A Pumice Stone for Your Vocal Folds? Of Nodules and Intervention

There are many factors that can cause an individual to be hoarse. Vocal fold swelling from sickness or overuse affects the ability for vocal folds to vibrate. Lesions, like polyp, cysts or nodules, can impact closure patterns and vibratory abilities with weight and stiffness. This can greatly affect vocal quality and pitch control. So if a person is diagnosed with one of these issues, is there effective treatment?

It is important for each healthcare provider involved with a patient’s case to weigh all factors when considering surgery like direct microlaryngoscopy. Whenever you are making cuts or removing portions of the vocal fold epithelium, you risk damaging the delicate tissue that is responsible for vibrating and displacing to make sound. Vocal folds are made up of 5 layers, the epithelium on top, the lamina propria (Superficial, intermediate and deep layers) and the thyroarytenoid muscle underneath. Surgeons must be conscious of each layer and do their best to prevent any excess damage, as this tissue will not regenerate with the same chemical makeup. Any surgical intervention will cause swelling, or edema, and can possibly result in worse vocal quality than before. Surgery can be very effective in vocal fold lesion cases, but should be carefully considered.

Vocal fold nodules are very common benign vocal fold lesions. Nodules are unique in that they are usually bilateral, located on the portion of the vocal folds that creates the greatest movement when vibrating, and they are usually symmetrical. They can be gelatinous or hard fibrotic callouses. They occur from overuse of the voice that has caused the vocal fold mucosa to change composition in response to constant abuse. Vocal nodules can actually respond to behavioral voice therapy and can lessen or even disappear. Dr. Lesley Childs discusses why surgery for this is a last resort following conservative behavioral voice sessions. It is very important for patients to understand why they developed vocal fold nodules in the first place, so they can reverse bad vocal behaviors and prevent them from reoccurring.

A case for conservative treatment can be made because often times money, time and tissue can be saved if the patient will commit to changing abusive vocal behaviors in therapy sessions. There is also the very likely chance of recurrence if nodules are surgically removed without the patient receiving voice rehabilitation therapy. Communicate with your referring surgeons and work together with them to determine the best and most comprehensive plan of care for each patient with nodules.

The key to the best patient care is communication and being open to suggestions. In my practice I operate as transparently as possible and with education with the patient in mind. A patient of mine asked me if I was like a “pumice stone for the vocal folds,” and I had to laugh as I told her yes. What a gift to be able to help a person in the way a pumice stone does—aesthetically and functionally.


Sources: Clinical Voice Pathology: Theory and Management 4th Edition, Stemple, Glaze & Klaben. Plural Publishing.

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  www.atempovoicecenter.com. 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.


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