What are singer's nodules?

Singer's Nodules (Vocal Cord Nodules)

Singer's nodules are benign, bilateral, callous-like lesions that develop at the midpoint of the membranous vocal folds due to repetitive mechanical trauma from voice overuse or misuse. 1, 2

Definition and Pathophysiology

• Vocal cord nodules are also known as laryngeal nodules, singer's nodes, teacher's nodules, or screamers' nodes—all referring to the same condition 3
• These lesions form as a result of vascular disorders secondary to overstrain of the vocal apparatus during phonation, combined with disorders of autonomic innervation 4
• The nodules typically appear as benign growths with a callosity-like appearance located at the junction of the anterior and middle third of the vocal folds 2
• They represent a phonotraumatic injury pattern resulting from chronic vocal fold collision during voice production 1

Clinical Presentation

• Characteristic voice symptoms include hoarseness (dysphonia), voice instability when speaking or singing, vocal discomfort, and vocal fatigue 2
• Associated symptoms may include dry cough, laryngeal discomfort, and reduced vocal endurance 2
• The condition most commonly affects individuals aged 20-50 years who engage in vocally demanding occupations or activities 4
• Over 50% of teachers experience dysphonia attributable to voice overuse, with vocal nodules being a common finding 1

Diagnosis

• Laryngoscopy is mandatory for definitive diagnosis—empiric treatment without direct visualization is not recommended 2
• The American Academy of Otolaryngology-Head and Neck Surgery recommends visualizing the larynx when hoarseness persists beyond 3 months or when a serious underlying cause is suspected 1
• Laryngoscopy reveals bilateral lesions at the mid-membranous vocal fold, the point of maximum mechanical stress during phonation 1, 2
• Stroboscopy provides enhanced characterization of benign vocal fold lesions including nodules 1
• Comprehensive voice evaluation should document the functional impact on voice quality and professional performance 2

Natural History and Prognosis

• In children, vocal nodules are extremely common (prevalence 15-24%) and typically resolve during normal development 1
• In one pediatric study, 77% of hoarse children had vocal fold nodules 1
• In professional singers, nodules tend to recur despite treatment, particularly hard (fibrotic) nodules 5, 6
• Soft nodules may temporarily disappear with physiologically correct voice use, but hard nodules typically persist and do not resolve with conservative management alone 5, 6

Common Pitfalls

• Do not treat dysphonia empirically without laryngoscopic confirmation, as this delays appropriate diagnosis and management 2
• In smokers or patients over 60 years, maintain high suspicion for malignancy—28% of dysphonia causes in this age group are malignant 2
• Professional voice users (singers, teachers, clergy) require early evaluation due to significant occupational impact 1
• Recurrent nodules in professional singers indicate that physiologically correct singing alone is insufficient for permanent resolution, particularly for fibrotic lesions 5, 6