HomeDiagnoseTherapySurgeryPhotosLinksPhysician
anatomyphotosvideoaudiocase histories
Updated: 06:38 a.m. PDT (11:38 GMT), June 1, 2007 Current time:

Case histories: Nodules: flat

History

Complaints

  • mid 20's (third decade)
  • female
  • Two years of hoarseness or difficulty with her voice when singing
  • lost upper range

Character

Vocal capabilities

  • Reading voice
    • clear to slightly husky
  • Pitch range
    • Anchor pitch G3
    • Low pitch - C3
    • High pitch - C6
    • vocal ceiling: E5
    • Maximum phonation time: 12 seconds at G3

This 1 minute, 10 second video elaborates on the photos below. Compare a distant vs a close view and hear the air leak when the hard to find nodules touch. The office endoscopy is "upside down" in the sense that the anterior commissure is at the bottom of the video and that makes the sides appear to be switched.

This case is so typical. The patient is a vocal overuser. They see an otolaryngologist or two and they are told they have redness on their voice box. That redness is typically on the arytenoids which are the joints at the to of the video image above. However, they are normally the color above and they do not play any direct role in vocal cord vibration so they have zero impact on the voice. They are more of a distraction in making the diagnosis.

As the endoscope gets closer and as the patient is asked to go up in pitch, the vocal elevations become more apparent. You may call them nodules, they are on both sides here, but the right vocal cord thickening is more prominent. This is a callous or thickening of the mucosa of the vocal cord. The other evidence of vocal trauma is the dilated blood vessel in the middle of the vocal callous.

Video Examination

Exam photos
central vocal cord nodules

View during Respiration: This view was taken from a mid-pharyngeal location. There is some whiteness along the mid vocal cord edges which is a bit of mucous collecting there, but the prominent finding (if you want to call it that) is the "red arytenoids". This was called "GERD" (GastroEsophageal Reflux Disease) or "LPR" (LaryngoPhayrngeal Reflux) and the patient was treated with 2 weeks with Proton Pump inhibitors and then again later with 3 months of Proton Pump Inhibitors. She did not improve.
central vocal cord nodules

View during Respiration: This is the same photo as above, which was taken from a mid-pharyngeal location and I have zoomed in a bit on it. I have color corrected the photo by white balancing it and now the arytenoid "redness" is not so prominent and the closer we get, the more we can perceive the mid-cord thickenings. There is some whiteness along the mid vocal cord edges which is a bit of mucous collecting there.

central vocal cord nodules

The scope was moved closer to the larynx and this is the resulting view. You may be able to appreciate the central elevations once your attention is directed to them. Click on the photo for the full resolution view.
nodules during ABduction

When the cords are in full ABduction, the medial surface of the right vocal cord can be seen and there is a central capillary dilation visible in the middle of the swelling.
nodule - high pitch

This stroboscopic picture taken at a high pitch and the frame selected for a partial open phase demonstrates the central vocal cord swellings with an air gap anterior and posterior to them.

Surgery

No surgery has been done.

Post-operative

No surgery has been done.

Treatment

Medical

No medications were recommended.

Behavioral

Voice therapy to reduce the patients vocal volume, vocal overuse. Trouble shooting noise levels in the classroom. Voice amplification systems were appropriate explorations.

Surgical

The need for surgery would be determined by failure to improve with behavior modification and the patient's desire to sing in her upper register.
Contact the author: James P. Thomas, MD

Created 22 May 2007