Vocal Cord Nodules — Persistent Hoarseness

What are vocal cord nodules?

Vocal cord nodules (also called "singer's nodules" or "teacher's nodules") are small, benign growths that appear on the free edge of the vocal cords, usually bilaterally and symmetrically, in the zone of maximum vibration (the junction of the anterior third with the middle third). They result from repeated mechanical trauma — the vocal cords collide with each other during every vibration, and the zone of maximum impact develops a chronic inflammatory reaction with thickening of the epithelium.

Who is at risk?

• Teachers — especially those in primary education, who talk for hours on end, often over classroom noise
• Singers — particularly those without formal vocal training, who strain their range
• Lawyers, public speakers, TV presenters — intensive daily voice use
• Sports coaches — frequent shouting on the training ground
• Children who scream frequently — nodules are surprisingly common in children aged 5 to 12

Aggravating factors include: smoking, gastro-oesophageal reflux, chronic dehydration, excessive air conditioning, and recurrent upper respiratory tract infections.

Symptoms

• Progressive hoarseness — the main symptom; the voice becomes "rough", "gravelly", with loss of clarity
• "Breathy" voice — the nodules prevent complete glottic closure, allowing air escape during phonation
• Vocal fatigue — the voice "fades out" throughout the day
• Reduced vocal range — loss of high notes in singers
• Increased effort when speaking — the sensation of having to "push" the voice
• Reflex cough or "throat clearing" — a frequent tic that worsens the lesion

Diagnosis

The diagnosis is established by videolaryngoscopy or videostroboscopy. The typical appearance:

• Two small, pearly white or translucent, symmetrical growths on the free edge of both vocal cords
• Incomplete glottic closure — an "hourglass" gap
• Localised mucosal stiffness (visible on stroboscopy)

Stages of nodules

1. Soft nodules (early stage) — recent inflammation, oedema. Potentially fully reversible with vocal rest and speech therapy.
2. Fibrous nodules (chronic stage) — collagen deposition, mature lesion. May require microsurgery.

Treatment

Conservative treatment (first line)

• Speech therapy (vocal therapy) — the central component: breathing technique, vocal resonance, elimination of harmful vocal behaviours
• Vocal hygiene — hydration, avoidance of irritants, regular vocal breaks
• Treatment of gastro-oesophageal reflux — if present
• Smoking cessation — mandatory

Surgical treatment (laryngeal microsurgery)

Indicated when fibrous nodules do not respond to 3-6 months of conservative therapy. Microlaryngoscopy with excision under general anaesthesia (20-40 minutes), followed by strict vocal rest for 7-10 days and postoperative speech therapy.

Nodules in children

In children, nodules are common and have an excellent prognosis: most resolve spontaneously at puberty. Surgical intervention is exceptionally rarely indicated — speech therapy and vocal education are preferred.

Prognosis

With appropriate treatment, the prognosis is excellent. The key to preventing recurrence is permanent modification of vocal behaviour.