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Pre-nodules, acid reflux & vocal care

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Recently, I've been getting emails about the best way to care for pre-nodules and other vocal pathology issues. Obviously, the best first step is to go to an Otolaryngologist (Ear, Nose and Throat Doctor) who can look at your vocal folds directly to see exactly what the problem is. (If you're in New York, Dr. Benjamin Asher- a TMV member- is excellent!) With that said, here are some helpful tips for both before you see the doctor and after your visit:

  • First, not everything is a nodule or a pre-nodule. Nodules- or calluses on the vocal folds- are caused by prolonged vocal misuse or strain. Polyps on the other hand, are watery sacs often caused from a single, powerful vocal blowout; hemorrhaging is a similar situation resulting from the bursting of a blood vessel in the vocal fold. Treatment for these two issues often differ, but a great first step regardless of the problem is vocal rest until you have the chance to visit your doctor.
  • Many singers assume that singing is the cause of most or all vocal fold injury and problems. While this is true in many instances, in fact, there are two other important issues to also consider.
  • Acid Reflux- as you may know- causes the stomach acid to come back up through the esophageal sphincter and into the larynx, reddening and swelling the area around the vocal chords. Unlike indigestion, many people don't feel reflux, only the symptoms of it... itchy throat, hoarse voice (especially in the morning), and an inability to 'clear the chords'. These 'vocal problems' cause singers to overcompensate by working harder to produce sound, often in unhealthy ways, through 'thick' chords.

While not necessarily the direct culprit in the creation of vocal nodules, polyps and other vocal issues, reflux can certainly exacerbate problems. Obviously there are some purely physical & biological causes of reflux (eating too late, intense exercise after eating, going to bed on a full stomach, too much caffeine, eating spicy and other acidic foods... as well as hormone treatment therapies and birth control pills which loosen the sphincter), but in my experience, anxiety and acid reflux usually go hand in hand; I’ve met very few calm, centered people with this issue.

  • If indeed pre-nodules exist, complete vocal rest for two weeks is a good start to treatment if you want to avoid making them worse and/or surgery (which you do!). While this will help, and sometimes even get rid of the pre-nodules, rest won't take care of what caused the problem; an issue which needs to be addressed once the vocal folds and vocal tract are both back to normal. While pushing, straining and other forms of improper use of the singing voice are common causes of nodules and other vocal issues, improper use of the speaking voice often creates a host of problems as well. Evidence of improper use may not be as aurally obvious in the speaking voice, but a disconnect from breath support caused by tension or stress (muscular & skeletal manifesting in the vocal) and unexpressed emotions/difficulty expressing emotion can be huge contributors to what seem to be singing issues.

Often singers are diligent about their voices, overlooking the myriad external influences, tensions and stress and that are affecting their vocal mechanism. Make sure to take a few steps back for a broader view of the situation. As well, remember that vocal fold problems are rare; they're not the result of normal, powerful and even prolonged, healthy practice or training. In fact, favoring your voice- going easy on it for fear of causing 'damage'- may often cause more problems than singing in a full, confident and comfortable voice. Fear tends to cause not only muscular tension, but for singers to 'pull off their air' thereby restricting the vocal tract and putting undue pressure on the vocal chords.

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