Vocal Nodules: Overview
- How are vocal cord disorders diagnosed?
Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient's mouth that allows the examiner to view the larynx (images are often recorded on video).
The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion. Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication’s side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor (www.ETNet.Org: Fact Sheet).
- Treatment for vocal cord disorders: Vocal cord disorders caused by abuse or misuse are easily preventable. Most disorders of the vocal cords can be reversed. Specific treatment for vocal cord disorders will be determined based on: your age, overall health, and medical history , extent and type of vocal cord disorder , tolerance/reactions with specific medications, procedures, or therapies , Expectations for the course of the disease , and personal opinion/preference .
- Treatment may include the following: A referral to a speech-language pathologist who has specialized training in treating voice, speech, language, or swallowing disorders that affect communication.
- Resting the voice
-Eliminating the behavior that caused the vocal cord disorder
-Medication
-Surgery to remove growth
-Voice Rest (following surgical removal)
-Steroid Injections
- Voice Therapy:
Voice rest may still be recommended even if you have not had surgery. If the vocal nodules are soft, you will require a course of voice therapy.
- SLP's will aim to teach patient how to: Eliminate vocal abuse and misuse, increase breath support, relax the muscles around the head and neck area, use optimal/natural pitch, reduce loudness, encourage vocal cord movement in a relaxed/easy manner. (Williamson, 2008).
* Develop Voluntary Vocal Management Skills:
- Reduce amount of talking
- Reduce vocal loudness
* Tension reduction in musculature of the larynx:
- Increase the flow of breath during phonation
- Easy onset of vocal fold adduction
- Progressive relaxation exercises (shoulder lifts, neck rolls, & soft humming)
A) Adults Patients= 4 point program for therapy with adults: identifying abuse/misuse, reducing the occurrence, searching with patient for various voice therapy facilitating approaches for easy/optimal vocal production.
* Most often recommended for adult patients.
B) Children= The overall aim of voice therapy is to teach a healthy, non-abusive voice production pattern. The speech-language pathology treatment of nodules and vocal strain in children begins by educating the child and his or her family about the nature of the problem, including its signs and symptoms, causes and risk factors.It is helpful for the child and family to understand the normal anatomy and physiology of the larynx , in relation to the child’s specific laryngeal pathology -Ex.= nodules, thickened vocal cords, etc. (Bowen, 2011).
The potentially damaging effects of tension and strain upon the larynx due to forcing the voice need to be explained to the child and his or her family.The child is taught about voice production: phonation (how the sound is produced by the vocal cords); respiration (breathing); and, resonance.The idea of adequate breathing patterns are explained, and the child is helped to “feel” the sensations of appropriate breath support sitting, standing and lying down. They are shown how to check that the level of the thyroid notch does not rise excessively during gentle humming (e.g., “hmmm, ummm, hummm...”). They also learn to palpate (feel) their own necks, or to look in a mirror, for excessive neck muscle tension around the larynx.Finally, the child learns, by imitating the therapist, how to produce resonance in different parts of the vocal tract: e.g., “chest” voice, “head” voice, and “nasal” voice, and front and back oral resonance.
This voice training provides a foundation for learning to produce the best voice with the least effort. Resonance training is especially important, since it helps if children with abusive voice production habits can be taught to “project” their voices to achieve increased loudness, rather than using a loud strained voice.The term 'hyperfunctional' means 'overused'. Hyperfunctional voice disorders, and laryngeal pathology such as vocal nodules almost always result from some form of vocal abuse or misuse. It is therefore essential to identify abusive behaviours (hence the need for detailed case history taking at the outset of therapy) and reduce or eliminate them, so that the cords can heal and recover, allowing a return to normal voice (Bowen, 2011).
- Medical Therapy:
Treatment options for vocal fold nodules include both invasive and noninvasive techniques. Prevailing thought reflects the opinion that the etiologic mechanisms of both lesions are most directly related to vocal use and technique. Therefore, attention to correcting the underlying causative factors, largely through voice therapy and education, plays an integral role in any treatment plan of action.
- Surgical Intervention:
A) Advantages: Immediate removal of vocal nodules and high rate of initial success.
B) Disadvantages: Nodules are likely to recur if strategies are not learned and maintained
C) Important points to discuss: Surgical intervention is avoided if at all possible.
- Hard (fibrosed) vocal nodules will, however, need to be surgically removed.
- Prior to surgery it is helpful to receive advice from a speech-language pathologist.
- Following surgery, you will need to rest the voice (without whispering) for at least three days.
- You will also require a course of voice therapy following surgery to help you eliminate the damaging vocal behaviors that led to the nodules.
- Surgery to remove vocal nodules inevitably causes scarring of the vocal cords.
- It is essential to eliminate all possible causes of vocal misuse and abuse as soon as possible and to receive advice on improving your vocal technique for both speaking and singing.
- Vocal Hygiene: VERY IMPORTANT to the vocal mechanism for effective speech production.
Discussing the mucosal wave, the vocal folds are covered in mucous (mucosal lining) which helps to dissipate heat and keeps the folds moist. As a result, this helps to get rid of heat generated by fast movement/excessive force of the vocal folds. Establishing a vocal hygiene program is a valuable therapy approach/technique as it will assist the clinician/client in:
-Examining the factors maintaining the voice disorder and demonstrates healthy habits to improve vocal fold function. Examples: quit smoking, avoid air pressure pollutants, avoid dry/moldy atmospheres, increase fluid intake, avoid very hot/cold/spicy foods, and reduce alcohol and caffeine intake.
Education regarding proper vocal hygiene and hydration and avoidance of vocal abuse, misuse, and overuse is a necessary baseline. The patient must comprehend how specific behaviors or patterns thereof may have contributed or may in the future contribute to vocal fold lesions.
- Facilitation Techniques: Techniques to consider for therapy
A) Chant Talk- Used for loudness and vocal quality services. This approach is aimed to reduce effort by reciting many syllables on one continuous tone through singing monotone. This is accomplished by elevating pitch, prolonging vowels, reducing syllable stress, and soft glottal attack.
B) Vocal Hygiene- avoid talking against background noise, reduce amount of speech, avoid loud voice, moderate pace, moderate phone conversations, easy onsets to avoid hard glottal attack, avoid vigorous coughing, use proper singing technique, encourage relaxation/stress management for vocal folds.
C) Yawn-Sigh-
- Minimizes tension effects of vocal hyperfunction
- One of the most useful relaxation techniques
- Yawn, exhale gently with light phonation
- Increase phonation with /h/ attack