Vocal Nodules

If your child has vocal nodules, it is important for you to understand their cause and treatment. You and others in your child’s environment must play an important part in the healing process.

The larynx or “voice box” produces voice. It is situated at about the level of the Adam’s apple in the neck. The vocal cords (or vocal folds) are two small muscles, located within the larynx. During speech, vocal cords come together and use the air from the lungs to make them vibrate. These vibrations produce sound and the movements of the lips and tongue modify this sound to create the individual speech sounds.

Vocal nodules are callous-like bumps on the vocal cords. They can form on one or both of the cords. During normal speech, the vocal cords should press firmly together. However, if nodules are present the cords cannot close completely. Therefore, extra air escapes and the voice sounds hoarse and breathy. Causes of vocal nodules include by the misuse or abuse of the voice.

What causes vocal nodules?

Vocal abuse is the most common cause of vocal nodules in children. Vocal abuse includes:

• Excessive shouting, screaming, cheering or crying
• Strained vocalizations, such as the sound used to imitate motors or animal noises
• Excessive talking
• Reverse phonation which is talking during inhalation rather than exhalation
• Explosive release of vocalizations resulting in staccato-type of talking
• Abrupt hard vocal attacks
• Excessive coughing or throat clearing

Chronic upper respiratory infections, allergies and air pollution can also contribute to vocal nodules.

Nodules may range in size from the size of a pinhead to a split pea (one to three millimeters; keep in mind that the vocal cords are small.) At no time during the development of the nodules is there pain connected with this process. The only notable symptom of the presence of nodules is a breathy and hoarse quality to the voice.

Our ENT specialists can diagnose vocal nodules by performing flexible laryngoscopy in our clinic setting. During this procedure, a small camera passes through your child’s nose to view the vocal cords. CHOC specialists can then evaluate the vocal cord for nodules or other causes of hoarse voice.

What are the treatment options?

Treatment of vocal nodules usually includes voice therapy or a home program, regardless of whether the nodules are surgically removed. The purpose of therapy is to eliminate the causes of the nodules and to teach the child more efficient use of his or her voice. Unless we eliminate the causes, the vocal nodules will inevitably return, no matter how often they are surgically removed.

Parent Cooperation

Successful management of the child with vocal nodules is dependent upon the involvement of the parents and people in the child’s environment in the remediation process. The first step is to identify the vocal abuse habits. Children be aware of these habits in order to eliminate them. It may be necessary to establish a new set of rules regarding the way in which the child uses his voice. These rules may include the following:

• No screaming, yelling or shouting.
• Your child must walk to where you can hear them rather than shout.
• They may use a whistle on the playground to get the attention of the other children rather than yell.
• The child must take turns talking.
• Motor sounds or animal sounds are not allowed.
• The child must use a moderate volume at all times. (Not too loud, but no whispering either.)
• Discourage throat clearing.
• Do not encourage loud singing.
• Don’t permit talking when the television, record player or radio is on. Talking should only be allowed in a quiet environment.

It is very important to enforce these rules consistently. That is, don’t allow any exceptions. However, you should positively reinforce the appropriate vocal behaviors and not nag about the child’s bad habits. It is also important that you set a good example for the child with your vocal habits. Don’t expect him to refrain from doing something that he hears you doing. It is also important that all family members follow the same rules. Don’t single out the child with the voice problem. Be consistent with all family members in terms of discipline.