IJOPL

Does Voice 10.5005/jp-journals-10023-1083

Therapy Cure All Vocal Fold Nodules?
ORIGINAL ARTICLE

Does Voice Therapy Cure All Vocal Fold Nodules?

1
Baisakhi Bakat, 2Abhishek Gupta , 3Arunima Roy, 4Amitabha Roychoudhury, 5Barin Kumar Raychaudhuri

ABSTRACT nous part of the vocal fold, resulting in wound formation

Introduction: Vocal nodules are known to be one of the most and subsequent tissue remodeling during the healing
common benign lesions, commonly situated at the junction of process of the wound. As a result pathological changes
anterior one third and posterior two third of vocal folds. Voice occur in the vocal folds which may lead to formation of
therapy is considered to be the gold standard of treatment of vocal nodules, vocal polyps and cysts.1
vocal fold nodule.
Vocal nodules (Fig. 1) develop on the free edge of the
Objectives: vocal folds as bilateral small swellings, less than 3 mm
treatment of vocal fold nodules and to identify any possible
reason for failure to voice therapy in managing vocal fold in size. They are histologically characterized by thicke-
nodules. ning of epithelium with a variable degree of underlying
Materials and methods: A prospective study, conducted over
a period of 6 months. Eighteen adult patients diagnosed with known but traditionally thought to occur due to vocal
vocal fold nodules at a tertiary care hospital were subjected abuse or misuse rather than overuse.2
to 6 weeks of voice therapy. Pre and post therapy subjective According to McGlashan3 vocal nodule, also known
laryngoscopy) evaluation was done. Patients with no improve-
as singers nodule, is a localized chronic hypertrophic
ment after 6 weeks of voice therapy underwent micro laryngeal laryngitis, more commonly found in females as compared
surgery. All patients were followed up at 3 months and 6 months. to males. Patients present with a history of hoarseness
Results: In majority of patients, objective and subjective and vocal fatigue.4
Psychological factors, infections of nose, throat and
chest and allergies have been implicated in the etiology
improvement after therapy, they recovered completely after
microlaryngoscopic surgery. It was found that patients who
of vocal nodules in the past.5-7
required surgery even after voice therapy had hard nodules.
Keywords: Vocal fold nodule, Voice therapy, Microlaryngoscopic
etiological factor of vocal fold nodule in addition to vocal
surgery. abuse and misuse.8-10
How to cite this article: Bakat B, Gupta A, Roy A, Roy-
Diagnosis is clinched by eliciting a proper history
choudhury A, Raychaudhuri BK. Does Voice Therapy Cure All from the patient including duration of voice abuse per
Vocal Fold Nodules? Int J Phonosurg Laryngol 2014;4(2):55-59. day, status of hydration, profession and personal habits
Source of support: Nil like smoking or alcohol intake. Though indirect laryngo-
None scopy can detect vocal fold nodules in most of the cases,

INTRODUCTION laryngoscopy, with or without stroboscopy. Stroboscopy

is useful to distinguish between vocal nodule and vocal
Benign vocal fold mucosal disorders, causing varying
fold cyst.11
degrees of dysphonia have serious impact on the
personal and professional well being of a person. Vocal
fold vibrations produce stress on the vocal fold surfaces
during phonation. Maximum mechanical stress occurs
at the mid portion of the membranous vocal fold during
phonation. Therefore vocal overuse, misuse and abuse
lead to excessive stress and trauma in the mid membra-

1,2
Postgraduate Trainee, 3Speech and Language Therapist
4
Professor and Head, 5Professor and Honorary Consultant
1-5
Department of ENT and Head and Neck Surgery, Vivekananda
Institute of Medical Sciences, Kolkata, West Bengal, India
Corresponding Author: Amitabha Roychoudhury, Professor
and Head, Vivekananda Institute of Medical Sciences, Kolkata
West Bengal, India, e-mail: [email protected]
Fig. 1: Vocal fold nodules

International Journal of Phonosurgery and Laryngology, July-December 2014;4(2):55-59 55

Baisakhi Bakat et al

Table 1: The voice handicap index—10 questionnaire

Sl. no. 0 1 2 3 4
P1
P2 I run out of air when I talk
F3
F4 The sound of my voice varies throughout the day
F6
throughout the house
E7 I use the phone less often than I would like to
F8 I am tense when talking to others because of my voice
E9 People seem irritated with my voice
P10 People ask ‘what is wrong with your voice?’
Min. score: 0; Max. score: 40

Vocal fold nodules can be treated with voice therapy Exclusion Criteria
(e.g. voice re-training, rest or hygiene advice) and adjunctive
Any other associated vocal fold pathology.
medical or pharmacological treatment of underlying
A detailed history was taken in a specially designed
laryngopharyngeal reflux. Cases refrac tory to voice
voice clinic Proforma which included duration of com-
therapy are usually amenable to phonomicrosurgery.12
plaints, history of vocal abuse or overuse, and if yes
But there is a need for high-quality randomized controlled
how many hours per day, status of hydration, history of
trials to evaluate the effectiveness of surgical and non-
hyperacidity, addictions, etc. the profession of the patient
surgical treatment of vocal cord nodules.13
was noted including number of hours of professional
Voice therapy is the treatment of choice in which
talking. This was followed by generalized ENT examina-
patients are re-educated for proper use of voice by suit-
tion including indirect laryngoscopy.
able training programs that motivates them to change
Subjective evaluation was performed by using Voice
faulty vocal habits and eliminate vocal misuse and abuse.
Unless the incorrect vocal habits are addressed there is
the patients at diagnosis, 6 weeks and 6 months (Table 1).
a high possibility of recurrence. Voice therapy from a
speech language therapist includes teaching good vocal
laryngoscopy (FOL) with a 70° endoscope, performed in
hygiene, reducing or stopping vocal abusive behaviors
all 18 patients. In FOL, nature of the lesion, glottic closure
-
pattern and look of the lesion whether hard or soft was
vers and exercises to alter the pitch, loudness or breath
noted.
support for good voicing.14
All patients were subjected to voice therapy for
Thus, mainstay for managing vocal fold nodules
6 weeks. At the end of 6 weeks, VHI-10 and FOL were per-
remains voice therapy and vocal hygiene, which encom-
formed to check for responses to voice therapy. Patients
who showed no improvement after 6 weeks of therapy,
of vocal behavior and providing guidance for vocal care.
either subjectively or objectively, were subjected to surgery
In spite of compliant voice therapy, some patients
eventually need phonomicrosurgery for the treatment of for excision of the vocal fold nodule. Microlaryngoscopic
cold steel surgery was done in all cases taking care not to
disrupt the deeper layer of lamina propria. Voice therapy
also to look for reasons behind failure of treatment, if any. was continued for 6 weeks following surgery. All patients
were advised to continue vocal hygiene for 6 months
MATERIALS AND METHODS following surgery. A follow-up was done at 3 months
and again at 6 months when subjective and objective
A prospective study was undertaken, over a period of
oted.
6 months on 18 adult patients. All these patients attending
the OPD of ENT and Head Neck Surgery, Vivekananda
Institute of Medical Sciences, a tertiary care hospital, were RESULTS
diagnosed to have vocal fold nodules. Of the 18 patients studied, 14 (77.78%) were females and
4 (22.22%) were males. The mean age was 31.56 years.
Inclusion Criteria
Mean VHI score of 18 patients at diagnosis was
15.61 (Fig. 2). Fifteen out of 18 (83.33%) patients showed
diagnosis of vocal fold nodule. significant subjective improvement after 6 weeks of

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Does Voice Therapy Cure All Vocal Fold Nodules?

On laryngoscopic evaluation, after 6 weeks of voice

therapy, 15 out of 18 patients (83.33%) showed resolution
of nodule and rest 3 (16.67%) patients had persistent
nodule (Fig. 3). On further analysis, it was noted that
these 3 patients (16.67%) who were refractory to voice
therapy were diagnosed to have hard nodules at initial
visit, whereas 15 patients (83.33%) who responded to voice
therapy had soft nodules (Fig. 4).
Three patients with hard nodules were subjected to
microlaryngoscopic excision of vocal nodule. They were
also continued with postoperative voice therapy for 6
weeks. All 18 patients were advised to practice vocal
hygiene upto the end point of the study, i.e. 6 months.
At 6 months follow-up, 1 patient (5.5%) out of 18
Fig. 2: Subjective evaluation at the end of 6 weeks patients was found to have recurrence of nodule and this
patient belonged to the hard nodule group.

DISCUSSION
Benign lesions of the vocal fold are common cause for
hoarseness. More thorough understanding of these
benign lesions has been the goal of laryngologists and
voice scientists over the last several decades, since
Hirano’s description of the complex layered microanat-
omy of the human vocal fold.
Ratio of prevalence of nodules in male and female
before puberty is seen to be around 3:1, while after
puberty it is 1:3.15 Among women most often seen around
aged 20 to 50 years.16-18 In our study, 77.78% patients
were females and the mean age of these females was
Fig. 3: Objective evaluation at the end of 6 weeks 30.14 years.
Vocal fold nodules are commonly believed to occur
as the result of phonotrauma which includes vocal abuse
and vocal misuse. Vocal abuse refers to vocal behaviors
that lead to trauma of the vocal fold microstructure.
Excessive and prolonged talking with excessive loudness,
use of inappropriate pitch, excessive cough, and throat
clearing are some of these vocally abusive behaviors. All

Vocal misuse is an inefficient method of voice

production due to inappropriate laryngeal tension and or
poor respiratory drive. This often leads to vocal fatigue
and odynophonia. Long-term misuse along with abuse
leads to changes in microarchitecture of vocal folds.19
Even anatomical considerations like anterior web and
short membranous vocal folds are said to predispose to
Fig. 4: Number of hard and soft nodules
develop vocal fold nodule.
voice therapy with a mean VHI reduced from 15.61 to 4.1. Gray et al20 gave a detailed description of ‘basement
membrane zone’ which anchors the epidermis to the
improvement of their symptoms with pretherapy and
post-therapy mean VHI being 18.66 and 17.33 respectively. -

from 15 to 1.46.

International Journal of Phonosurgery and Laryngology, July-December 2014;4(2):55-59 57

Baisakhi Bakat et al

shear leads to disruption of basement membrane zone uncommon, recommendations for such a procedure
21
In some indi- include minimal normal tissue disruption. Given that
viduals basement membrane zone is excessively widened surgery for vocal fold nodules is rare and fewer than 5%
of cases and it should be considered only after a thorough
them to excessive trauma during phonation.22 nonsurgical treatment regimen is unsuccessful.34 In our
Nodules are bilateral swelling with a classic location study, 3 cases out of 18 (16.67%) even after 6 weeks of voice
at the junction of the anterior and middle third of the therapy required surgery. However, statistical analysis
vocal fold (i.e. the midpoint of the membranous vocal was not possible in the series, as it was conducted in a
fold). This region is said to be the ‘striking zone’, being limited number of patients.
most active segment during phonation.23 This is the site Also known as ‘calluses of vocal fold’, nodules
of maximal aerodynamic and muscular forces and also basically are of two types depending upon duration and
has rich reticular vascular network (venules) on the lower laryngoscopic appearance: soft or young nodule and hard
surface of the vocal fold free edge. or old nodule. Soft nodules are acute nodules and are
Objective assessment of vocal folds can be done using usually translucent, soft and pliable compared to hard
35,36

other hand subjective assessment can be done by using All 3 patients who underwent surgery in our study were
various quality of life related questionnaire such as VHI,24 found to have hard nodules.
VHI-10,25 VoiSS (Voice symptom scale),26 V-RQOL27(voice At the end point of our study at 6 months, 1 patient
related quality of life) to explore the impact of voice (5%) had recurrence of nodule. The fact that this patient
disorder on their life. It can also be used for measuring the had hard nodule and is a voice therapy failure, may
outcome for estimating the effectiveness of intervention. suggest that ‘hard’ and more robust nodules may have
VHI-10 which has been adapted from a 30 point scale. a tendency to recur. Pre-existing anatomical variants
VHI is an easy, practical clinical and research tool with predisposing to excessive shearing force, genetically
strong reliability and validity.28 In our study at the end determined changes in vocal fold microanatomy may
of 6 weeks mean VHI-10 scores were seen to reduce also account for recurrence.

did not improve satisfactorily, i.e. from 18.66 to 17.33 who CONCLUSION
were found to have hard nodule.
Voice therapy is the primary recommended treatment It is evident from the present study that majority of
for vocal fold nodules.29 Attention to correct the under- soft vocal fold nodules are amenable to voice therapy,
lying causative factors, largely through voice therapy and whereas hard variety are resistant to therapy. However,
education, plays an integral role in treatment. Education hard nodules tend to resolve after phonomicrosurgery,
regarding proper vocal hygiene and hydration and provided postoperative voice therapy is given.
avoidance of vocal abuse, misuse, and overuse is the In our opinion, vocal fold nodule should be categorized
necessary baseline.30 Inhaled irritants such as tobacco and
toxic chemicals should also be avoided. Gastroesophageal hard type should be surgically treated with supportive
pre- and postoperative voice therapy. It will also be useful
regarding proper fluid intake, and medications that to develop some validated diagnostic criteria of soft and
have drying potential should be minimized to optimize hard vocal fold nodule. This will enable the clinician to
laryngeal hydration.31 Apart from vocal hygiene, voice optimize the treatment for vocal fold nodule right from
therapy consist of some voice rehabilitation exercises

to dysphonia which is individualized according to REFERENCES

patients need. When performed by a speech language 1. Ju TH, Jung KY, Kwon SY, Woo JS, Cho, Park MW, et al. Effect
pathologist (SLP) in a compliant patient, voice therapy is of voice therapy after phonomicrosurgery for vocal polyps: a
highly effective in helping most patients with vocal fold prospective, historically controlled, clinical study. J Laryngol
nodule.32 Out of 18 patients studied, 15 (83.33%) were Otol 2013 Apr;127(12):1156-1159.
cured after 6 weeks of voice therapy well corroborating 2. Chalabreysee L, Perouse R, Cornut G, Bouchayer M, Loise R.
Anatomie et anatamopathologie des lesions benignes des cordes
with the study by Mc Crory33 in which 76% patient were
vocalis. Revue Laryngologie Otology Rhinologie 1999;120:
cured only by voice therapy. 275-280.
Several authors have published papers relating to 3. McGlashan J. Disorders of the voice. In: John Hibbert. Scott
phonosurgical techniques for removal of benign lesions. Brown’s Otolaryngology, Head and neck Surgery. London:
Although, the surgical removal of nodules is relatively Hodder Arnold 2008;2:2198.

58
 IJOPL

Does Voice Therapy Cure All Vocal Fold Nodules?

4. Roychoudhuri BK, I 19. Courey MS, Postma GN, Osoff RH. The professional voice.
dhuri BK, editor. Synopsis of Otorhinolaryngology. India: In: Richardson MA, Flint PW. Cummings otolaryngology
CBS publishers and distributers Pvt Ltd; 2013. p. 270. head and neck surgery. Philadelphia: Mosby; 2010;1:5:p. 871.
5. Mcmurray JS. Medical and surgical treatment of pediatric 20. Gray SD, Hirano M, Sato KM. Molecular and cellular structure
dysphonia. Otolaryngologic clinics of North America 2000; of vocal fold tissue. In: Titze I Red Vocal fold physiology. San
deigo. Singular publishing group, 1993.
33(5):1111-1126.
21. Dikkers FG, Hulstaert CE, Oosterbaan JA, et al. Ultrastructural
6. Carr MM, Nguyen A, Poje C, Pizzuto M, Nagy M, Brodsky L.
changes of Basement membrane zone in benign lesions of the
vocal folds. Acta Otolaryngol (Stockh) 1993;113(1):98-101.
22. Gray SD. Cellular physiology of the vocal folds. The otolaryn-
Laryngoscope 2000;110(9):1560-1562. gologic clinics of north America 2000 Aug;33(4):684.
7. Kalach N, Gumpert L, Contencin P, Dupont C. Dual-probe pH 23. Hochman I, Sataloff RT, Hillman RE, Zeitels SM. Ectasias and
varices of the vocal fold: Clearing the striking zone. Ann Otol
the course of chronic hoarseness in children. Turkish J Pediat Rhinol Laryngol 1999;108(1):10-16.
2000;42(3):186-191. 24. Jacobson BH, Jacobson A, Grywalsky, et al. The voice handicap
8. Kuhn J, Toohill RJ, Uluaip S O, Kulpa J, Hofmann C, Arndorfer index (VHI): development and validation. American Journal
of Speech Language Pathology 1997;6(3):66-70.
vocal cord nodules. Laryngoscope 1998;108(8 pt 1):1146-1149. 25. Rosen CA, Lee AS, Osborn J, et al. Development and validation
of the voice handicap index-10. Laryngoscope 2004 Sep;114(9):
1549-1556.
laryngeal disorders. Am J Med 1997;103(Suppl 5A):S100-106.
26. Deary IJ, Wilson JA, Carding PN, Mackenzie K. Voi SS: a
10. Uluaip S, Toohill RJ, Massey B, Arndorfer RC, Hogan WJ,
patient derived voice symptom scale. J Psychosom Res 2003
Shaker R. Esophagopharyngeal distribution of refluxed May;54(5):483-489.
gastric acid in patients with vocal cord nodule and chronic 27. Hogikyan ND, Selhuraman G. Validation of an instrument
sinusitis: Gastroenterology 1998;114:A315. to measure quality of life. J Voice 1999;13(4):557-559.
11. Hirano M, Bless DM. Videostroboscopic examination of the 28. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development
larynx. London: Whurr Publishers Ltd, 1993. and validation of the voice handicap index-10. Laryngoscope
12. Benninger MS, Jacobson B. Vocal nodules, microwebs and 2004 Sep;114(9):1549-1556.
surgery. J Voice 1995;9(3):326-331. 29. Blood GW, Blood IM, Bennett S, Simpson KC, Susman EJ.
13. Pedersen M, McGlashan J. Surgical versus nonsurgical Subjective anxiety measurements and cortisol responses
interventions for vocal cord nodules. Cochrane Database of in adults who stutter. J Speech and Hearing Res 1994;37(1):
69-82.
Systematic Reviews 2012, Issue 6. Art. No.: CD001934.
30. Wang CT, Liao LJ, Lai MS, Cheng PW. Comparison of benign
14. Vocal cord nodules and polyps. Available at: http://www.
lesion regression following vocal fold steroid injection and
asha.org/public/speech/disorders/NodulesPolyps. Accessed vocal hygiene education. Laryngoscope 2014;124(2):510-515.
on Nov. 10th, 2014. 31. Voice therapy. Available at: http://emedicine.medscape.com/
15. Kleinsasser O. Microlaryngoscopy and endolaryngeal article/866712-overview#a30. Accessed on 10th Nov, 2014.
m icrosurger y: tec h n ique a nd t y pical f i ndi ngs. I n: 32. Garcia RT, Garcia RA, Diaz RT, Canizo FRA. The outcome
Kleinsasser O. Philadelphia: Hanley and Belfus 1990. p. 42-43. of hydration in functional dysphonia. An Otorrinolaringol
16. El Uali Abeida M, Fernández Liesa R, Vallés Varela H, García Ibero Am 2002;29(4):377-391.
Campayo J, Rueda Gormedino P, Ortiz García A. Study of 33. Mc Crory. Voice therapy outcomes in vocal fold nodules: a
retrospective audit. Int J Language Communication Disorder
nodules in women. J Voice 2013;27(1):127. 2001;36 Suppl:19-24.
17. Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, 34. Jensen JB, Rasmussen N. Phonosurgery of vocal fold polyps,
Lester R, et al. The clinicopathologic spectrum of benign
4577.
mass lesions of the vocal fold due to vocal abuse. Int J Surg
35. Sataloff RT, Spiegel JR, Carroll LM, Schiebel BR, Darby KS,
Pathol 2011 Oct;19(5):583-587. Rulnick R. Strobovideolaryngoscopy in professional voice
18. Yamasaki R, Behlau M, Brasil Ode O, Yamashita H. MRI users: results and clinical value. J Voice 1988;1(4):359-364.
anatomical and morphological differences in the vocal tract 36. Sataloff RT, Spiegel JR, Hawkshaw MJ. Strobovideolaryngo-
between dysphonic and normal adult women. J Voice 2011 scopy: results and clinical value. Ann Otorhinol Laryngol
Nov;25(6):743-750. 1991 Sep;100(9 pt 1):725-727.

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