The Seriousness of Vocal Fold Nodules

Last night, I was contacted by someone I taught briefly, and this chat brought up the seriousness of vocal fold nodules.

This person was someone I taught for a short period of time whilst collaborating with a local dance and drama school. This singer successfully auditioned and secured a place at a major National dance school, where they have been for a little while now. I’m being intentionally vague about whether they are male or female, or which school they are studying at… I’ll leave you to read between the lines.

This student has a nice voice, but ultimately an untrained one. The reason they contacted me was that it was confirmed they have nodules, and they wanted to know what they could do about it, whether coaching could help, etc, as they had received little help from their instructors they were studying under.

Before we go any further, let’s talk about nodules and what they actually are.

Nodules are the result of swelling of the vocal fold, typically due to overuse/misuse – i.e. ABUSE. Excessive use or abuse of the vocal folds can lead to redness/swelling of the folds (swelling = vocal edema), which (if they are continued to be sung upon) can lead to localised swelling (like the formation of blisters on your hands – soft nodules), and can become hard and fibrous (like the formation of callouses – hard nodules).

The progressive nature of this interferes with correct use of the vocal folds, and corrupts the sound you here from the vocal folds.

Vocal Edema – Like swelling of any other part of the body, if you catch it at that stage, adequate rest can return it to normal. Most of us have had this, maybe during a bad respiratory infection, excessive coughing, shouting at a sporting event, talking too loudly at a party or a pub/club, etc. With adequate rest, you can recover in a relatively short space of time, but if you keep using your voice despite this, it can progress towards…

Soft Nodules – This is not an official term, it’s just to help you realise there are certain progression levels of nodules. If I had to give an analogy, these are like the beginning of blisters on the palm of your hand as they are beginning to form. This is obviously a more advanced condition than just straight swelling, but despite this, adequate rest and some care/medication can reduce this, and a return to normal can be achieved.

Continued singing on the folds is NOT a good idea, as this can lead to…

Hard Nodules – UNLIKE swelling or blisters, and very much like callouses on the rest of your body, these do NOT disappear with rest. The fibrous material that these turn into need to be cut off surgically, and there are risks and long-term hazards with dealing with this. Trust me, this is serious. Which then obviously begs the question of…

How do you avoid nodules as a singer?

As a normal person whose job doesn’t involve singing or raising their voice, adequate rest for their voice and simple exercises like Ingo Titze’s semi-occluded straw exercise is massively helpful.

For singers who just sing at home/very occasional gigs, or maybe normal people who don’t sing but who use their voice a fair bit in their day to day job (e.g. teachers, call centre staff, etc) the above combined with avoiding excessive volume of speaking/singing on a regular basis will help.

For those who sing regularly, train in a dance school, gig in a band, or perhaps those who hold down a job behind noisy bars or clubs, etc, more serious measures should be taken… because once you start down the road of swelling, without immediate rest, the progressive nature of swelling > soft nodules > hard nodules tends to take over.

What can coaching do for people with nodules?

If they are hard nodules, as far as I am aware, there is nothing that can be done by a coach to improve the situation… not until the nodules are removed surgically. The fibrous mass that defines the hardness of hard nodules is just too solid to shift by the body’s natural processes.

For those who’ve had hard nodules removed or who have even serious but still soft nodules, rehabilitation can still be done.

Frankly, if nodules occur even once, just standard speech therapy is (in my opinion and experience) rarely enough. Most speech therapists deal with SPEECH, the demands of which are substantially lower than the demands of high intensity singing. What they often prescribe are great for restoring a speaking voice for someone in whom the nodules were a freak accident. But for singers, they will be given a lot of vocal rest, some limited rehabilitation, and then they will go right back to doing what they did before.

The nodule is not the disease, it’s the symptom.

It’s the symptom of a voice that is not capable of surviving under the demands the singer chooses to place on it. It is the state of the voice that is the problem… and that is something that a skilled voice coach can help dramatically with.

For example, with lower level edema and some small soft nodules, the voice can often feel a lot weightier than normal, which only serves to aggravate the voice as it is used even minutely throughout the day… only making things worse and prolonging recovery. A way that I have found successful in assisting recovery is to get the singer OUT of that part of their voice with various functional stretching exercises (prescribed on a per singer basis, dependent on the state of their voice and what they can cope with in their damaged state) helps to lift their voice out of the bottom end. What does this mean? Whereas before the very symptom created a vicious cycle where the voice couldn’t recover properly, this cycle is broken, and assisted recovery is possible.

Another thing this does, is help to retrain the singer to accept more correct vocal function. Typically singers that develop nodules sing too hard and too heavy for too long, not allowing the right resonances to happen as they ascend, and that fatigues the voice dramatically. As such, by introducing the singer to an extremely light but ultimately correct connection from bottom to top and back down again (where possible), helps them to accept a more functionally correct and ultimately sustainable singing approach once they have recovered…

In truth, if the singer doesn’t retrain even a little, once the nodules are gone, it is extremely likely they will just occur again, because nothing has really changed.

If you ARE concerned you have nodules, book in a visit with your ENT. If you DO have nodules, and they have said speech therapy will be necessary, please do drop me a line – if this has happened before (and if you want to make sure it doesn’t happen again) retraining to some extent will go a LONG way to helping this.

Learn More: Related Articles

If you want to learn more about vocal health and voice issues, you may enjoy the following articles:
Shouting masquerading as singing: Why so many singers are just yelling
Why vocal problems so regularly derail careers, permanently
Famous Singers with Voice Problems
Vocal Health Issues
My Singing Voice Hurts: 5 Habits for Vocal Health
Vocal Longevity: The Icarus Effect
Why do I keep losing my voice: Overuse, Misuse and Abuse

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