Adult+-+Vocal+Fold+Nodules

= Adult Vocal Fold Nodules =

==** ﻿ What are Adult Vo cal Fold Nodules? **== 

Vocal fold nodules are benign (noncancerous) growths that appear over time as a result of repeated vocal cord abuse. They are soft swollen spots that develope into harder, callous-like growths. They usually appear at the midpoint of the vocal folds. The nodules continue to become larger and stiffer the longer the vocal abuse continues (ASHA 1)

** How are Vocal Fold Nodules diagnosed? **   The symptoms of vocal fold nodules are very similar to polyps. They can include but are not limited to painless hoarsness, breathy or husky voice, shooting pain from ear to ear, decreased pitch range and “lump in throat” sensation.

Nodules are typically diagnosed by a team of professionals specialized in the area of voice. These professionals include a physician or otolaryngologist (ear, nose, throat doctor) who would use a video stroposcopy or endoscope to look at vocal cords. These instruments are inserted through the nose or mouth and the video stroposcopy allows the physician to watch the vocal folds as they move while producing sounds. Typically, a stroboscopy would be covered by insurance.



A SLP conducts a voice evaluation. This would include looking at vocal quality, pitch loudness, and ability to sustain voicing. (ASHA 1)

A neurological examination can also be helpful to rule out diseases such as Parkinson’s or supranuclear palsy which can cause abnormalities in the vocal fold movement. (Snow)

==** What are the Theoretical Approaches that Guide the Treatment of Vocal Nodules? ** == Treatment for vocal fold nodules typically includes vocal fold rest, voice therapy, and in some cases, microlaryngoscopic surgery.

The most common theoretical approach for the treatment of vocal nodules is voice therapy (Boone et al). <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">Voice therapy for patients with vocal fold nodules can positively alter the perceptual qualities of the voice, the patient’s perceived voice-related quality of life, and the anatomical vocal fold status (McCrory). <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">In some cases, a voice therapy regimen might begin with a period of total voice rest. This period of time may consist of up to two weeks of absolutely no sound production, and is often a method that is used to start therapy with patients who simply cannot seem to achieve an appropriate level of moderate voice use. For those who can commit to sound production in great moderation, relative voice rest may be employed to begin their therapy regimen. This involves almost complete silence with short periods of time allotted for voicing; for example, relative voice rest might be prescribed over a span of 4-7 days with 15 minutes per day allotted for voicing.
 * <span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">Voice therapy: **

Following voice rest, the therapist instructs the patient to:

<span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">1. Maintain optimal breathing patterns. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">2. Speak relatively slowly. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">3. Articulate clearly. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">4. Speak with a comfortable pitch level. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">5. Speak at a comfortable loudness level. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">6. Use pitch change, rather than loud volume, for emphasis, practice intonational patterns. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">7. Monitor posture (even and not hunched shoulders with no curve of the spine). <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">8. Avoid monotonous delivery. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">9. Watch out for muscle tension. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">(Bowen).

<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">**Voice therapy aims to:** <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· eliminate vocal abuse and misuse <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· increase breath support <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· relax the head and neck muscles <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· use the patient's natural pitch <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· reduce loudness <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 0pt 0.5in; text-indent: -0.25in;">· ensure relaxed and easy movement of vocal folds <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt 0.5in; text-indent: -0.25in;">help the patient to project the voice using their easiest, most relaxed voice (Boone et al).

<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">**Surgery:** <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">Surgical treatment is usually sought only after therapeutic methods have been exhausted or ruled out. It is not usually recommended for people with vocal fold nodules because there is no guarantee that the lesions will not return post-illness. Surgery is performed using microlaryngscopic techniques. The hardened, calloused part of the vocal fold is cut away. Below is a video of a surgical removal of vocal fold nodules: <span style="font-family: 'Trebuchet MS',Helvetica,sans-serif; margin: 0in 0in 10pt;">media type="youtube" key="4yXY61PG1gU" width="425" height="350"

<span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0in 0in 10pt;">It is important to remember that the patient's voice may be different after surgery, and that a large amount of counseling must occur before the patient undergoes surgery. The effects of surgery on the voice may not always be desirable. Film actress and singer Julie Andrews had surgery to remove vocal nodules from her vocal folds, leaving her to never be able to sing again. For many, this may seem like a small sacrifice for functional voice use post-surgery. For professional voice users, however, such a change could seriously impact the patient's psychological and emotional state. Below, Julie Andrews recounts her experience: <span style="font-family: 'Trebuchet MS',Helvetica,sans-serif; margin: 0in 0in 10pt;">media type="youtube" key="ohzSg7BtaeI" width="425" height="350"

=<span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">**<span style="background-color: #ffffff; color: #0d3107; margin: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 5px;">What are the General Goals of Treatment? ** =

<span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">There are many goals that come along with the treatment of vocal nodules. If surgery is the option chosen the main goal is to reduce and hopefully eliminate the nodules. However even with surgery the vocal nodules may return if habits are not altered. There for it is important to try voice therapy. The main purpose of voice therapy is to reduce the vocal abuse or eliminate vocal misuse. It helps eliminate the causes of the nodules teach a person more efficient use of his/her voice. <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 90%; line-height: normal;">Source: Pediatric Otolaryngology Head and Neck Surgery A. (2004). Vocal Cord Paralysis. In //Pediatric Otolaryngology//. Retrieved April 8, 2011, from http://www.pediatric-ent.com/learning/problems/vocalcord.htm <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;"><span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">Therapy Goals- (Including but not limited to): · Reduce or eliminate vocal nodules <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Reduce or eliminate vocal abuse  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Learn healthy loud voice production  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Increase vocal awareness  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Increase the understanding of normal phonation  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Increase proper vocal tract postures and use of gentle vocal fold vibration  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Increase the clarity and richness of the voice  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Increase in quality of life  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Improve visual appearance of vocal folds  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Decrease the maladaptive compensatory vocal tract behaviors  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Decrease in breathiness and overall hoarseness of the voice  <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">· Modify communicative environment to increase compliance with voice conversation/voice rest guidelines **<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">Examples of Long Term Goals: ** <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">“Mary (client) will resume professional voice use and independently incorporate appropriate speaking and singing technique.” <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">“John (client) will achieve voice quality free of breathiness and hoarseness.” **<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">Examples of Behavioral Objectives: ** <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">“When given a list of 20 sentences, Mary will read each sentence aloud with the appropriate breath support 18/20 times (90%).” <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; line-height: normal;">“After hearing the same phrase spoken at different loudness levels, John will choose the sentence (F=3) whose speaker uses the appropriate volume 10/10 times (100%)." <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 90%; line-height: normal;">Sources:

<span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 90%; line-height: normal;">//Do you hear what I hear?//. (n.d.). Retrieved April 20, 2011, from [] <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 90%; line-height: normal;">The Voice and Swallowing Institute. (2011). About Voice Therapy. In //The New York Eye and Ear Infirmary//. Retrieved April 20, 2011, from [] <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 90%; line-height: normal;">Pedersen M, McGlashan J. Surgical versus non-surgical interventions for vocal cord nodules (Cochrane Review). In: //The Cochrane Library//, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd non-surgical interventions for vocal cord nodules (Cochrane Review). In: //The Cochrane Library//, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd

==**<span style="background-color: #ffffff; color: #0d3107; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%; margin: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 5px;">What are the Techniques and Activities Used in a Typical Treatment Session? **== <span style="color: #404040; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">Techniques for reducing the discomfort and hoarsness that accompany vocal fold nodules includes vocal rest and patient education on vocal hygiene. Vocal rest involves little to no use of voice for more than 15 minutes in a 24 hour period, avoiding any overuse of voice, avoiding throat clearing and coughing, avoiding inhaling smoke, dust and other irritants, and using good voice production techniques. Vocal hygiene should accompany vocal rest for optimal results. Vocal hygiene includes drinking 4 to 8 ounces of water daily, using breath support, being well rested, avoiding excessive throat clearing and mucus production, minimizing alcohol, dairy and caffiene intake as they encourage mucus production and dryness, avoid menthol lozenges, avoid smoking and trying not to raise voice volume to an uncomfortable level. Patients can elect to have a laryngeal steriod injection using a laryngeal telescope or laryngeal flexible endoscope in order to improve maximum phonation time and mean flow rate. This technique could be more beneficial to patients who have voice related occupations where vocal rest may not be as effective or realistic. Botulinum toxin injections are becoming increasingly popular in the treatment of resistant vocal fold nodules because of it's ability to resolve the issue without the scarring that comes with surgery. The toxin works by causing temporary vocal fold paralysis, which induces voice rest.

=<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">Laryngology101- Vocal nodules =

<span style="color: #000080; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 110%;">Videostroboscopy of a person with vocal nodules.
media type="youtube" key="z9LKwISwb_c" height="390" width="480" align="left"

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<span style="color: #404040; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">﻿Sources
<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">ASHA 1: [] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Picture 1: [] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Picture 2: [] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Snow: Snow, J. B., & Wackym, P. A. (2009). //Ballenger's otorhinolaryngology: head and neck surgery// (pp. 917-920). , NY: BC Decker Inc. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Boone, DR., McFarlane, SC., Von Berg, SL., & Zraick, RI. (2010). //The voice and voice therapy//. Boston: Allyn and Bacon. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Bowen, C. (1998). <span class="goog_qs-tidbit-0">Voice therapy for adults with vocal nodules and voice strain. Downloaded on (date) from www.speech-language-therapy.com/adult-voice-strain.htm <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%; line-height: normal;">//Do you hear what I hear?//. (n.d.). Retrieved April 20, 2011, from<span style="background-clip: initial; background-origin: initial; background-position: 100% 50%; cursor: pointer; padding-right: 10px;">[]  <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%; line-height: normal;">The Voice and Swallowing Institute. (2011). About Voice Therapy. In //The New York Eye and Ear Infirmary//. Retrieved April 20, 2011, from<span style="background-clip: initial; background-origin: initial; background-position: 100% 50%; cursor: pointer; padding-right: 10px;">[]  <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%; line-height: normal;">Pedersen M, McGlashan J. Surgical versus non-surgical interventions for vocal cord nodules (Cochrane Review). In: //The Cochrane Library//, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd non-surgical interventions for vocal cord nodules (Cochrane Review). In: //The Cochrane Library//, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">McCrory, Eimear//. International Journal of Language & Communication Disorders //, Nov2001 Supplement, Vol. 36, p19, 6p <span class="medium-font" style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%;">[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 90%; line-height: normal;">Pediatric Otolaryngology Head and Neck Surgery A. (2004). Vocal Cord Paralysis. In //Pediatric Otolaryngology//. Retrieved April 8, 2011, from http://www.pediatric-ent.com/learning/problems/vocalcord.htm