A Singer's Nodules

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A Singer's Notes: Preventing Vocal NodulesTeresa Radomski, MM

"Do I have nodules?!" This is one of the questions most often asked by singers who have been having problems with their vocal production. Repeated hoarseness, breathy or "husky" tone (especially in the middle register), difficulty singing in the upper register (especially the inability to sing high notes pianissimo), the need to use greater-than-normal breath pressure to sustain the voice, thereby increased the overall effort of singing -- these are danger signals that indicate the possibility of nodules on the vocal cords. What are vocal nodules? Normal vocal cords have smooth, white mucosal surfaces without any irregularities on the vibrating borders. Excessive tension or force used when singing or speaking often "overloads" the vibration of the vocal cords, resulting in too much friction. A hematoma, or bruise on the vibrating edge develops, generally occurring at the anterior one-third of the vocal cord, which is the point of maximal contact during phonation. Later, fibrous tissue replaces the hematoma, becomes larger, and eventually appears as a soft or hard white nodule. Typically, two nodules are present; they appear opposite each other on each vocal fold, indicating the place of excessive friction and/or impact. How are nodules treated? Once vocal nodules have been diagnosed, treatment usually begins with complete vocal rest followed by a careful regimen of speech therapy and/or appropriate singing exercises. If the nodules are large, surgical removal may be necessary. However, regardless of how the nodules are treated, it is imperative that destructive singing or speaking patterns be corrected -- if the singer returns to his or her old habits of voice production, the nodules will return. How can nodules be prevented? Proper vocal technique and a sensible lifestyle, which includes necessary rest and relaxation, aerobic exercise, and a healthy diet, are sufficient to prevent vocal nodules! Recent studies of the laryngeal biomechanics of singers at the Center For Voice Disorders have shown that excessive muscle tension patterns in the larynx are greatly reduced in singers with vocal training, as compared to singers who have never studied voice. See "Laryngeal Biomechanics of the Singing Voice" Singers need to learn how they can be both relaxed and energetic in their vocal production -- a delicate "balance" that is accomplished gradually through increased kinesthetic awareness. Breath support must be appropriate; too much breath pressure can result in excessive laryngeal tension. The vocal cords must be protected from overexertion: for example, through the avoidance of a hard "glottal attack." Learning to "open up" pharyngeal space with a loose jaw, tongue, and soft palate increases resonance and enhances vocal production without "forcing" or "pushing." Careful development of the registers of the voice safeguards against vocal strain; for example, the "blending" of the male falsetto voice or the female "head" voice with the "chest" register aids in appropriate vocal cord vibration. Appropriate voice classification is essential to ease in singing; singing out of range (in the wrong tessitura) is asking for vocal trouble. Likewise, singers should use care in developing the extremes of their range, and should avoid singing too many high (or low) notes during a practice period. Singers


should also be aware that the "correct technique" applies not only to their singing voice, but also to their speaking voice. Misuse of the speaking voice, usually by forcing it to a lower pitch, causes problems for singers, including the possibility of developing nodules. (See "BogartBacall Syndrome.") Once proper vocal technique has been learned, it remains the responsibility of the singer to maintain optimal vocal performance through a sensible regimen of daily practice, including a careful warm-up before all rehearsals and performances. No athlete would attempt to compete without warming-up, yet singers frequently neglect to prepare themselves adequately for the physical intricacies of singing! Certain types of singing are much more prone to the development of vocal nodules: rock, jazz, gospel, and most popular styles, for example, in which the technique resembles shouting or screaming, greatly "overload" vocal cord vibration. Performing for long hours in the smoky, dusty, and noisy environment of nightclubs further aggravates a tendency toward vocal abuse. The prevalence of nodules among popular singers is often evidenced by the typical "husky," or "breathy" tone quality -- a characteristic sound that can become a personal "vocal trademark." Indeed, many pop singers diagnosed with nodes do not wish to treat them, for fear of losing their "persona"! Such singers should be aware, however, that continued vocal abuse (singing with nodules), combined with smoking, alcohol, or drug abuse can lead to serious laryngeal disease, including cancer. The fact that many popular singers are untrained also increases their chances of vocal disorders. In the aforementioned recent study of laryngeal biomechanics at the Center For Voice Disorders, two female popular singers were examined, by transnasal fiberoptic laryngoscopy. The two singers were about the same age, and sang a similar repertoire, but one had never studied voice, while the other had had many years of "classical" voice study. The untrained singer had vocal nodules, with a resulting breathy tone, and exhibited a great deal of muscle tension while performing. The trained singer showed a healthy larynx with little muscle tension, and sang with a clear, strong tone -- evidence that vocal study benefits popular as well as "classical" singers. Most professional "classical" singers are very protective of their voices, occasionally to the extent of hypochondria. Nonetheless, their best intentions to preserve their voices may be undermined by overly-demanding rehearsal/performance schedules, often combined with the fatigue of travel (usually on dry, dusty, and noisy airplanes), and the necessity to fulfill their performance contract obligations, regardless of whether they are healthy or ill. Aspiring young singers often allow themselves to be overworked during the early stages of their careers, a time when they should instead be carefully developing and nurturing a healthy technique that will enable them to perform well for many years. Would-be professional singers, in their desire for "experience", often accept roles that are out of their optimal vocal range. Unfortunately, the demands of today's high-pressured professional world have resulted in the "early retirement" of many of these singers. The importance of maintaining one's general health as a contributing factor to one's vocal hygiene cannot be overestimated. Regardless of the style of singing, rest and relaxation are essential as antidotes to the rigors of extensive vocal use, nervous tension, and performance stress. Proper diet is important, especially since many voice disorders result from gastroesophageal reflux disease, in which stomach acid backs up into the larynx, causing irritation of the vocal cords. (See "Medicine in the Vocal Arts"). Overuse of alcohol adversely affects the voice through its drying effect on the tissues of the vocal tract. The damaging effects of cigarette smoke, including "secondhand smoke," are well known, and obviously should be avoided by singers. Any drug that is inhaled, swallowed or injected may affect the muscles of vocal production, aside from the obvious dangers of being an addict on substances. Commonly used drugs such as antihistamines can irritate the vocal cords through over-drying


of the mucosa, and aspirin can increase the tendency to hemorrhage. Finally, a routine of aerobic exercise, yoga, and/or meditation, can greatly help to relieve stress and tension, thereby enhancing the singer's overall well-being. References: 1. Bunch, Meribeth: Dynamics of the Singing Voice, Springer-Verlag, New York, 1982. 2. Punt, NA: The Singer's and Actor's Throat, William Heinemann Medical Books Ltd., London, 1979. 3. Saunders, WA: The Larynx, CIBA Pharmaceutical Company, Summit, N.J., 1964.

Radomski.T, A Singer's Notes: Preventing Vocal Nodules, Center For Voice Disorders of Wake Forest University, Medical Center Boulevard 2004.


Vocal Cord Disorders What Is It? Symptoms Diagnosis Expected Duration Prevention

Treatment When To Call A Professional Prognosis Additional Info

What Is It?Vocal cords are two bands of elastic muscle tissue located side by side in the voice box (larynx) just above the windpipe (trachea). When you are silent, the cords remain open, creating an airway through which you breathe. When you speak, the air you exhale from your lungs is forced through the closed vocal cords, causing them to vibrate faster for higher-pitched sounds, slower for lower-pitched sounds. Like other tissues in the body, vocal cords can be strained and damaged. But unlike a strained arm or leg muscle, strained vocal cords generally aren't noticed until the problem becomes severe. People who use their voices for a living or who shout or scream frequently are at particular risk. This group includes lawyers, teachers, singers, cheerleaders, actors and clergy. People who work in noisy environments, such as airports or racetracks, that require shouting to communicate are also at risk. Vocal cords are also subject to infections, tumors and trauma. Common vocal cord disorders include: Vocal cord nodules are small, hard, callus-like growths caused by vocal abuse. They occur in pairs, with one nodule on each vocal cord at the site of greatest irritation. They sometimes are called singer's, screamer's or teacher's nodules. Vocal cord polyps are small, soft growths that usually appear alone on a vocal cord. They are caused most often by vocal abuse or long-term expo