Dr. T. Balasubramanian M.S.
Synonyms: Singer's nodule, Teacher's nodule.
This disorder frequently affects children and adults. In
children it appears as spindle shaped thickenings of the edges of
the vocal cords, whereas in adults they appear as more localised
thickenings, varying from small points - nodules. These nodules
typically appear at the junction of the anterior and middle 1/3 of
the vocal cords. They appear almost aways symmetrically.
Are caused by a combination of overtaxing and incorrect
use of the voice. This is also aggravated by the presence of
infections in the para nasal sinuses, tonsils, and adenoids.
Patients with habitual dysphonia frequently encounter this
condition. This condition can be effectively prevented or cured by
voice rest or by using the voice properly. Infact the nodules can
appear and disappear in a matter of weeks. If the aggravating
factors persist for a long time then these nodules become
Stages of vocal nodule formation:
Stage of transudation:
Oedema occurs in the submucosal plane in this stage. This
occur during the acute phase of the disorder. This stage is
reversible in nature and may become normal on giving voice rest.
Stage of ingrowth of vessels:
In this stage neovascularisation of the area occur. This
phase is also reversible, but takes a long time to become
Stage of fibrous organisation:
In this stage the transudate in the submucosal area is
replaced by fibrinous material. This stage is more or less resistant
to conservative line of management.
These stages can be clearly observed by laryngoscopy
under stroboscopic light. Local oedematous swelling of recent onset
vibrates in phase with the whole vocal fold, whereas an older and
more fibrous swelling can impede the vibrations so much that only a
part of the cord is seen to vibrate. The improvement in the
vibration pattern or signs of recovery are picked up early during
1. Change in voice
2. Fatiguability of voice
3. Decreased pitch range
Fig showing bilateral
1. Voice rest plays a sheetanchor role in the management
of vocal nodule. This may range from complete voice rest to partial
2. Speech therapy will help patients with habitual
dysphonia from developing vocal nodule.
3. Treatment of sinus infections, tonsillitis and
adenoiditis must not be ovelooked.
4. If the vocal nodule bceome permanent then
microlaryngeal removal is advocated.
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