Vocal cord nodules: causes, voice therapy and treatment in the UK

When we speak or sing, the vocal cords (vocal folds) come together and vibrate, producing sound. ENT UK explains that hoarseness results from the vocal cords in the voice box not working properly. Nodules are one of the structural causes. The British Voice Association sheet describes vocal nodules as small swellings that develop at the site of repeated trauma to the vocal folds and that interfere with the closure and vibration of the folds, causing hoarseness.

The sheet explains that if soft nodules are ignored, persistent damage may produce fibrous scar tissue, and they are then often referred to as hard nodules. It also points out that vocal nodules normally affect only the outer covering of the vocal fold, which it gives as a reason they can be treated successfully.

ENT UK groups them with polyps as "a build-up of soft tissue (polyps) or thickenings (nodules) on the vocal cords" that can develop when the voice is used too much or too loudly for long periods of time, giving "singer's nodules" as the example.

The changes tend to creep in. The Oxford Health sheet describes an early stage in which the voice becomes cloudy (minimally husky) and less responsive over a certain pitch range, losing clarity and brightness. The voice is slow to warm up and may sound deeper, breathy and weak, particularly over the upper pitch range. Over time the speaking voice may become noticeably hoarse and breathy, and the voice may start to cut out around certain notes, causing characteristic voice breaks that are most obvious when the voice is used quietly.

For people who rely on their voice for work, such as singers and actors, these changes may be noticed first as a loss of range or stamina rather than as outright hoarseness. Because the problem can build gradually, the sheet's advice is not to ignore symptoms, because the development of nodules is an ongoing process and the sooner it is treated the better the result.

The sheet attributes nodules to repeated trauma to the vocal folds. In practice this means using the voice hard or for long periods: shouting, speaking over noise, forceful coughing or singing with strain. The British Voice Association sheet is gentle about this, saying vocal nodules are not a crime nor even necessarily the result of bad technique, but an injury, much as a marathon runner might sustain during training or a race.

Other things can add to the strain. The MyHealth Devon page on dysphonia lists acid reflux, post-nasal drip from chronic allergy and muscle tension dysphonia, a group of voice disorders that develop from the way the voice is habitually used. NNUH adds stress and infection or allergy of the larynx as causes of voice change in general. Smoking and dehydration are listed as things to avoid in the self-help advice.

ENT UK advises that people suffering from hoarseness lasting more than four weeks, repeated spells of hoarseness without reason, or a prolonged sore throat or difficulty swallowing for more than two weeks should seek urgent medical advice from their GP, particularly if they smoke or drink more than the recommended amount of alcohol. The Norfolk and Norwich University Hospitals page uses a slightly shorter threshold of two weeks for a voice problem that has not resolved.

MyHealth Devon lists red flag features that should not wait: pain or difficulty when swallowing, a lump or swelling in the neck, a chronic cough, a persistent sore throat or earache, noisy or difficult breathing (stridor) and unexplained weight loss or fatigue, especially with a history of smoking or heavy alcohol use. These could suggest something other than a nodule and need prompt assessment.

The NHS laryngitis page lists difficulty breathing as a reason to call 999 or go to A&E, and says to contact NHS 111 now if it is very painful or difficult to swallow. Those thresholds apply to any throat or voice problem that comes with breathing trouble.

Your GP may be able to treat a short-term voice problem, otherwise they can refer you. At ENT, according to ENT UK, the surgeon examines the throat by passing a flexible telescope (fibreoptic endoscope) through the nose, done in the outpatient visit without hospital admission. The Oxford Health sheet adds that some other conditions can look like nodules, and that assessment in a voice clinic with stroboscopy may be needed to tell them apart, because some of those conditions respond less well to voice therapy and may need more complex surgery.

The sheet also notes that terminology for vocal fold swellings varies between clinicians and may be confusing, and that you can ask your surgeon for clarification if you are unsure about your diagnosis. It suggests asking your GP for a referral to a multidisciplinary voice clinic and a laryngologist experienced with voice problems.

The Oxford Health sheet says voice rest is important in the acute stage and that early nodules will often resolve in 7 to 10 days or so with rest and good voice use, and more than this is rarely necessary. After a period of rest it is important to use the voice normally again to keep muscles strong, with guidance from a speech therapist and, for singers, a singing teacher. It describes voice therapy as being like physiotherapy or Pilates for the voice, and says it may well be all that is needed.

ENT UK says that the majority of people will have no structural abnormality identified and that the problem will relate to how they are using their voice, in which case a voice therapist can give advice or suggest exercises, and that therapy may need more than one visit. Self-help measures in both the ENT UK and MyHealth Devon pages are to rest the voice without whispering, which can make matters worse, drink plenty of fluids, avoid alcohol and cigarette smoke, and take antacids such as Gaviscon if acid builds up in the throat.

If surgery is suggested, the sheet says not to panic, that it may be the quickest and most effective way to deal with the problem, and that surgical techniques have changed considerably, allowing nodules to be removed safely and effectively. ENT UK describes microlaryngoscopy as an operation usually done under general anaesthetic with a rigid telescope and a microscope, which can remove nodules, polyps and cysts and provides tissue for laboratory analysis.

The Oxford Health sheet is aimed at performers and is reassuring: it says vocal nodules are a nuisance and will require hard work to resolve, but are not likely to end a career. Practical tips it gives include avoiding speaking against noise, shouting or violent coughing, inhaling steam, staying well hydrated and avoiding smoke. The NNUH page adds good posture, breath support and drinking 6 to 8 glasses of water a day among its tips for keeping the voice healthy.

On the NHS the usual route is GP, then ENT clinic with fibreoptic examination, then speech and language therapy for voice therapy and, if needed, surgery. Private ENT and voice therapy services follow the same clinical approach; the principles of voice care and therapy are the same either way.