Vocal cord nodules are symmetric, mid-vocal fold lesions that occur due to physical stresses on the vocal folds from heavy voice use. They cause hoarseness by impairing vocal fold closure and vibration during voicing. Nodules appear in pairs and resemble mounds of tissue protruding from the vocal folds. While voice rest and steroids can reduce swelling, voice therapy is the primary treatment to develop healthier voice use techniques. Surgery may be considered in severe, longstanding cases not improving with therapy. Nodules require ongoing management rather than a one-time "fix" and do not necessarily end a singing career if properly treated.

1. Vocal Cord Nodule
Dr. Ornouma Sriwanishvipat MD, ENT
Otorhinolaryngologist
Voice Change Surgeon (Transgender)
Snoring, Nose, Sinus Surgeon
Yanhee International Hospital
Charansanitwong, Bangok, Thaiand
Website: dr-ornouma.com
Email: yanhee_ent@yahoo.com

2. What are nodules?
 Nodules are symmetric, broad-based masses
(“mass” simply means “lump,” and does not imply
cancer) which occur at the midpoint of both vocal
folds. This location suggests that nodules are the
result of phonotrauma, the physical stresses on the
vocal fold which occur with heavy voice use or
voice use under adverse circumstances. It is a fact
that nodules are found almost exclusively in young
women and pre-adolescent boys, which suggest
that laryngeal size may also be a factor that
predisposes to nodule formation. Nodules are a
well-known problem of professional and amateur
singers. Some have hypothesized that it is due to
the particular style of singing prevalent in musical
theater, and others have proposed that it is simply
related to the increased amount of voice use or the
intensity of the performance schedule.

3. What are nodules?
Nodules are symmetric mid-
vocal fold lesions
Bilateral vocal fold lesions in men are almost
never nodules. Any adult male should be
examined very carefully before settling on a
diagnosis of nodules. Stroboscopy is very helpful
in clarifying the diagnosis in most cases.

4. What are nodules?
 Nodules are not precancerous or
cancerous lesions. In general, the
symmetric bilateral nature of
nodules, and the fact that they occur
in younger people is enough to
remove any doubts about malignancy
and make a biopsy unnecessary.

5. What are nodules?
 The term „nodules‟ is sometimes used
to refer to any mass of the vocal folds,
even by otolaryngologists. In addition
to being imprecise, this can lead to
confusion and errors in treatment and
should be avoided.

6. What are the symptoms of
nodules?
 Nodules generally cause painless
hoarseness. The hoarseness results
from irregularities in vocal fold closure as
well as irregularities in vibration, both the
result of the bulk of the nodules. The
hoarseness of nodules typically worsens
with voice use or during a cold or sore
throat and improves with voice rest.
People with vocal fold nodules typically
find their voice worse after cheering at a
game, or an evening out with friends, or
a strenuous vocal performance.

7. What are the symptoms of
nodules?
Nodules impair voice by blocking effective vocal
fold closure
and disturbing vibration of the vocal fold surface
during voicing.

8. What do nodules look like?
 Nodules are symmetric or nearly
symmetric mid-vocal fold masses.
They may vary in size from patient to
patient. They are broad-based and
resemble a mound of tissue that
stands out from the edge of the fold.
Nodules are the same color as the
rest of the vocal fold. Nodules do not
grow dramatically over the short-term,
although they may swell with repeated
trauma from voice use.

9. What do nodules look like?
Nodules always occur in pairs

10. How are nodules treated?
 Voice rest, often prescribed in cases of
hoarseness, may improve the voice
somewhat, and even shrink the nodules, but
is not likely to make them go away. Voice rest
serves soften and dissolve swelling
associated with phonotrauma. Voice rest can
help restore baseline voice, but the
hoarseness will recur the next time the voice
is used strenuously unless underlying
patterns of voice use change.
Similarly, steroids, an anti-inflammatory
medication, are often used to reduce
swelling, but do not address the root problem.

11. How are nodules treated?
 Voice therapy is the mainstay of treatment for
nodules. The goal is to make the person
aware of circumstances and habits of voice
use that have led to the problem, and to find
strategies of voice use that will be less
troublesome. It is important to understand
that even excellent voice therapy and a
determined patient usually do not make
nodules disappear, because nodules appear
to be partly a product of other factors like
anatomy. Voice therapy will make nodules
softer and more flexible and thereby improve
the voice.

12. How are nodules treated?
Microlaryngoscopic Surgery is
considered in the management of
nodules. Sometimes, however,
nodules are so well-formed as a result
of long-standing and repeated
phonatory damage that no amount of
voice therapy can improve the voice.
Microlaryngoscopic surgery may be
used to remove the tangle of
hardened tissue that has
accumulated.

13. Misconception
Misconceptions about nodules abound,
particularly in the performing arts
community. Because nodules result from
many factors, some beyond our ability to
change, they represent a condition that
needs to be managed over time, rather
than “fixed” once and for all. Also,
nodules are not a “career-ender” for the
professional vocalist. With discipline and
good judgment, nodules need not impair
a performing arts career.

14. Thank you!