Vocal Cord Nodules

by , last modified on 4/13/21.

Vocal cord nodules are painless "bumps" that develop on the vocal cords causing symptoms of a slowly progressive raspy voice. Initially, the raspiness may only occur in the high pitches characterized by onset delays (voice that starts silent before a sound is produced) or pitch breaks (certain sounds that disappear). However, as they get bigger, the raspiness may extend to throughout the entire vocal pitch range. Listen to some examples of patients with vocal cord nodules here.

Watch Video of Actual Vocal Cord Nodules

Vocal cord nodules are not cancerous and are almost always due to excessive voice use (singing, cheerleading, teachers, etc) leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands. Given they commonly occur in untrained singers, the other name such vocal cord bumps go by commonly is "Singer's Nodules." However, vocal cord nodules can also occur less commonly due to other abusive vocal behaviors including chronic throat clearing, chronic coughing, and whispering.

Vocal cord nodules most always occur slightly anterior to the middle of the vocal cord on each side (more specifically in the anterior 1/3 of the vocal cords). Before going into how they form, let's take a look at the diagram below depicting what NORMAL vocal cords looks like:


In the picture, the thin white blades are the true vocal cords. When they move apart, air can move in between the vocal cords into the lungs allowing a person to breathe. When they come together with talking or singing, they vibrate creating the voice. Watch a video to see how a normal voicebox works.


The take-home point here is that the vocal cords come together to create a voice. As such when the voice is abused (screaming, yelling, or just plain talking too much), the vocal cords aggressively vibrate against each other resulting in irritation triggering at first swelling of the vocal cords as shown to the right. Note that rather than being perfectly straight, there is now a bulge in the center of the vocal cords resulting in an hourglass gap when they come together.

During this state, patients typically note that their voice is best in the morning and worse by end of the day after talking a lot. They are also unable to hold a note with a single breath for as long as they used to, typically around 15 seconds or shorter (normal is around 20 seconds or longer).

With continued abusive vocal patterns, the swelling eventually changes into a "callous" as shown by the pictures below. This situation is analagous to a blister on a hand eventually turning into callous with continued dirt shoveling. Unless the underlying abusive vocal pattern is reversed, the nodule just gets bigger with time with corresponding degradation in vocal quality. This progression from vocal cord swelling to nodule formation can be seen in this time-lapse video.


Small Vocal Cord Nodules

nodule medium

Medium Vocal Cord Nodules

nodule bad

Severe Vocal Cord Nodules

Here is a cartoon diagram depicting the difference between vocal cord nodules and cysts/polyps. As you can see, vocal cord nodule is just a callous thickening of the vocal cord lining. Polyp is a blistering of the lining and a cyst is a mass under the lining.



Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

More aggressive management of vocal cord nodules include:

Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent and potentially permanent hoarseness. Watch video.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule. The video shown here describes this procedure, though the condition being treated is for a different reason (spasmodic dysphonia).

• Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

As a reminder, though there are ways of dealing with vocal cord nodules by surgery or medications, they also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

As such, EVEN if surgery or botox or steroid injection is performed, voice therapy is STILL recommended prior to and after treatment intervention to minimize recurrence risk.

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