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Vocal Fold Nodules

Vocal fold nodules are traumatic lesions that arise in the mid-portion of the musculomembranous vocal fold.  They essentially form from repetitive trauma as the vocal cords vibrate to create sound.  They can form in any setting where the use of the vocal folds exceeds the ability of the tissues to withstand the ongoing repetitive trauma.  As such, recurrent episodes of swelling and haemorrhage progress to fibrotic and hard vocal cord scar.  As such, the fibrovascular scar (nodules) can vary in size (both height and length).  Vocal fold nodules create hoarseness by preventing the vocal cords from completely closing.  They also reduce the surface pliability.  With the loss of pliability and the inability for complete closure, there can be substantial hoarseness. 

Such hoarseness can be significantly debilitating in high volume voice users, in particular singers, actors and other forms of professional voice users. 

The cornerstone for managing these patients involves a comprehensive and detailed videostroboscopic exam.  This is done to gain maximal information on the function of the vocal folds.  In conjunction with this, speech therapy is critical to establishing sound vocal practice and eliminating deleterious vocal habits.  Some patients can respond adequately to speech therapy and not require any further intervention.  Some patients, more often singers, do not achieve a complete response to speech therapy.  Despite months of dedicated exercises and review, nodules can persist and are then said to be refractory.  Refractory nodules then, after careful assessment, can be suitable for highly specialised phonomicrosurgery. 

A very clear distinction needs to be made and understood between the different surgeries for vocal fold nodules.  The most common way nodules are removed in Australia is by grasping the nodule and tenting it up.  Scissors are then used to carefully snip the scar free from the rest of the vocal fold.  Dr Broadhurst does not use this technique as he feels there is too much imprecision.  There is also unnecessary removal of healthy surrounding tissue.  The technique Dr Broadhurst uses for surgery on nodules was learned under Dr Zeitels and has proven highly successful on an endless number of high-end professional voice users.  This technique involves a mini microflap being created through a very small incision in the vocal cord (cordotomy).  This incision is between 3-5 mm in length.  After this is lifted from the vocal fold the under surface of that flap contains the fibrous scar tissue of the nodule.  The nodule is carefully removed from the overlying epithelium flap to complete the surgery.  As such, there is maximal preservation of all normal tissue and complete removal of the abnormal scar.  In many patients this is the only way to re-establish full pliability and complete vocal fold closure.