voice doctor

voice doctor

Vocal Nodules / Nodes

Thickenings or callouses that form on the vocal folds

What is are nodules?
Nodules are thickenings or callouses that form on the vocal folds. They are a result of vocal trauma without periods of rest.


What does that mean?

Vocal folds (also called vocal cords or, by some, vocal chords) are not just strings in your voice box. They’re actually folds of tissue with a delicate lining on the outside. This lining is very fine and soft, like the lining of the inside of your cheek (labeled “lining” below). When seen from above, the vocal folds look like a “V.” This delicate lining is quite easy to injure. The vocal folds vibrate (or contact each other) several hundred times per second when singing and speaking. This puts a lot of stress on that delicate lining. Speaking or singing incorrectly, in a bad environment (i.e., smoky, dry, etc), or for prolonged periods of time can cause that lining to swell.


Over time, that swelling becomes firmer, until it is a nodule. It is similar to what happens when you first start a running program. First, you may just get watery blisters. If you rest, the blisters go away. However, if you keep running, the blisters get more firm, until they are callouses. The same thing happens on the lining of the vocal folds.

What is vocal trauma?

Vocal trauma is using your voice:

      • Too much
      • Too loud
      • Incorrectly

What is rest?

Resting may mean not speaking at all. It may also mean:

      • Learning to speak correctly
      • Using amplification
What are the symptoms?

Symptoms of nodules vary based on your vocal demands.

If you are a vocational voice user (i.e., someone who uses their voice for their living, such as a singer, actor, voiceover artist, etc), you will possibly notice:

  • Hoarseness in your speaking voice
  • Hoarseness (irregular, inconsistent quality) in your professional voice (singing, voiceover, etc)
  • Decreased range (no longer hitting higher notes easily)
  • Inability to sing quietly
  • Inability to hold a pitch steady
  • Decreased color or vibrancy of tone
  • Vocal fatigue (feeling worn out after a performance)
  • Throat discomfort, pain, or tightness
  • Neck pain

Self Check:

Try to sing “Happy birthday” as quietly as you can. Are you able to hit all notes easily and quietly?

If not, you may have nodules or another vocal problem.

If you are an avocational voice user (i.e., not someone whose voice is their livelihood, such as a doctor, teacher, lawyer, etc), you will possibly notice:

  • Vocal fatigue (feeling worn out after a performance)
  • Throat discomfort, pain, or tightness
  • Neck pain
  • Hoarseness in your speaking voice
What do nodules look like?
Nodules  are whitish growths on the middle of the vocal fold, along the margin.

Why are nodules so common?

Nodules are actually not common at all. They are diagnosed so often because a general ENT has neither the expertise nor equipment to correctly diagnose vocal masses. Using inferior equipment, all an ENT can see is swelling on both vocal folds, which is a common finding in all vocal masses. Because they do not have fellowship training in laryngology, ENTs are not trained to differentiate various vocal masses. Therefore, all vocal masses are incorrectly called nodules, which makes them seem common.

The reality is that vocal masses (including cysts, polyps, nodules, etc) are common because we use our voices so much.  Unless we use our voices correctly, these masses develop fairly easily because of the delicate nature of vocal folds.

Imagine looking at a highway from a plane. All the vehicles on the road look the same. When you see something moving on the road, you will call it a car. It is only when you get closer, standing at the roadside, that you are able to differentiate a truck from an SUV, car, and motorcycle.

That is the difference between the average physician using sub-optimal equipment and a laryngologist using videostroboscopy. A traditional “scope in the nose” is a distant, poorly-illuminated view, revealing only “bumps.”  Videostroboscopy allows a laryngologist to get that closer look, differentiating between various vocal problems. This is critical because the treatment of nodules versus other pathologies is very different.

Complications of nodules

There are complications to nodules, particularly when the diagnosis is made too late.  Complications include:

  • Permanent hoarseness
  • Scarring
  • Painful phonation/voice use
  • Loss of vocal range

How can I avoid having a complication?

Early diagnosis is the key to avoiding these complications. This means, for a singer, coming in for evaluation as soon as you are hoarse.

Singers incorrectly assume it is okay to be hoarse after a long performance or rehearsal. It is not normal to be hoarse at these times; hoarseness is an indication that something is wrong. Evaluation at this time is critical to ensure reversibility.

Truths & Myths

I hear conflicting things about nodules. What is the truth?

One of the most common myths about nodules is the diagnosis itself! Usually doctor’s don’t have the necessary equipment (stroboscopy) to diagnose vocal problems. So all problems are called nodules. Every singer has a colleague who had “nodules” for this reason.

Myth: Nodules mean the end of my career.

Truth: Nodules, when caught early, are reversible with good voice therapy and medical management.

Myth: Nodules require surgery.

Truth: Only rarely, and in the case of long-neglected nodules, is surgery required.

Myth: Nodules are not preventable.

Truth: Nodules often occur to due voice overuse or misuse.  If good vocal hygiene is used, nodules are 100% preventable.

Myth: I can just stay silent for one month and the nodules will go away for good.

Truth: While total voice rest will make nodules disappear, as soon as the voice is used again, with the same technique that caused them to form in the first place, they will recur.

What is the treatment?

Treatment is most effective when nodules are caught early and diagnosed correctly.

This may seem simple, but without videostroboscopy it is nearly impossible.

How do you handle vocal fold nodules?

At the Voice Division at Osborne Head and Neck Institute (OHNI), we understand that your voice is your livelihood.  We take the utmost care to prevent poor voice outcomes.  Your evaluation at OHNI includes:

  • A complete history
  • A complete physical exam of the head and neck
  • Laryngoscopy
  • Videostroboscopy
  • Treatment planning – this usually includes voice therapy with a skilled therapist, trained in the treatment of voice disorders

With appropriate treatment, we are able to help your nodules resolve completely, without surgery.

Can I just see my regular doctor?

Unfortunately, few people are trained to correctly diagnose and treat voice disorders. Most doctors will simply push steroid pills on singers. While this often does make the situation better, it is not a long term solution. As soon you try difficult vocal tasks again, the problem will recur. Each time you are hoarse, you are potentially creating irreversible damage that a regular physician cannot see.

Only a laryngologist can accurately diagnose and treat you.

What should I ask my doctor when I see him/her to ensure I’m getting the right treatment?

It is very difficult for a patient to differentiate a qualified voice physician from someone who calls himself a voice doctor simply because their wall is covered in artists’ head shots. Most singers rely on word of mouth, which may not lead to a true laryngologist.

You should ask your voice physician the following questions to ensure you are getting the treatment you deserve:

  1. Are you board certified in ENT?
  2. Are you fellowship-trained in laryngology/professional voice?
  3. Do you perform videostroboscopy?
  4. Do you perform the examination on your patients?*
  5. When surgery is needed, do you perform the surgery yourself or are there other doctors or doctors-in-training involved?
  6. Do you accept insurance? Are your services covered by insurance?

Often, laryngologists are located in facilities where residents or fellows (doctors-in-training) perform a large portion of the services.

Does insurance pay for a laryngologist visit?

If the laryngologist accepts insurance, your visit is usually covered. Laryngoscopy with stroboscopy is also usually covered. It is best to ask your doctor’s office billers to clarify insurance issues.


Contact Dr. Reena Gupta

If you would like to speak with Dr. Gupta or another one of our physicians regarding an ear, nose, throat problem; or have other questions or concerns, please complete the contact form below or call us at 310-657-0123.