Treatment of Vocal Fold Nodules
There are four main methods for treating vocal nodules
including:
Treatment decisions are based on several factors including age, duration of nodules, extent of dysphonia, and choice of treatment (Pannbaker, 1999). As future speech-language pathologists we need to be knowledgeable about different treatment options and outcomes. This will allow us to have the ability to focus our services appropriately and to collaborate with other medical personnel effectively.
Choice of treatment depends on the preference of the patient, otolaryngologist, or speech-language pathologist. According to the study in the article “Treatment of Vocal Nodules: Options and Outcomes”, speech-language pathologists chose voice therapy for recent vocal nodules in both children and adults (Pannbaker, 1999).
Monique E. Signorelli, Catherine J. Madill, and Patricia McCabe (2011) conducted a study to determine the management options and voice therapy techniques currently being used by practicing speech-language pathologists (SLPs) to treat vocal fold nodules (VFNs) in children. 62 SLPs completed a 23-item web-based survey. Data was analyzed using frequency counts, content analysis, and supplementary analyses. SLPs reported using a range of management options and voice therapy techniques to treat VFNs in children. Voice therapy was reportedly the most frequently used management option across all respondents, with the majority of SLPs using a combination of indirect and direct voice therapy techniques. When selecting voice therapy techniques, the majority of SLPs reported that they did not use the limited external evidence available to guide their clinical decisions. Additionally, the majority of SLPs reported that they frequently relied on lower levels of evidence or non-evidence-based sources to guide clinical practice both in the presence and absence of higher quality evidence.
A paper from Mary Pannnbacker (1999) was also written that provides a review of treatment options and outcomes for vocal fold nodules. She addressed topics such as frequency of occurrence of vocal nodules; factors affecting treatment decisions, including age, duration of nodules, extent of dysphonia, and choice of treatment; types of treatment (voice treatment and/or surgery); and pertinent efficacy research. She discovered five major findings in her research. 1. Voice improvement and nodule reduction are possible with voice treatment alone, flowing surgery, or a combination of voice treatment and surgery. The treatment outcome is better for voice treatment alone or in combination with surgical removal. 2. There are few studies about the effects of voice treatment and surgery on vocal nodules. 3. There is a need for longitudinal data about spontaneous remission of vocal nodules. 4. Outcome measures should include both voice and laryngeal measures as well as functional status. 5. There is a need for specific criteria for selecting surgical versus nonsurgical treatment of vocal nodules.
- Voice therapy to include the use of facilitating techniques
- Surgery to remove vocal fold nodules
- Combination of voice therapy treatment and surgery
- No treatment
Other, helpful ways to treat vocal nodules include:
- Voice Rest
- Steroid Injections
- Treatment of Comorbid Conditions
- Psychological Support
- Good Vocal Hygiene
Treatment decisions are based on several factors including age, duration of nodules, extent of dysphonia, and choice of treatment (Pannbaker, 1999). As future speech-language pathologists we need to be knowledgeable about different treatment options and outcomes. This will allow us to have the ability to focus our services appropriately and to collaborate with other medical personnel effectively.
Choice of treatment depends on the preference of the patient, otolaryngologist, or speech-language pathologist. According to the study in the article “Treatment of Vocal Nodules: Options and Outcomes”, speech-language pathologists chose voice therapy for recent vocal nodules in both children and adults (Pannbaker, 1999).
Monique E. Signorelli, Catherine J. Madill, and Patricia McCabe (2011) conducted a study to determine the management options and voice therapy techniques currently being used by practicing speech-language pathologists (SLPs) to treat vocal fold nodules (VFNs) in children. 62 SLPs completed a 23-item web-based survey. Data was analyzed using frequency counts, content analysis, and supplementary analyses. SLPs reported using a range of management options and voice therapy techniques to treat VFNs in children. Voice therapy was reportedly the most frequently used management option across all respondents, with the majority of SLPs using a combination of indirect and direct voice therapy techniques. When selecting voice therapy techniques, the majority of SLPs reported that they did not use the limited external evidence available to guide their clinical decisions. Additionally, the majority of SLPs reported that they frequently relied on lower levels of evidence or non-evidence-based sources to guide clinical practice both in the presence and absence of higher quality evidence.
A paper from Mary Pannnbacker (1999) was also written that provides a review of treatment options and outcomes for vocal fold nodules. She addressed topics such as frequency of occurrence of vocal nodules; factors affecting treatment decisions, including age, duration of nodules, extent of dysphonia, and choice of treatment; types of treatment (voice treatment and/or surgery); and pertinent efficacy research. She discovered five major findings in her research. 1. Voice improvement and nodule reduction are possible with voice treatment alone, flowing surgery, or a combination of voice treatment and surgery. The treatment outcome is better for voice treatment alone or in combination with surgical removal. 2. There are few studies about the effects of voice treatment and surgery on vocal nodules. 3. There is a need for longitudinal data about spontaneous remission of vocal nodules. 4. Outcome measures should include both voice and laryngeal measures as well as functional status. 5. There is a need for specific criteria for selecting surgical versus nonsurgical treatment of vocal nodules.
Doctors at Mayo Clinic demonstrate the importance of voice therapy in the treatment of vocal nodules.
Voice Therapy
This form of treatment is usually recommended for the early or
recent nodules that are soft and reddish. It involves teaching good vocal
hygiene, reducing/stopping vocal abusive behaviors, and direct voice treatment
to alter pitch, loudness, or breath support for good voicing. Stress reduction
techniques and relaxation exercises are often taught as well (“Vocal Cord
Nodules and Polyps, n.d.).
Boone developed a four-point program for vocal nodule therapy involving:
Boone developed a four-point program for vocal nodule therapy involving:
- Identifying abuse-misuse
- Reducing the occurrence of such abuse-misuse
- Searching with the patient for various voice therapy
facilitating approaches that seem to produce an easy, optimal vocal production
- Using the facilitating approach that works best as a practice
method
(Boone, 1971)
Facilitating Techniques used during
Voice Therapy
Some facilitative techniques that have been useful for vocal
nodules include:
Change in Loudness: Because a patient with vocal nodules loses airflow around the nodules, this therapy can aid in producing a more intense vocal fold vibration to achieve a louder voice. This will aid in reducing the hyperfunction for the individual with nodules (Boone, 1971).
Chant Talk: Chant talk is characterized by reciting many syllables on one continuous tone, also known as “singing monotone”. This aids in reducing hyperfunction because it allows the words to run continuously together without stress or a change in prosody for the individual word segments (Boone, 1971) .
Chewing: This strategy can aid with those who speak through clenched teeth and very little mandibular or labial movement (site book). During chewing, you hear less strain in the voice, easier glottal attack, and an improvement in voice quality (Boone, 1971) .
Confidential voice: Also known as “quiet voice”, using a soft or confidential voice as an alternative to using a voice produced by much effort and hyperfunction, can not only reduce voice loudness but also affects breath control, slows down speaking rate, and seems to create a more open, relaxed airway (Boone, 1971) .
Voice treatment results can be affected by variables such as number, age, and gender of subjects, type of treatment, length and duration of treatment, laryngeal status, severity and duration of dysphonia, patient compliance, and outcome measures (Pannbacker, 1999).
Change in Loudness: Because a patient with vocal nodules loses airflow around the nodules, this therapy can aid in producing a more intense vocal fold vibration to achieve a louder voice. This will aid in reducing the hyperfunction for the individual with nodules (Boone, 1971).
Chant Talk: Chant talk is characterized by reciting many syllables on one continuous tone, also known as “singing monotone”. This aids in reducing hyperfunction because it allows the words to run continuously together without stress or a change in prosody for the individual word segments (Boone, 1971) .
Chewing: This strategy can aid with those who speak through clenched teeth and very little mandibular or labial movement (site book). During chewing, you hear less strain in the voice, easier glottal attack, and an improvement in voice quality (Boone, 1971) .
Confidential voice: Also known as “quiet voice”, using a soft or confidential voice as an alternative to using a voice produced by much effort and hyperfunction, can not only reduce voice loudness but also affects breath control, slows down speaking rate, and seems to create a more open, relaxed airway (Boone, 1971) .
Voice treatment results can be affected by variables such as number, age, and gender of subjects, type of treatment, length and duration of treatment, laryngeal status, severity and duration of dysphonia, patient compliance, and outcome measures (Pannbacker, 1999).
Voice Rest
Voice
rest (vocal rest) is essential following certain injuries or surgeries of the
vocal folds. Without proper rest, the
vocal folds will not heal properly if overused during this vital time period. A few general guidelines for vocal rest immediately
following an injury or surgery may include:
- NO
talking, throat clearing, whispering, or coughing (if it can be avoided for a
prescribed number of days).
- Exercising,
weightlifting, straining while in the bathroom, or any activity requiring forceful
vocal fold closure may result in injury.
- Avoid
making any noises that may be damaging to the vocal folds.
- Avoid
playing musical instruments that may require forceful contact of the vocal
folds.
- Speaking
with a natural, easy voice
- Do
not use the phone for a prescribed amount of time
- ALWAYS
avoid extremes (yelling, singing, throat clearing, strenuous exercising, weight
lifting, talking for a long period of time without breaks)
- Contact
the physician or SLP if any pain, fatigue, or hoarseness is experienced
- Increase
daily intake of water
- Avoid
caffeine and alcohol
- Continue
to take vocal breaks
- Consider
voice therapy – consult with the SLP
- An
acid-reducing or acid-blocking medication may be prescribed in order to
decrease or prevent exposure and irritation of the vocal folds to stomach acid.
Surgical Removal of Vocal Fold Nodules
Although the surgical removal of nodules is relatively uncommon,
recommendations for such a procedure requires minimal, normal tissue
disruption. Given that surgery for vocal fold nodules (VFN) is necessary in
fewer than 5% of cases, it should be considered only after a thorough
nonsurgical treatment regimen is unsuccessful (Buckmire, n.d.). Usually,
surgical removal of vocal nodules is recommended for established or chronic
nodules.
Steroid Injections
Steroid injection using a laryngeal telescope or a laryngeal flexible endoscope under topical anesthesia enables surgical manipulation under a good visual field through a monitor and an easy and accurate approach to the lesion on an outpatient basis. Although the literature is limited, steroid injection improves maximum phonation time and mean flow rate of the cases with vocal nodules.
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 ofspasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.
In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.
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 ofspasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.
In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.
Treatment of Comorbid Conditions
Comorbid conditions experienced in patients presenting with vocal fold nodules include, but are not limited to, gastroesophageal reflux diseas (GERD), laryngopharyngeal reflux disease (LPR), allergies, and thyroid conditions. These must be treated in order to reduce their negative effects on the vocal cords. Other comorbid conditions that may be managed by the patient or are considered modifiable behaviors include caffeine consumption, alcohol, smoking, and stress.
Psychological Support
Boone suggests that the clinician will also need to provide psychological support in the treatment of nodules. For young children with vocal nodules, quality of life is often compromised in the social—emotional, and physical—functional domains. Studies have shown that as children get older, their nodules and resulting dysphonia will cause them to suffer more social and emotional handicap (Boone et al., 2010).
Vocal Hygiene...It's Important!
Voice therapy for vocal fold nodules will also include having the client practice vocal hygiene. This involves simple practices to help decrease the hyperfunction of the voice:
1. Hydrate: People are often more dehydrated than they realize. It is important to drink 8- 8oz. glasses of water a day to keep the vocal folds moist both internally and externally. Simply carry a water bottle around with you during the day and make an effort to take small sips frequently.
2. Stop throat clearing: Throat clearing is extremely traumatic to your vocal cords- causing excess wear and tear. The irritation and swelling produced by the throat clearing can cause saliva to sit in your throat. This causes more throat clearing. More throat clearing causes more stagnant mucus which causes more throat clearing, which causes more mucus, etc.
1. Hydrate: People are often more dehydrated than they realize. It is important to drink 8- 8oz. glasses of water a day to keep the vocal folds moist both internally and externally. Simply carry a water bottle around with you during the day and make an effort to take small sips frequently.
2. Stop throat clearing: Throat clearing is extremely traumatic to your vocal cords- causing excess wear and tear. The irritation and swelling produced by the throat clearing can cause saliva to sit in your throat. This causes more throat clearing. More throat clearing causes more stagnant mucus which causes more throat clearing, which causes more mucus, etc.
- To help this, simply suppress throat clearing by swallowing hard or taking a sip of water.
3. Stop irritating your voice: Avoid lengthy conversations on the phone. Rest your voice 10 minutes for ever 2 hours of talking. Talk at a moderate volume. Avoid shouting and screaming because these traumatize the vocal folds. Avoid smoking and alcohol use because it is very hard on your voice, causing chronic irritation and dehydration.
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No Treatment
Treatment for vocal nodules in children has been questioned due
to vocal nodules resolving spontaneously during adolescence and requiring no
treatment. In addition, some persons who have asymptomatic vocal nodules
(those without vocal symptoms) may not need treatment. Also, those who
are showing symptoms (symptomatic), may simply refuse treatment based on their
own personal preferences (Pannbaker, 1999).