Vocal nodules recur after surgery unless vocal behavior is modified and vocal overuse reduced

Elizabeth is in her 20s and began singing about 3 years ago. About 1 year ago, she noted some roughness in her singing voice. She loves to talk and rates herself a 7/7 on the talkativeness scale and a 7/7 on the loudness scale. Here are her vocal cords when I met her.

Abduction, bilateral vocal nodulesADduction, bilateral vocal nodules

On the left with the vocal cords open (abduction), there are fairly large white calluses in the center of each vocal cord with the right one being slightly larger. The vocal impairment they create is visible on the right. As she brings her vocal cords together at high pitch, vocal nodules touch each other splitting her vocal cord into 2 vibrating segments.

She went through with therapy and then subsequently microlaryngoscopy to remove the vocal cord nodules.

Surgery

30° endoscopic view of vocal cord nodules during surgery70° endoscopic, close-up view of left vocal cord nodule during surgery70° endoscopic, close-up view of left vocal cord nodule during surgery70° endoscopic, close-up view of right vocal cord nodule during surgeryoverview with microscope of both vocal cord nodulesLeft vocal cord nodule and laser

The vocal cords are viewed with 30° and 70° endoscopes as well as a microscope. Then the nodules are excised by pulling the nodule away from the vocal cord and cutting with a CO2 laser.

70° endoscopic view of left vocal cord after excision of nodulestroboscopy, vocal nodules, 3 weeks after removalvocal nodules 2 months after removal30° endoscopic view of vocal cords after excision of nodule

At the conclusion of surgery, there is a depression where the mucosa or epithelium has been removed on each side.

She rested her voice completely for one week.

Vocal nodules 1 week after surgery

After 2 weeks of voice rest and one of speaking:

vocal nodules, 3 weeks after removalstroboscopy, vocal nodules, 3 weeks after removal

 vocal swellings are starting to reappear.

Two months after surgery, further voice therapy and rather active voice use:

vocal nodules 2 months after removalstroboscopy, vocal nodules 2 months after removal

Four months after surgery and continued voice use:

vocal nodules approximate 4 months after removalstroboscopy, vocal nodules approximate 4 months after removal

She is now able to sing 7 semitones higher before her recurrent vocal swellings touch and impair her singing. One of the most important things about vocal overdoers is that the operation is on the vocal cords and not the patient's brain. It takes a great deal of vocal behavior modification to reduce vocal overuse, otherwise vocal swellings/nodules tend to recur.