Dear Dr. Jahn,
It has been over 6 months since my nodules healed and I have had several successful performances where my voice is behaving reasonably well, but there are many times where I seem to be going backwards. The littlest things seem to throw my voice into a tailspin for days and days! Also, my very highest notes have still not come back since my vocal injury. Any advice?
-Kathy
Dear Kathy,
I have a number of questions for you which should be considered. Did the nodules resolve spontaneously, or did you have surgery? If spontaneously resolved, did this happen because of just voice rest, or due to voice therapy or a change in repertoire and technique? If the nodules were surgically removed, was this done with a laser, or microsurgery?
In general, nodules are not a disease, but a sign of excessive or poor voice use. To completely treat the nodules, it is essential that you change how you use your voice, both in performance and socially. Often, a singer can modify their vocal technique, but continues to abuse the speaking voice, either due to habit or because of the demands of a day job. So, a complete evaluation and vocal overhaul is necessary, under the watchful guidance of an experienced voice therapist.
I compare nodules to corns on your toes: they result from wearing ill-fitting shoes (or using an inappropriate voice). You can remove the corns surgically, but unless you also change your shoes, they will inevitably come back.
But let’s assume that the nodules are truly gone, and you have changed your technique, your venue, and your repertoire. Consider two other confounders: the first is the need to get rid of any pre-treatment compensatory behavior. This means that, if you were singing adequately with your nodules, this usually requires excessively squeezing the vocal folds together, tightening the pharynx, raising the larynx, and in general “muscling” the voice, rather than sing with good bottom-up support and a relaxed upper vocal tract. You may have hung on to this compensatory behavior after your treatment, but now that compensation, which was a necessary evil before, has no place, and has, in turn become the disease. So, both nodules and faulty vocal technique need to be changed.
The second issue is, of course, any scarring from your surgery. This can happen with laser treatment as well as conventional removal. If the vocal folds are left stiff, it becomes difficult to sing softly at the top of your range. By pushing in this range, you may again revert to “muscling”, and the vicious cycle starts again.
Two suggestions – one, consider that scars (no matter how microscopic) take about six months to completely heal, at the end of which time they are as small and as soft as they will be. So continue to work the voice, especially with exercises like a “siren” or glissando, which stretch the vocal folds. Hydrate assiduously. If the problem remains, consider having a stroboscopic examination to check for stiffness. It is best to do this with a laryngologist, who may be in a position to offer you treatment. Treatment options include injection of cortisone, elevation of the scarred area by injection of saline, as well as aggressive voice therapy.
-Anthony F. Jahn, MD, FACS, FRCS(C)
This discussion is for general information and not to be construed as specific medical advice that you should obtain from your own physician.
Dr. Jahn is an internationally renowned otolaryngologist based in Manhattan with a sub-specialty interest in the professional voice. His practice includes classical and popular singers. He holds academic appointments at Mount Sinai School of Medicine and Westminster Choir College in Princeton. He is Medical Director at Jazz at Lincoln Center, and former Director of Medical Services at the Metropolitan Opera in New York. Dr. Jahn has published several books for vocalists, including “Vocal Heath for Singers” (Singdaptive) and “The Singer’s Guide to Complete Health” (Oxford University Press).
