Music Teacher's Helper Blog

Teacher, Know your Instrument

This past Christmas break I was working on music for a faculty voice recital, scheduled for January 20, 2011.  As I practiced, I noticed that something was just NOT right with my voice.  Singing classically, I was fine, if sounding slightly tired.  The problem came when I was trying to sing a slightly higher Broadway belt sound (D4-E4).  My voice was making extra noise and just wouldn’t phonate properly.  I knew that I felt I was working too hard, and my self-diagnosis was muscle tension dysphonia (in other words, using too much muscle and “overblowing” the cords).

So, on January 13, 2011, I went to an ENT to have my cords looked at.   I was shocked when the doctor told me that I had small bilateral pre-nodules on the leading edge of the vocal folds.  I have always had “cords of steel” and been able to pretty much sing through anything.  This diagnosis of pre-nodules really made me re-think how I was approaching my voice.

What are pre-nodules? Here’s the layman’s version: the vocal folds are covered with the same skin as the outer layer of the skin on the outside of your body (squamous epithelium). Nodules are similar to calluses that form from repetitive motion.  If, when you notice that a callus is forming, you change your behavior, the callus can go away pretty quickly.  This is similar to the situation of pre-nodules on the vocal folds: it’s what is the beginning of the formation of a callus, but the skin has not yet hardened. Because I knew my voice and knew that what was going on was NOT just because I was exhausted, I got myself to the doctor quickly.  

What causes nodules? Nodules are most often a vocal disorder of vocal misuse.  But, in any voice disorder, there are generally a confluence of factors that contribute to the diagnosed disorder.  In my case, I had many factors that contributed: 1) On top of my private studio teaching and my regular performance schedule, I began teaching in a university setting in September 2010 (including 13 private students and class voice) which drastically increased my voice use, 2) in December my daughters became ill, & I ended up with very little sleep for 2+ weeks while continuing the crazy schedule that is a singer’s life in the Christmas season, 3) because I am able to be loud, I was speaking too loudly at home to my daughters, 4)  I was singing in the Turandot chorus, which for mezzo-soprano is on the upper end of the tessitura (it hangs D5-F5), 5) I was working learning how to belt while my voice was tired, not the style in which I’m most highly trained, 6) I had an undiagnosed case of Laryngo-Pharyngeal Reflux Disease (LPRD).  All of these factors combined to create what I had felt was just a “tired voice,” but ultimately resulted in something that COULD have been very drastic.

How are pre-nodules diagnosed? The rule of thumb is, if the voice does not work “normally” for TWO WEEKS, after an illness, get to the doctor for a diagnosis.  When it comes to the voice, self-diagnosis is not going to cut it.  I ended up seeing several doctors, in my search to get enough information.  The first doctor I went to (on January 13, 2011) did a intra-nasal mirror exam – he put a flexible tube through my nasal passage to look down onto my cords.  He told me that I had pre-nodules, the constant post-nasal drip down the back of my throat was NOT allergies, but LPRD.  My treatment was for me to lower my vocal use, go on the “Anti-reflux” food regimen, and come back in 8 weeks.  I was so schocked that I, who had just completed 24 class-hours of training in voice disorders and the singing teacher (ONE weekend before), left the office without saying “That’s not enough, I need more information.”  As a result, I DID cancel my faculty recital on January 20, 2011, but I also decided I needed to see another doctor who would be more pro-active with my care and treatment.  The second doctor that I saw put me on a 6-day predolisone steroid pack to reduce swelling in the larynx, gave me a prescription for prilosec, and sent me to a Speech Language Pathologist (SLP) to get “scoped” and a full diagnosis. (see picture).

What is the treatment of vocal fold pre-nodules?  First, I purchased a portable voice amplifier, called a Chattervox. This allows me to speak in a normal tone of voice while in a classroom situation – especially helpful since I’m teaching Italian Diction in the classroom this semester, as well.  For two weeks, because I also got a respiratory infection during this period of time and was coughing quite a bit, I also used the Chattervox in the studio during private lessons, so that I didn’t have to raise my voice to be heard over my singers.  This helped to lower my “vocal dosage:” the amount of work I do with my voice every day.

I also quit one of the semi-professional choirs I was in, giving me one night off per week (and I did NOT put any private students into that spot, so as to give my voice a rest).  Finally, during the worst of my respiratory infection, I took two days of total vocal rest (not talking at all).  That was the hardest, but I needed to get my voice back in a hurry, and that was the best way for me to not further exacerbate the problem.

I spoke with my mentor in the area of voice disorders, Dr. Karen Wicklund, and she gave me several speaking tips: elongate my vowels and reduce my glottal onsets (just as we would when singing).  Also, pay really strict attention to my speaking voice for two 15-minute, SCHEDULED, times daily.  After a few weeks, extend the time to two 30-minute sessions.  After this, it starts to become second nature and I only have to check in with my voice and how I’m using it every once in a while.

I take Prilosec twice daily: ½ hour before eating in the morning, before going to bed at night (2 hours after eating).  I watch my diet.  Things that help ameliorate LPRD are: last morsel if food into my mouth 3 hours before I lie down, last sip of liquid 1 hour before I lie down (either for the night or for a nap in the middle of the day), avoid certain foods (carbonated beverages, caffeine, tomato, chocolate, spicy food, mint and alcohol).  This has immediately gotten rid of the constant post-nasal drip that was obviously causing irritation of the arytenoid cartilages of the larynx (the final step in closing the vocal folds cleanly).

I have also gone back to voice lessons with my own voice teacher – I also had a DMA audition on February 26, 2011 (originally February 19, they were kind enough to push it to the second audition date for me).  There are certain voice exercises that help to release tension in the cords (yes, I WAS overworking the cords because they weren’t coming together cleanly) and allow the edges to come together cleanly and freely.

The result of this aggressive awareness of how I’m using my voice is that on February 16, 2011, I was scoped again and (see video Vocal fold exam February 16, 2011) the bilateral (both sides) swelling on the leading edges of the vocal folds is no longer noticeable.  I completed my DMA audition on February 26, 2011, feeling like I had the full range of my vocal repertoire.  I have tried belting a little bit, and it’s still not quite there – I’m going to be very careful as I go back into that technique to make sure I am well warmed-up and am not using excess muscular tension either within the larynx or in the neck muscles outside the larynx.

If I had allowed the “tiredness” to continue for much longer, the standard time of recovery for nodules is six to eighteen months of speech therapy and often no singing.  This would have been disastrous for all aspects of my career – voice teacher, performer, voice student, mom….  By knowing my voice and what was absolutely NOT normal, I was able to get diagnosed and change habits so that I am no longer scared that I will never sing again.  Since I have now been injured, I will have to be more careful in the future, but I consider myself back to normal (while still continuing the modifications I started).

Always be aware of your voice, how it’s working and if it’s been a while since it’s felt healthy.  Be careful of blaming everything on exhaustion – it CAN turn into something more serious that needs attention.  Your voice is your livelihood, if you’re a teacher (even an instrumental teacher) and I recommend taking the care with it that any professional athlete would.

About the Author

Rachel Velarde
I began my music career in Bloomington, Indiana. After receiving my B.A. in Music from Smith College, Northampton, Massachusetts, I earned two Master of Music degrees at Arizona State University, Tempe, Arizona. Luminaries I have worked with include Vernon Hartman, James Caraher, Lorenzo Malfatti, Shirlee Emmons, Mary Sue Hyatt, John Sikora, David Jones, David Britton, and Carol Smith.

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4 Comments

  1. Art

    Rachel,

    Wonderful article. As a vocal student, this is an invaluable article on vocal preservation, especially as a teacher’s account –excellent.

    I would really like your thoughts and/or elaborations on the process of recovering from pre-nodules.

    I was diagnosed with pre-nodules about a year, maybe year and a half ago almost. Due to an absence of changing my vocal habits and lifestyle choices, the pre-nodules have not left.

    It’s convenient to be reading your article this month, as it marks the start of my recovery from pre-nodules. Just two weeks ago, I had a septoplasty completed in order to alleviate severe sinusitis, and nasal pressure that was also causing excess post-nasal drip. The results have been very, very positive.

    With the absence of post-nasal drip, and easy nose-breathing, my sleeping has improved tenfold, as well as my symptoms with TMJ.

    My question:

    Being that I was diagnosed with pre-nodules, and the doctor continues to insist that there is not an overbearing cause for concern, since they have not transitioned to full vocal nodules, what sort of time expectation would I be looking at to recover, if I were to take full vocal rest?

    And is full, strict vocal rest necessary if I modify my lifestyle choices, which mirror many of those you listed above?

    ***Also, is it really possible that my nodules are only pre-nodules, and not full nodules, even though they’ve persisted longer than 1.5 years? (Truly, voice faculty abound have told me that they hear no traces of vocal damage, but I personally know the presence of the pre-nodes, both via diagnosis and endurance, as well as pitch-ceiling issues).

  2. Rachel Velarde

    Hi Art –
    I’m sorry it’s taken me so long to respond to you. I wanted to gather my thoughts and make sure I stayed within my scope of practice as a voice teacher. I also found, on March 5th, that it was NOT pre-nodules (it never was), it was a vocal cyst and it is still there. I am FINALLY beginning work with a Speech Language Pathologist (SLP) next week (early May).
    I do not feel qualified to comment on whether or not your nodules are truly only pre-nodules, nor the mode of treatment. What I can say is that you are a voice professional and should be treated as a vocal athlete. For most “normal” voice users, a recovery of 90% is good enough for doctors, as well as most patients. As a professional voice user, you must be treated aggressively and insist on 100% return of function. If your doctor is unwilling to take you seriously, get another opinion from a VOICE SPECIALIST (often an otolaryngologist with specialist training), not just an ENT. Dr. Robert Sataloff has spoken/written at length about this (he’s the one who diagnosed my vocal cyst and is one of the leading voice specialists in the world). He teaches at Drexler University and has pioneered many voice therapies and surgeries.
    Pre-nodules ARE cause for concern in a voice professional. They are most often a disorder of abuse/misuse and should be addressed as serious by your doctor. Dr. Karen Wicklund (CCC, SLP, author of Singing Voice Rehabilitation) recommends voice therapy (with an SLP) under a doctor’s supervision, in conjunction with working directly with a Singing Voice Specialist (SVS – voice teacher with specialised training in voice disorders). This is the route I would suggest to you. Most of all, make sure your doctor takes you seriously and understands that “not yet full nodules” is not okay. Prevent them from becoming nodules and there will be much less time lost and a much faster rehabilitation period. Both Dr. Sataloff and Dr. Wicklund have stated that full vocal rest is only rarely indicated (most often only after vocal surgery), and that the voice truly must be used in order for the muscles to relearn the correct habits of vocalization. Vocal rest will not re-teach the muscles (thus the speech therapy work with an SLP and the singing habilitation work with an SVS).
    Best of luck to you!
    Rachel

  3. Louise Cook

    Such a great article. Has helped me a lot.

    Just wondering if you could give me some advice. I’m a singing and dancing musical theatre student, 20 years old and i have quite a large voice. After having an awful cough for a month and it’s not going anywhere fast, 4 weeks on my voice still isn’t back. My situation happens to be the complete opposite to yours, my belt range has never been better up to an Eflat, but my mix to upper range is suffering. I can still hit a top C but not with the strength I normally could my mix range in wide vowel sounds going from sometimes a C to an E is very breathy and hardly there but the same notes are fine in a head resonance or in belt or closed vowels/ words such as ‘doo’. I’ve also had this feeling for about 2 weeks it comes and goes of having a lump in my throat, like when you get an emotion lump in the throat, and sometimes some swelling around the top part of my throat. I’m pretty sure I’m pre-nodular and I’ve got myself extremely upset about it because I’ve always had excellent training up to just under two years ago where the college i’m at now the singing training isn’t up to scratch.
    My main concern is that I have our end of year summer show coming up in which I have alot to sing and with the top choreographers and directors I have been working with I can’t afford to not do the shows. It’s a 9 show run and I don’t want the pre nodules to get any worse. Is there anything I should particularly do other than steam and not to talk or sing other than for the vocal warm ups and shows to conserve the state of my voice?
    I’m going to book an ENT appointement monday but the earliest I’ll be able to get one will be after the show run. The hardest thing is when everyone compliments how good my voice is and I know it’s not healthy, I can’t enjoy this amazing opportunity I’ve been given. I feel embarrassed and ashamed with myself and my pride feels wounded. Any help would be extremely appreciated.

    Louise.

  4. Rachel Velarde

    Hi Louise –
    If I were your voice teacher, I would definitely be concerned and try to get you in with a VOICE specialist ENT as soon as possible. Many ENT’s, unfortunately, do not have specific training in laryngology and do not know what to look for. You need to have a rigid videostroboscopy to get a clear picture of the larynx and what’s going on. The biggest this is you CANNOT self-diagnose, and until you get a good look at the folds, you can’t tell what’s happening.
    The lump in the throat is a symptom of reflux – you don’t have to have any heartburn or feelings of indigestion to have reflux; LPRD (Laryngopharyngeal Reflux Disorder) is mostly pooling of acid at the larynx. It affects the arytenoids and the vocal folds, but there is not necessarily ANY feeling of symptoms, except for reduced vocal function. Things to ask yourself: does your voice take a while to “warm up” in the morning (do you have really distinct morning voice)? Is the lump more present after you eat certain foods (caffeine, carbonation, tomato, mint, chocolate, alcohol) or eat late at night? You can try several non-medical interventions and see if they help – if so, you likely DO have reflux (a contributing factor in MANY voice disorders).
    Try:
    1) limiting caffeine, carbonation, tomato, mint, chocolate, alcohol
    2) your last bit of food goes into your mouth 3 HOURS before you lay down (even if you take a nap in the middle of the day)
    3) your last drink of anything goes into your mouth 1 hour before you lay down
    4) raise the head of your bed 4-6 inches (best way is to put books between the mattress & the box spring)
    5) exercise daily – 30-40 minutes (will help your body to function better AND will help lower your stress levels)
    6) lose weight (especially stomach weight presses on the epigastrium when you’re laying down & the sphincter is looser)
    7) increase your water intake – you should be drinking 1/2 your body weight in ounces of water daily (ex. Weight= 120, water intake = 60 oz)
    8) try to drink 1L of water in the first hour after you get up in the morning – you’ve been asleep for approximately 1/3 of the day, you need to hydrate.

    I completely empathize with your stress levels – I’ve just recently been there. The most important thing is that you get a doctor’s visit as soon as possible – check the ASHA (American Speech-Language Hearing Association) website, http://www.asha.org/, for doctors who specialize in voice disorders to get a better ENT. Insist on a videostroboscopy with a RIGID scope (the flexible scope doesn’t have enough magnification or clarity).

    Really work on singing using the resonance – for broadway, that can be VERY “nasty” sounding in your head, but balanced by an open & relaxed jaw can be done safely (look at mouth space on Youtube of amazing belters – especially in the “superbelt” above D5). For warmups, work on allowing the really free edges of the folds to cleanly come together throughout the range – sirens from top to bottom are wonderful, always approaching even the belt from a “top down” manner so you get maximum effect with minimum effort.
    TALK with your teacher – even if you feel your instruction is not up to par, talk about your concerns with your teacher. Also, if you feel comfortable, talk with the choreographers and directors of the summer show – they’ve all been there at some point in their career. Most of all, make sure you see the doctor sooner than “this is the best we can do.” Call every day to see if someone has cancelled. Make it a priority to KNOW what’s happening – a lot of the stress is the not knowing what’s going on & imagining the very worst.
    Feel free to email me at rachel@velardevoice.com and keep me updated. I wish you the best in everything.
    Good luck!
    Rachel

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