Institute Day

April 5, 2011

Vocal Cord Nodules:Diagnosis and Treatment

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Video of Nodules

• http://www.youtube.com/watch?v=z9LKwISwb_c

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Facts about Vocal Cord Nodules

• The most common benign lesion on the vocal folds

• Start off being soft and pliable• Can become callous-like with continued vocal

abuse and misuse• Air escapes through the edges of the vocal

folds, causing hoarseness and breathiness• More common in boys than girls• Added mass from nodules can cause a lower

pitched voice

What causes nodules?

• Vocal abuse and misuse– Yelling– Screaming– Cheering– Excessive throat-clearing– Hard glottal attacks

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Low Incidence?

• Voice disorders affect as much as 10% of the US population

• 6-23% of school-aged children have been considered hoarse in various studies

• But approximately only 1% of children on a school -based SLP’s caseload have voice disorders

» cited in The Source for Children’s Voice Disorders

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Screening Tools

• Quick Screen for Voice by Lee, Stemple, and Glaze– See handout for a copy– Includes normative data for mean Maximum

Phonation Time by age– In Language, Speech, and Hearing Services in Schools Vol. 35, 308-319, 2004

• CAPE-V: Consensus Auditory-Perceptual Evaluation of Voice (from ASHA Special Interest Division 3)– See handout for a copy

Components of the Evaluation

• Voice sample during conversation• Voice sample during oral reading• Maximum phonation time on /a/• S/Z ratio• Assessment of pitch, loudness, and laryngeal

tension• Medical evaluation must be completed prior to

starting voice therapy. Prescription should be written by ENT. We cannot tell the etiology of a hoarse voice without this medical evaluation.

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S/Z Ratio• Use stopwatch.• Instruct student to produce /s/ sound for as long as

possible, after taking a deep breath. After three trials of the /s/, follow the same procedure for the /z/ sound.

• Calculate s/z ratio by dividing the longest trial of /s/ by the longest trial of /z/.

• If the ratio is greater than 1.4, then it is possible that the child may have some vibratory dysfunction of the vocal folds

• **This is not a specific measure that diagnoses voice disorders**

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Parent/Teacher Observation

• Can be used in the classroom, for extra-curricular, and home settings

• See sample observation checklist in handout, entitled, “Observation of Child’s Voice Use”

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History

• Have parents fill out case history– Medications?– Allergies?– Previous surgeries?– Onset?– Etc.

• See sample case history in handout from The Source for Children’s Voice Disorders

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Possible Educational Impacts

• Communicative effectiveness

• Social development

• Scholastic performance

• Self-esteem

Components of Treatment

• Vocal Hygiene and Awareness

• Reducing/Replacing Vocal Abusive Behaviors

• Eliminate hyperfunctional use of vocal mechanism

Vocal Hygiene

• Drink lots of water- keep water bottle on desk

• Get enough sleep• Avoid caffeine• Avoid smoky areas• Use an appropriate volume• Speak to others from an appropriate

distance

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Educate about the Vocal Mechanism

• Use rubber bands, balloons, and other materials to demonstrate the vocal mechanism

• Plush larynx: “Larry Larynx”– By Blue Tree Publishing

• Online videos, diagrams

• Quiz (see handout)

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Improving Vocal Behaviors

• Rating scales, charts, and games can be used to help the student become aware of his own voice quality and vocal behaviors.

• Identify behaviors (i.e. yelling)• Identify acceptable alternatives (i.e. clapping

instead of yelling to cheer at a sporting event)• Reduce abusive behaviors and substitute with

alternatives.

Eliminating Hyperfunction

• Relaxation techniques– Identify tension– Use techniques to reduce tension– Use techniques in speech

• See handout for sample exercises to reduce hyperfunction– Lip trills, sirens, head turns, shoulder rolls

Yawn-Sigh (by Boone 1971)

• During a yawn, the upper airway and oral cavity expand, so that the musculature relaxes and opens

• Open mouth and begin yawn.• Inhale deeply.• Release air slowly into a vocalization.• Gradually shape into words beginning

with “h” or vowel sounds. QuickTime™ and a

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Voice Therapy is Effective!

• A study of 31 schoolchildren with nodules showed the following results:– 84% of the students had reduced nodule

size after six months of treatmentcited in The Source for Children’s Voice Disorders

Dismissal Criteria

• Evidence of laryngeal improvement

• Student and significant observers feel the voice is better

• Student demonstrates no improvement in voice quality

• Student withdraws from therapy– From Boone, D (1974). Dismissal criteria in voice therapy. Journal of Speech and

Hearing Disorders 39:133-139.