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A Case Study : Anterior Nodules … diagnosis.


The anatomical drawing above shows a perfect set of ‘abducted’ vocal folds. This commission was drawn by Jessica April. (all rights reserved)

Spring term teaching singing at NTU kicked off last week for me - two solid days meeting and greeting students, getting the new term’s vocal goals underway. 

I was particularly interested to see Susan, who, at the end of November 2012, was  fed-up and tired of intermittently having little or no voice. A keen and capable singer, a reliable Alto, musical, confident, committed - Susan was at the end of her tether with her voice barely being able to sing anything beyond the B above middle C. We had discussed it at length in lessons. She was tired, stressed, and anxious about potentially losing her singing voice. We backtracked to basic vocal technique, taking care with posture, breathing, onset of sound and support issues. We switched to songs with ranges that didn’t overwork the voice.


Susan made her mind up to get the problem professionally looked at by an ENT consultant and after her first appointment on 10th Jan she told me in an email: 

I had my ENT appointment today and they have found that I have anterior nodules - I think that’s what they’re called. I have to have voice therapy for the next two months as they try to shrink them down. They think they’ll be able to as they are relatively new and soft still and won’t need surgery. I’m not allowed to shout and speak above normal talking levels but to carry on singing lessons with all the stuff we’ve been doing - not stretching my range, or pushing it, but keeping it going. But I have to stop choir for a while so I don’t end up over using it. 

When I met up with Susan for her first lesson of the term on Friday last week, I could hear that her voice was much more rested. The tone of her speaking voice was far more firm, less husky - less excess air escaping through the vocal folds. We went through a basic vocal warm-up: thinking about posture, airflow, doing lip trills and sirening. In a week since her diagnosis, there had already been significant recovery of the vocal range that she had lost. Good news.

I’ve asked Susan to keep a journal of her therapy as the weeks go by and she’s agreed to my reporting about it here: 

First Consultant Appointment 

When I went for my appointment i was really nervous because i didnt really know what to expect. The consultant asked me some questions about how much I sing, (basically all the time) and other lifestyle things:

  • was I a teacher?
  • did I overuse my voice in that way?
  • what sport did i do?
  • any other unnecessary shouting?
Then he put a fiber-optic camera up my nose and down the back of my throat which was not only painful but highly uncomfortable because my natural reaction is to cough it out. He then drew me a picture and told me I had ‘anterior nodules’ and explained vaguely what they were. I was surprised when he told me because I didn’t think there would actually be a problem - just an overtired voice. It was a shock because you hear so many horror stories about people (Julie Andrews) just losing their voices as a result of having nodules, but he and the nurse reassured me that it wasn’t a death sentence for my singing.
I then went to see the speech therapist, Susanne, who explained that I would need ‘vocal therapy’ which would involve more cameras and finding the root of the problem, breaking the habits and putting them right. She then told me for the next 8 weeks I can’t:
  • raise my voice above quiet talking - so no unnecessary singing (very difficult) 
  • no choir 
  • no shouting from room to room
  • no talking in loud environments - bars, clubs, restaurants 
  • no talking over music or television 
I have to drink lots of water and daily steaming. I am allowed to keep my singing lessons to keep everything moving as long as I don’t strain my voice or push it too hard.
Being quiet is proving quite difficult as I am a social person, I love catching up with my friends over coffee or drinks but the most difficult bit is not shouting between rooms where I live at Uni - it means lots of running up and down stairs - or singing along to music or the radio.
But I am feeling slightly better about it all now that I know what the problem is and that I am on the road to some kind of solution - I just have to get used to not being the chatterbox that I usually am!

I shall be interested to see how Susan gets on and what the speech therapist determines as ‘the root cause’.

This problem hasn’t just arrived, it has been around for a few years and certainly it has hampered Susan’s singing in the past. A couple of extra factors to note:

  • She is a keen swimmer, to competition level; her favourite stroke is front crawl, necessitating the habit of taking quick snatched breaths. 
  • She has recently been diagnosed as asthmatic and uses a nebulizer. Susan did wonder if her already present vocal problem had been exacerbated by the medication.

I’d be happy to receive thoughts from other sufferers, or other fellow professionals along the way who might want to comment.


Here’s the next installment in Susan’s story:  ’Therapy 1’

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