Vocal Nodules The whole process of voice production involves voice mechanism composed of three sub-systems with independent task and role yet the combination of these functions support and aids each sub-system to make the voice mechanism operational. The three (3) sub-systems are: air pressure system causes the vocal fold to vibrate; vibratory system changes the sound waves to produce voiced sound as well as varies the pitch of sound, and; resonating system changes the sound into a more personal, recognizable voice of an individual person. When discussing voice disorders the main breakdown (although failure can occur in any of the three) will always point out to the vibratory sub-system. And it always follows that any abnormalities or changes in the vibratory system will always result in voice impairment. The person is said to have a voice disorder when the quality, pitch, or/and volume of his voice greatly differs from that of the majority of like age, language, and geographical location. The impairment is classified as either organic disorder when there is an interruption in the smooth functioning of the vocal folds (vocal cords).
The second category is termed functional because these kinds affect the quality and volume of the voice. There are also cases wherein the disorder is both functional and organic. A vocal nodule is an abnormal, noncancerous mass of tissue growing on the vocal folds which greatly affects the production of human speech. The vocal nodules, also known as calluses of the vocal fold, mainly reduce and eventually obstruct the ability of the vocal folds to transform the air pressure to create the buzzing sound which is the human voice. These nodules typically appear as symmetric swellings at the frontal midpoint section on both sides of the vocal fold where contact is frequent and forceful. These callous-like bulges can be as small as a pinhead and as big as a split pea. The presence of these nodules prevents the total closure of the vocal folds thus extra air escapes and the disruption of the vocal fold closure and the vibration pattern produce a hoarse and breathy voice/sound.
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The excessively forceful closure of the vocal folds caused by frequent vocal abuse (i.e. excessive shouting, screaming cheering or crying) and/or vocal misuse (i.e. use of an incorrect pitch, volume, or quality) often result in the formation of vocal nodules. Before a visible formation can occur, one can observe a slight reddening on the edge of the vocal folds. This is then followed by a localized bilaterally symmetrical thickening or swelling on the margin of the fold; then by definite nodules or lumps which will become harder and more fibrotic as long as there is a continued strenuous or abusive voice practices. It should be noted that at no time during the formation of vocal nodules is there any pain associated. The patient can only hear the pronounced difference between his normal voice and the present speech sound produced.
People who are susceptible to this disorder are those who use their voices in loud environments. Singers, cheerleaders, politicians, stage actors, teachers, and basically anyone who have to use their voices quite frequently can be a victim of this disorder. In 1999, Hogikyan et al in a non-conclusive study observed that females are most likely to develop vocal nodules. Properly identifying and analyzing the patients medical history, symptoms, and probable causes of these symptoms will yield an accurate diagnosis which is vital and central for effective treatment. Being able to precisely pinpoint the cause or causes of the voice disorder is the most crucial step in finding the apt treatment. Most practitioners follow a comprehensive, sequential multi-step process. Before a treatment can be prescribed, the patients voice impairment history together with an evaluation of the patients speaking method must be properly put together, noted and analyzed to accumulate and gather together all data pertinent to the disorder. A comprehensive examination not only of the mouth and vocal cavities but including head, neck and laryngeal exams must be administered to the patient before performing any diagnostic test.
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Common diagnostic test administered by an otolaryngologist is the vocal fold examination using rigid laryngoscopy with a stroboscopic light source which allows the examiner to have an optimized view of the voice box and make assessment of the mucosal wave alterations which marks the vocal fold vibration. Oftentimes the patient is given some voice rest before repeating the process to assess any change in the vocal cord nodules. The severity and rigidity of the diagnostic exam will ensure that there will be no misdiagnosis of any kind particularly because there are several medical problems that contribute to voice disorder (i.e. reflux, allergies, medications side effects, and hormonal imbalances).
The evaluation of these conditions is also a very decisive diagnostic factor. Although these three vocal impairments are categorized as one kind of vocal disorder (vocal fold lesion) the treatment of vocal fold nodules is quite different with the vocal fold cysts or polyps. For vocal fold nodules, most otolaryngologists will treat it with voice therapy and rest while vocal fold cysts and polyps are both treated with surgery. Because of this, the magnitude of making an accurate diagnosis cannot be overemphasized.
Treatment usually involves voice (or speech) therapy best performed for at least 6 months in twice-weekly 30 minute sessions. The therapy is geared to reduce the vocal abuse or eliminate vocal misuse; it is important that the patient understand that unless the causes are eliminated, the vocal fold nodules will most likely keep growing even if they are surgically removed. Occasionally, vocal rest is also prescribed and in rare cases, surgery may also be required. Although, phonomicrosurgery (a type of surgery involving the use of microsurgical techniques and instruments to treat abnormalities on the vocal cord) for benign vocal fold lesions is highly successful, those who sing professionally or love to sing should take serious consideration before having surgery. The medical community is not united in not just more than one medical breakthrough and research results. One is the widely held but erroneous belief that surgery on the vocal fold will hinder the singer from performing after surgery. This is incorrect as a global statement.
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In 1996, Batian reported that he had operated on sixty-two singers and all of them resume all their prior vocal activities, including singing. But it should also be noted that all patients have undergone a very rigid preoperative and postoperative therapeutic and behavioral regimens. Another point of contention is the effectiveness of the surgery called “vocal cord/vocal fold stripping” which according to current best practices in the field has no role in the treatment of benign vocal fold lesions. Without doubt, the dispute over ideal therapeutic regimens, surgical techniques and instrumentation will continue as more practitioners seek out answers and new data are made available. Even though this medical science is growing and developing progressively, the question of how exactly a benign vocal cord lesion is formed is still unknown. Up until today, professionals in the field still maintain that lesions arise after heavy or traumatic use of the vocal fold. In fact, in a 1999 survey performed by Hogikyan et al to professional directly involved with voice (i.e. laryngologists, speech language pathologists, and singing teachers), it has been found out that majority of the respondents have the prevailing and nearly unanimous belief that “Practices that constitute either abuse or misuse of the speaking and/or singing voice were felt by all groups to be of greatest importance in causing vocal fold nodules.” Reference List Bastian, R.W., Keidar, A., & Verdolini-Marston K.
Simple vocal tasks for detecting vocal fold swelling. J Voice, 4, 172-183. ———–. (1996).
Vocal fold microsurgery in singers.
J Voice, 10(4), 389-404. Buckmire, R. A. MD. (July 2006).
Vocal Fold Nodules, Polyps, Cysts and Reactive Lesions. Retrieved March 25, 2008, from www.emedicine.com/ENT/topic352.htm. Hogikyan, N.D., Appel, S., & Guinn, L.W.
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Vocal fold nodules in adult singers: regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing. J Voice, 13(1), 128-42. Kotby, M.N., Nassar, A.M., & Seif, E.I. (1988).
Ultrastructural features of vocal fold nodules and polyps. Acta Otolaryngol, 105(5-6), 477-82.
Vocal Fold Nodules, Polyps and Cysts: Frontiers. Retrieved March 25, 2008 from http://www.voiceproblem.org/disorders/vflesions/fr ontiers.asp. Ragab, S.M., Elsheikh, M.N., & Saafan, M.E. (2005) Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol, 119(12), 961-6..