Vocal Nodules

The overall aim of voice therapy is to teach a healthy, non-abusive voice production pattern.

Causes

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It is rare to find just one “abusive” behavior producing voice symptoms.

Classically, children with nodules are in the habit of talking too long, too loudly and with too much effort.

Usually children develop vocal nodules or vocal strain due to the interaction of two or more of the following, done to excess:

1. talking and singing, for example: excessive and over-enthusiastic rehearsal of school plays or concerts; excessive choir or solo-singing practice; overusing the voice on school camps or excursions; shouting in the playground; talking and shouting against background noise, such as in a swimming pool; overusing the voice during an infection such as a head cold; cheer leading; and overusing the voice when tired or emotionally upset. Lengthy talking, even at normal rate and volume, but without a quiet “recovery time” can also contribute to vocal strain and nodule formation.
2. glottal attack, sharp glottal attack and forceful use of the voice can seriously damage the vocal cords.
3. coughing, and loud, forceful sneezing: many children with nodules do not rest their voices when they have upper respiratory tract infections, even when their throats are sore. Coughing and sneezing can be particularly problematic for a child with asthma or a post nasal drip.
4. crying, laughing and loud or prolonged outbursts of emotion: for example, even very young children who tantrum frequently can develop nodules. Inappropriate or unresolved coping mechanisms for negative emotions (anger, fear, sadness, nervousness) can lead to bottled up anger, explosive outbursts or irrational behaviour, accompanied by loud, forceful voice use.
5. shouting, cheering and screaming: one loud episode at a sporting event or pop concert is sufficient to produce an episode of aphonia.
6. throat clearing: the chronic throat clearing associated with post nasal drip puts a constant strain on the vocal cords, which are g-r-o-u-n-d together each time the throat is cleared.
7. making sound-effects: explosion and monster noises, especially if they are made while breathing IN (!) put a tremendous strain on the cords, as can assuming character accents, for example Power Rangers, Rambo, Street Sharks, and macho villain and “tough guy” impersonations, and using excessive and deliberate glottal fry when speaking.
8. dryness: the overuse of certain medications, such as cough lozenges, antihistamines and patent “cold cures”, especially in conjunction with voice overuse, infections or allergy dries out the delicate lining of the larynx and vocal cords, making voice symptoms worse. Caffeine (e.g., in cola) can act as a diuretic, adding to drying effects. Mouth breathing is also potentially drying.
9. restricted fluid intake: for a healthy respiratory and vocal system good hydration is necessary. A simple way of checking for adequate fluid intake is to ensure that urine is pale in colour.

Risk factors

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Some children are more vulnerable to developing vocal nodules and vocal strain than others. Children who are more at risk may have one or more of the following:

1. a family with loud voice habits such as yelling around the house and calling from room to room in constant background noise. Some children with vocal problems have developed habitually loud voices simply in order to “get the message across” in a constantly loud household.
2. chronic asthma and/or allergies (including post nasal drip and allergic rhinitis); and incorrect use of some puffers (i.e., no spacer and/or drink of water when they are recommended)
3. recurrent and frequent upper respiratory tract infections including infected tonsils, sinuses, adenoids and throat
4. gastric reflux
5. affective disorders such as attention deficit disorder and hyperactivity, or a “temperamental personality”
6. behaviour problems
7. excessive stress or tension in the child’s life, due to internal factors (within the child), external factors (within the environment) or interpersonal factors (e.g., conflict or competition)
8. a loud, outgoing, enthusiastic, competitive personality with a tendency to “act out” emotionally (their parents can often remember them as terrible “terrible two’s” who tantrumed loud and long and who could whinge endlessly). Some babies just seem to be born loud and lovable, and grow into loud and lovable toddlers and children, some of whom are, unfortunately, 'at risk' for voice problems.