Vocal Cord Nodules (Nodes)
A Guide to Avoiding Vocal Nodes & Recovering From Them For Singers
It seems to me as I peruse the web that there is a lot of misinformation about vocal nodes (aka: vocal nodules) and my purpose here is to help you sift through information you need to avoid misuse of the voice that may result in the formation of vocal nodes/nodules.
What the H-E-Double-Eck are Vocal Nodes or Nodules?
Nodules are little growths your body forms on your vocal cords where they meet when you make noise such as singing or talking. These are formed because your body is trying to eliminate repetitive stress on the delicate cords.
Nodules can be very difficult to deal with for people who use their voice a lot. That means us – vocalists. It also means people who speak a lot, though. The reason the voice is difficult to use is because the vocal cords need to start the flutter (vibrate) as air is passed through them. In order to make a solid sound, they need to make contact with each other for much of their entire length. The nodes often will prevent the cords from closing enough for the singer to be functionally able to use the voice in the rigourous and demanding way that vocalists use their voice – even with good technique. To illustrate what I am talking about, out your hands together so that the palms touch. You can pretty much make contact the entire length of the hands. Now, place an M&M in an open palm (the color is irrelevant but I have been getting *excellent* results with a blue one). Place the second hand on top and try to make contact the full length of the hands. You can’t make 100% contact because there is an M&M in the way (damn – how did *that* get there?). And not only can you not make contact at the point where the M&M is, but also there is some surface area *surrounding* where the M&M is that is not making contact because the M&M is depressing the skin around it as well. Any kinda bump on the cords will have a similar effect except that you wil not get to eat the M&M at the end of it. Which you should do now – we are done with the M&M…
Nodes are formed on the vocal cords when an irritation occurs which will cause inflammation to occur. This stage is called a “pre-node”. During this stage, you may experience a little hoarseness or sore throat. It is during this stage that action should be taken if you have a choice in the matter. Therefore, if you have a sore throat that is not related to a cold or persists more than a week or so, please so an Dr. immediately. For normal people, it may be possible to live with a node but for a singer it would be very difficult if it developed into a node.Please note, if you are poor, you may be able to get treatment at a “General Hospital”. It is unfortunate that we are the only industrialized country with no medical care for it’s people but *I* am *not* bitter! There are free clinics in most cities (look in the yellow pages in the front for medical stuff and if you are stuck, call a mental health line or a shelter cause they usually have a good handle on the free medical resources in the area). Even if you go to a free clinic or general hospital, though, still demand to get good medical care. If you annoy them enough they will do it for you.
The person to see is an “ENT Doctor” aka: “Ears Nose Throat Doctor”, aka otolaryngologist, etc. A general practitioner will be able to look at your vocal cords but it is easy to miss without a little camera that a fully equipped ENT will have to examine the cords closely. If you suspect a node or vocal injury, you will need to get two exams that they give together. The first exam is sometimes called the “soft scope” and consist of a flexible fiber optic camera places near the cords to examine them. This is great and gives you a full view of the cords. However, it does not give you a super close up view so you will also need to get a “hard scope” which does not view the entire cords but does give you a closer look. Sometimes the soft scope catches stuff the hard scope misses and vice versa so get both. Push for it and be persistent. Do not accept the little dentist mirror exam.
How do you get Pre-Nodes and Vocal Nodules?
Vocal nodes will develop from pre-nodes (or some say spontaneously with no pre-node phase in certain situations). Nodes can be caused by a variety of things but most likely it is a combination of causes.
If you are a vocalist, the 1st thing the doctor will THINK is it is bad singing technique. It is possible that is the cause and certainly many singers of varying levels of training have developed vocal nodules. It is particularly easy to do if you sing a lot and have poor technique. Or if you sing a lot at very very high levels of performance such as opera and have slight problems. It doesn’t necessarily mean you have super awful technique in all cases, but if you make demands of your voice at very high levels, little problems can magnify into big ones. Even those with extensive training have developed nodes from time to time (causes include poor speaking habits, screaming, singing in a range that is not comfortable for you, continuing to sing when you have a sore voice, singing in night air, and a veritable plethora of other things.
As far as technique goes, stress in the voice can cause them. This stress is most often caused by tension in the tongue (you will get a “tight” feeling in the throat and the larynx may move to a higher or lower position than normal), lack of proper breathing support, etc.
Recent famous people who have gotten nodes include Julie Andrews (belting on Broadway in a voice not natural to her), Bing Crosby, and Madonna (Great entertainer but poor singing technique coupled with extensive use of the voice resulted in nodes for her).
They are not uncommon in rock singers due to the way they use their voices (ie: screaming), but it is not very common for people to admit that they have them as it is sometimes looked upon as a stigma. However, even people with good technique can get them through other ways than singing and so this stigma is misplaced.
For the untrained vocalist, it is easy to stress the cords to the point where they will form nodes. In order to lessen your chances of this, you will want to learn not only “breathing” which is fundamental to singing but NOT the only thing to keep your voice safe, but also the so-called “resonation” or “Singing in the mask” or “forward placement” which will stop the cords from taking all the stress of singing and also resonating and amplifying. This is often achieved not in ways you might think but by standing in a relaxed manner that is also fairly tension-free. I know this seems like a weird concept to some people and that is why there are voice teachers! Various things including “poor posture” can cause a tight tongue or tight feeling in the throat which may induce a node or pre-node.
The larynx is suspended by many structures from the top and bottom. From the top, it is very closely connected to the tongue so pressure there will cause strain on it. From the bottom it is connected to the torso so pressure there will cause strain too.Posture is often overlooked and can be a significant contribution to the formation of things such as nodes. Learning posture form a voice instructor OR instructor in Alexander Technique is crucial. If you live far removed from anywhere where you know a good teacher might be, you may want to have your posture looked at by a very conservative Old Lady Voice Teacher in any case – one that is very nitpicky and preferably is an Opera Star! They may not be your cup of tea but one session with them just to check what you are doing is terrific. It is important to note, also, that all of the techniques I mentioned above inter-relate with one another – good posture with a level head will stop tightness in tongue and throat to a certain extent and many other inter-relationships.
Another likely candidate for abuse that results in vocal nodes (and one that is overlooked often) is your speaking voice. Many well trained vocalists have poor speaking voices. It is well documented that most people with problems of this kind speak either too high (less likely) or too low (very common). Sometimes people raise or lower their voices artificially to achieve a more powerful sounding voice (lowering) or a more “feminine” voice (higher). Speaking out of your optimal range can cause stress on the cords. Do not try to compensate for this on your own – it can be damaging to you if you are wrong – get a speech pathologist or voice teacher to give you their opinion. Artificially raising a voice to compensate for possibly artificially lowering can somtimes just compounding the problem. Just be aware that these things are possibilities and bring them up when you see a professional.
Are there any gnarly pictures online of vocal nodes?
Yup! You came to the right place…Her are some links to someone who was brave enough to admit they have them and post them for the benfit of all of the rest of us:
OK, I Have Pre-Nodes. What To Do?
Although many singers continue to work with the nodes, it is likely that any kind of impacted performance schedule or other situation where you are singing or practicing daily (or even less than that by a long shot) will exacerbate the situation and make the nodes larger or at best maintain them at their current state making them older (older nodes are harder to eliminate. Therefore, the best course of action is to try to eliminate them using non-invasive techniques. Especially if they are fairly recent or in the pre-node state. So go easy on your voice. Some speech therapists recommend not speaking but in any case, definitely no yelling, no prolonged singing, and stuff like that. See someone immediately would be my very strong recommendation. I know it is scary but if you see someone now you can start to work to fix it right away and it is likely to be no big deal if you are in pre-nodes. Even nodes can be not too horrible to deal with so don’t get scared and not want to go in. It is important to letcha know, too, that whispering is generally more stressful on the voice than speaking outright so just be aware that whispering is not really resting your voice.
It is the best idea to see a doctor and to get a second or third opinion. The kinda doctor you want is a nice, conservative one who doesn’t much care for the idea of surgical removal. Cutting should be the LAST resort, especially for singers or anyone else who relies on their voice for their livelihood or happiness (that would be most of us I think). If you are poverty-striken, find the General Hospital nearest you and see if they have a sliding scale option for you. In any case, hospitals are likely to have payment plans which is a lot better than private doctors who are more likely to demand you cough the money up at the time of our appointment.
Your doctor may recommend a number of things. You want to try the MOST CONSERVATIVE ONE. So if you go to three doctors and one says “don’t worry, just try not to abuse your voice too much”, the second one says “let’s cut it out! Won’t THAT be fun?!” and the third one says “total vocal rest for 3 weeks” you go with the last one and rest the voice for 3 weeks. I will talk about techniques for this in a while. In general, the recommendation for voice rehab will tend to be total voice rest [this is somewhat different since this article was written in 2002. Total vocal rest is now not always the go-to move from speech pathologists – 19 December 2017]
IMPORTANT: SO-CALLED “SPRAYS FOR SINGERS” THAT NUMB THE THROAT IN ANY CAPACITY ARE BAD. THEY WILL CAUSE YOU TO *NOT FEEL* PAIN WHICH MEANS THAT YOU MAY CONTINUE TO WORK ON A VOICE THAT IS ALREADY INJURED OR TO FURTHER YOUR INJURY. NEVER TAKE THESE BEFORE SINGING AND IF YOU DO TAKE THEM DO NOT SPEAK EXTENSIVELY OR SING AT ALL. SAME GOES FOR LOZENGES, TEAS, OR ANYTHING ELSE THAT “SOOTHES” WHICH MIGHT MEAN “DEADEN” IN ENGLISH.
Other things to do include drinking a LOT of water which will hydrate the cords and make them less likely to irritate, avoid the points listed below in bullets as much as you can, do not drink or smoke (these dry the cords out and dehydrate them (see the water entry above), do not consume caffeine (coffee, tea, chocolate (!), etc),and try to remain low-stress as stress can aggravate these things).
Total Voice Rest?! What up!
Total Voice Rest equals you don’t make any sounds for whatever time period it is. So none of the following:
- whispering (added 1/17/06-sorry I forgot to put it in!!!! Yikes!)
- clearing throat
- yelling, screaming, carrying on…definitely out
- crying (the hardest one!)
- avoid sneezing
- making barn-yard animal noises (I don’t care if you DO live somewhere where you need to do that to get a date)
It is not as bad as it sounds. Even for those of us with jobs where we use our voices professionally. Most social situations can be remedied by carrying around a Dry Erase (white) board with LOW ODOR dry-erase pens – the delecate fragrance of chemical dry erase pencils is less than charming in my opinion. Avoid taverns or other situations where you cannot heard well – it is easy to vocalize unknowingly if you are not used to not speaking and cannot hear – and anyway you can’t drink so…BORING! Avoid 2nd hand smoke (and 1st hand, too). If you need to communicate with others like in a classroom situation, I suggest a word processor with a large font. You can get pretty good at this and it works great. If you are prone to yelling, get a little whistle (available at sporting good stores) – use it to call your dog from across the park, let your kids know you want to see them downstairs, get people’s attention on the street. This is now your job description so do not be embarrassed.
What else should I do?
You need to assess what you did to sustain the type of injury you have. It may be that you will never know really why EXACTLY. But “safening” up your life is in order. You might have a conservative voice instructor (no Am Way teachers!) look your technique over. You might want to contact a speech therapist to see what you can do to get better “oral hygiene” (this is what they call technique for speaking – it is similar to technique for singing). You might want to see someone certified in Alexander Technique about posture – often posture and ergonomics of movement plays a role in injuries. There are resources for Alexander Technique on my site – (http://lessons.EleonorEngland.com/yoga.html), but write if you need help finding a good voice teacher in your area or a speech therapist.
You may wish to get a test called a Video Stroboscopy which will document the nodes, produce a video and picture of them working for you to see how they are functioning, as well as give you a baseline to judge your progress when you again look at them to see if the node is smaller or not. Be sure you ask if they have the equipment before you book the appointment. ENT’s may be able to refer you to others who do have the equipment.
What if that doesn’t work?
If vocal rest does not work, you may need to consult three doctor again and see what they say. I have heard of surgical intervention working OK, *HOWEVER* please note that it is POSSIBLE (and likely enough to be a problem) that your voice will not recover to it previous state after a surgery. In fact, it may be screwed up permanently. That is why to be careful in allowing any existing nodes to become well-established nodes and why surgery is a LAST RESORT. You may have not heard the story of Julie Andrews, a clear-voice and famous singer who got nodes singing out of her comfortable range. She opted to have them surgically removed and has not recovered her voice in several years. It can really backfire. [Note that times are changing and surgical intervention has become much more sophisticated. Now they use lasers and it is muuuch safer. But still non-surgical intervention has a zero percent risk rate which really ou can’t beat – 19 Dec 2017]
- Pictures of nodes – you can see how they would not close well (http://www.mewsic.com/voice/nodes.html)
- A GREAT article by another voice teacher about nodes – READ IT! It RULES! (http://www.ent-consult.com/voiceproblems.html)
- A terrific page by an ENT Dr with all kindsa info (http://www.ent-consult.com/)
- Dr. Zeitels, a Massachusettes otolaryngological doctor who is one of the most prominant physicians treating nodules surgically these days (this link was added 19 December 2017)