vocal fold, which needs complete voice rest and prompt medical review.

06Diagnosis

ENT examination and selected stroboscopy

The NIDCD explains that your doctor will ask about your health history and how long you have been hoarse, and may refer you to an ear, nose and throat specialist (otolaryngologist). The specialist will usually look at the vocal folds with an endoscope, a flexible, lighted tube, and in some cases may recommend tests of voice quality or airflow.

The BVA sheet adds that assessment in a voice clinic with stroboscopy, which uses flashing light to study vocal fold vibration, may be needed to tell simple nodules apart from conditions that look similar. It recommends seeing a laryngologist experienced in voice problems, ideally in a multidisciplinary voice clinic.

07Voice therapy

Voice therapy and adapting daily demands

The NIDCD lists voice rest, voice therapy and surgery as the most common treatments for nodules, polyps and cysts. In voice therapy with a speech-language pathologist, you learn vocal exercises and ways to change how you use your voice. The BVA sheet compares voice therapy to physiotherapy for the voice and says it may be all you need to resolve nodules.

According to the BVA sheet, soft nodules usually respond well to voice therapy and good voice care, and after a period of rest it is important to use the voice normally again, with guidance, to keep the muscles working. Singers are advised to check their technique with a singing teacher and discuss suitable warm-ups. Our guide on voice therapy explains what sessions involve.

08Voice care

Rest, hydration and avoiding irritants

Both sources recommend basic voice care. The NIDCD says resting, reducing voice use and drinking plenty of water should help relieve hoarseness from overuse. The BVA sheet advises resting the voice whenever possible, avoiding speaking over noise, shouting or coughing violently, keeping well hydrated and avoiding inhaled irritants such as smoke.

The amount of rest needed varies. Complete voice rest is not usually required for long periods, and a therapist can advise how to balance rest with gentle, healthy voice use. Reflux can also irritate the larynx; the NIDCD explains that it is treated with dietary changes and medicines that reduce stomach acid.

09Sources

Where the sources differ

The NIDCD page covers hoarseness in general, while the BVA sheet, reprinted in 2015 and hosted by an NHS trust, is written for adults, particularly performers. Points to note:

• Age of the information. Both documents are several years old, so newer practice may differ in detail.
• Rest. The BVA sheet says early nodules often resolve within 7 to 10 days with rest and good voice use. Recovery times vary widely, and no fixed time frame applies to everyone.
• Steam. The BVA sheet suggests inhaling steam to soothe the vocal folds; the NIDCD does not mention it. Hot steam can scald, so follow your clinician’s advice.
• Surgery. The BVA sheet says hard nodules respond less well to voice therapy and usually require surgery, and that modern techniques remove nodules safely. Whether surgery is needed is decided individually after assessment and, usually, a trial of voice therapy.

10Summary

In summary

Vocal cord nodules are paired, benign swellings caused by repeated strain on the vocal folds. They make the voice husky, breathy, tired and prone to breaking, and are common in people who use their voices heavily. They are not cancer, but persistent hoarseness should always be examined, because other conditions can look or sound similar.

Most nodules are treated with voice therapy, voice care and adapting voice demands; surgery is considered when they do not improve. A simple record of your voice tasks, how long they last, how your voice feels afterwards and what changes you have made helps you and your therapist review progress. In our ENT practice in Bilbao we offer scheduled voice assessments for adults (consultations are in Spanish).