How to Erode the Dreaded Node


It's everyone's worst nightmare. The dreaded nodes! Never heard of nodes? The media portrays them as an end to a singer's career, like here in the movie Pitch Perfect. Chloe, one of the Barton Bellas, is diagnosed, unfortunately with vocal nodules.

Secretly, during the movie, she decides to have surgery to have them removed. The movie has a comedic theme, so she makes light of the situation which occurs post-operatively: a loss in vocal range. With her new-found bass notes accessible, she propels the group to a victory at competition with her ability to sing the male part in an all-female group. The movie ends, everyone is happy, end of story.

In real life, any type of voice disorder can be life-changing for individuals who use their voices in a professional context. Vocal nodules, although common, require intervention in most cases, especially in professional voice users like teachers or entertainers. Vocal nodules are two areas of lesion (bilateral, or both sides) at the front portion of the vocal folds. They are caused from overuse of the vocal mechanism, and the severity can depend on genetics, dehydration, vocal demands and poorly coordinated vocal subsystems. Some physicians term a unilateral (one sided) lesion as a "node" only adding to confusion, but for the purposes of this blog we are talking about bilateral vocal nodules. 

The mid-anterior 1/3 junction of the vocal folds is the area where the vocal folds collide the hardest and create the most movement during phonation, or sound production. This area is also where we find nodules. If a person develops vocal nodules, is it because of vocal loading? Possibly, but this study found no correlation. We also know that teachers are at a greater risk for voice disorders. So what makes a person more susceptible? We speculate it has a lot to do with genetic predisposition paired with this heavy vocal use/phonotrauma.

Nodules, unlike other vocal lesions, are sometimes described as swellings and can usually respond to voice rehabilitation and decrease greatly or be eliminated entirely with no surgery necessary. Degree of improvement and estimated length of time vary with severity of nodules. The harder, and more fibrous, the more recalcitrant the nodules may be. As science continues researching different treatment methods, we find that surgery to the vocal folds is not always the right choice for a certain vocal disorder. It seems that in modern medicine, a quick fix is what every patient wants. A pill for this, a surgery for that. 

When vocal nodules form, it is because of a repetitive behavior. If they are surgically excised with no treatment to eradicate the initial cause, they have a likely chance of returning. You also run the risk of scar tissue forming following surgery to the delicate membranes of the vocal fold tissues.

With the subspecialty of vocologists in the SLP world, many well-qualified professionals can provide treatment for decreasing vocal overuse and rebalancing vocal subsystems. This can often improve quality of life and vocal stamina so much that phonosurgery is not even necessary. A study even compared the difference in outcomes between traditional voice therapy recipients and intensive programs, with both groups resulting in better outcomes. Those who do choose to have nodules surgically removed, have a lower chance of recurrence if they participate in voice rehabilitation with a qualified SLP. 

So if your patient, loved-one, or even you are suffering from vocal fold nodules, like Chloe, you should seek the help of a qualified otolaryngologist and voice team to help you make the best decision based on your specific case.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.