Vocal Cord Nodules

How nodules form

The vocal cords are two bands of tissue in the voice box (larynx) that vibrate hundreds of times per second when you speak or sing. Repeated forceful collisions, from shouting, loud talking, singing with strain or habitual throat clearing, injure the soft surface layer at the midpoint of each cord. Over time the tissue thickens and hardens, like a callus on the hand. Because both cords strike each other, nodules usually form on both sides, opposite each other, and stop the cords from closing completely. Air leaks through, making the voice breathy and rough.

Who gets vocal cord nodules

• singers, especially without training or when singing outside their natural range
• teachers, coaches, fitness instructors, call center workers and clergy
• children, especially boys who shout and are very vocal
• adult women, who are affected more often than men
• people with reflux, allergies, smoking or dehydration that irritate the voice box

Symptoms

• hoarse, rough, raspy or scratchy voice
• breathy voice
• reduced vocal range, especially loss of high notes
• voice breaks or cracks
• vocal fatigue, with the voice worsening through the day or week
• frequent throat clearing or a feeling of a lump in the throat
• neck or throat discomfort after speaking

Nodules vs polyps vs cysts

Other causes of persistent hoarseness include laryngitis, reflux, muscle tension dysphonia, vocal cord paralysis, papillomas and, rarely, cancer.

Diagnosis

Hoarseness lasting more than 4 weeks should be examined. An ear, nose and throat specialist will:

• ask about voice use, singing, job, smoking, reflux and allergies
• listen to your voice
• perform laryngoscopy: a thin flexible camera through the nose, or a rigid scope through the mouth, to view the vocal cords
• often use videostroboscopy, a flashing light that shows the vibration of the cords in slow motion

A speech-language pathologist may also do a detailed voice assessment.

Treatment

Voice therapy

Voice therapy with a speech-language pathologist is the first-line treatment and resolves or greatly improves most nodules within weeks to a few months. It teaches:

• healthy breathing support
• easier, less forceful voice production
• resonant voice techniques
• reducing throat clearing and shouting
• vocal warm-ups and cool-downs
• healthy voice habits for work and singing

Vocal hygiene

• drink plenty of water to keep the vocal cords moist
• use a humidifier in dry environments
• avoid shouting, screaming and talking over loud noise
• use a microphone or amplifier when speaking to groups
• take voice rest breaks during long speaking days
• avoid whispering, which can strain the voice
• sip water or swallow instead of clearing your throat
• limit caffeine and alcohol, and do not smoke
• treat reflux and allergies

Surgery

Microsurgery to remove nodules is considered only when they persist and significantly affect the voice despite a full course of voice therapy. Voice therapy continues after surgery, because nodules can return if voice habits do not change. Surgery is rarely recommended for children.

Outlook

Most people improve with voice therapy and better voice habits. Nodules can return with renewed overuse, so long-term voice care is important, especially for professional voice users.

Frequently asked questions

What do vocal cord nodules feel like?

They usually cause a hoarse, rough or breathy voice that tires easily, with loss of high notes for singers. Some people feel a lump or tickle in the throat, need to clear their throat often, or notice neck discomfort after speaking. Nodules themselves are not painful.

Can vocal cord nodules go away on their own?

Small or early nodules may shrink with voice rest and healthy voice habits. Most people need voice therapy with a speech-language pathologist to change the patterns that caused them. Surgery is rarely needed.

What is the difference between vocal nodules and polyps?

Nodules form on both vocal cords from chronic overuse and are small and symmetrical. Polyps usually form on one side, often after a single episode of strain or with smoking, and more often need surgical removal.

When should I see a doctor for hoarseness?

See a doctor if hoarseness lasts more than 4 weeks, or sooner if you smoke, rely on your voice professionally, or have trouble swallowing or breathing, a neck lump or coughing up blood.