What are the symptoms and treatment options for vocal cord nodules?

Symptoms and Treatment of Vocal Cord Nodules

Vocal cord nodules primarily cause hoarseness and typically respond best to conservative management with voice therapy as the first-line treatment, with surgery reserved only for cases that fail conservative measures. 1

Primary Symptoms of Vocal Cord Nodules

Vocal cord nodules are benign phonotraumatic lesions that typically present with:

• Hoarseness - the predominant symptom 1
• Reduced voice quality and resilience 2
• Foreign body sensation in throat 2
• Frequent throat clearing 2
• Voice fatigue with prolonged use 3
• Unstable voice when speaking or singing 4

The symptoms are often worse with prolonged voice use and may be particularly problematic for professional voice users such as teachers, singers, and clergy 1.

Diagnostic Approach

Visualization of the larynx is essential for diagnosis:

• Laryngoscopy should be performed when hoarseness persists beyond 3 months or earlier if serious underlying cause is suspected 1
• Earlier evaluation (within 2-3 weeks) is recommended for professional voice users even without red flags 5
• Red flags requiring immediate evaluation include: hemoptysis, dysphagia, odynophagia, unexplained weight loss, neck mass, stridor, or breathing difficulty 5

Vocal cord nodules typically appear as bilateral, symmetric lesions on the mid-portion of the membranous vocal folds 4.

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Voice therapy is the primary treatment 1, 6

   • Focuses on retraining and rebalancing voice use
   • Shown to be effective for vocal nodules compared to vocal hygiene alone 1
   • May obviate the need for surgery 1

2. Voice rest and vocal hygiene 6, 3

   • Reduce voice overuse and misuse
   • Avoid shouting, excessive talking, throat clearing

3. Address contributing factors 1, 3

   • Treat reflux if present
   • Manage allergies or asthma if contributing
   • Hydration and humidification

Second-Line Treatment: Surgical Intervention

Surgery is reserved for cases that fail conservative management 1, 6:

• Indications for surgery:

  • Persistent nodules despite adequate voice therapy
  • Significant impact on quality of life despite conservative measures
  • No improvement after 3-6 months of voice therapy

• Surgical approach:

  • Microsurgical removal via suspension laryngoscopy 6
  • Post-surgical voice therapy is important to prevent recurrence 1

Special Considerations

• Pediatric patients: Nodules are common in children and typically resolve over time with conservative management; surgery should be limited to severe cases unresponsive to voice therapy 1

• Professional voice users: May require more aggressive and earlier intervention due to occupational demands 5

• Recurrence risk: Failure to address underlying causes of vocal trauma can lead to recurrence after surgery 1

Evidence Quality and Gaps

• A Cochrane review found no high-quality randomized controlled trials comparing surgical versus non-surgical interventions for vocal cord nodules 4

• Despite this lack of comparative studies, clinical guidelines consistently recommend voice therapy as first-line treatment 1

• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that surgery is not the primary treatment for most patients with dysphonia, including those with vocal nodules 1