Vocal Nodules (Singer's or Screamer's Nodes)

They appear symmetrically on the free edge of vocal cord,
at the junction of anterior one-third, with the posterior
two-thirds, as this is the area of maximum vibration of the

cord and thus subject to maximum trauma.
Their size varies from that of pin-head to half a pea.

Aetiology: They are the result of vocal trauma when person speaks in unnatural
low tones for prolonged periods or at high intensities.
They mostly affect teachers, actors, vendors or pop singers.
They are also seen in school going children who are too
assertive and talkative.
Pathologically, trauma to the vocal cord in the form of
vocal abuse or misuse causes oedema and haemorrhage in
the submucosal space. This undergoes hyalinisation and
fibrosis. The overlying epithelium also undergoes hyperplasia
forming a nodule. In early stages, the nodules appear
soft, reddish and oedematous swellings but later become
greyish or white in colour.
Symptoms: Patients with vocal nodules complain of hoarseness.
Vocal fatigue and pain in the neck on prolonged phonation,
are other common symptoms.
Treatment: Early cases of vocal nodules can be treated conservatively
by educating the patient in proper use of voice .
With this treatment, many nodules in children disappear
completely. Surgery is required for large nodules or nodules
of long-standing in adults. They are excised with
precision under operating microscope avoiding any
trauma to the underlying vocal ligament.
Speech therapy and re-education in voice production
are essential to prevent their recurrence.