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.