Keeping Secrets: or Vocal Nodes

Vocal Nodes are a subject that singers, voice teachers, and the like try to hide, cover up, and run from. But the reality is many opera singers get nodes at some point in their careers. But what really causes nodes? Natalie Dessay had 4 operations to remove vocal nodes in the last five years. Denyce Graves had a node removed from one of her vocal chords and she admitted she did not tell anyone about it because it is considered "taboo" to have nodes. >Why do singers really get nodes? Maybe because it signals that we have been singing on our interest and not on our principal? Or that we are so afraid to turn down work because there might be a downturn in work coming up? Or make all the money you can while you still can? Therefore we take every gig offered and thus overtax our voices? Or that we have to stay competitive with the herd? Why do singers wear themselves out singing until they bruise and mistreat their vocal chords? Is it safe to blame greed or self hate? And why is it such a secretive subject? Leontyne always said that the key to vocal health was to "refuse to sing some roles" whether it be because of an overtaxed schedule, or be it the wrong repertoire. There were operas that Leontyne refused to perform because she felt they were either not right for her lyric spinto soprano voice, did not fit within her singing/voice rest module, or maybe the spirit inside her said "girl you don't want to sing that." And conductors got red hot with her decisions but listening to that still voice inside is what cost her a beautiful healthy career. The crumbs that fell from Leontyne's table were I'm sure, quickly at up off the floor by the next diva in line. These refusal to sing decisions were made by Leontyne herself. Florence Page Kimball being her only voice teacher, passed on early in her career so Leontyne was on her own after Miss Kimball. I last heard her sing "This little light of mine" at the 10/01 9/11 Memorial at Carnegie Hall and her gorgeous pianissimi hit me way up there and the grand age of 76.

--------------------------------------------------------------------------------
Voice Disorders Related to Vocal Overuse and Misuse
Definition:

Occupational Hazards - Singers and vocal performers put a stress on their vocal cords akin to the physical exertion of a marathon runner. With their vocal folds vibrating at full volume for long periods of time, singers and orators often develop bumps, polyps, and rough surfaces on the tissues. These lesions can damage the voice that for many is also a livelihood. Though surgical removal is possible, there is a chance that any excision will permanently alter the voice. Zeitels set out to study this patient population more ystematically. "There's often not a lot of science to the surgical management of vocal performers," Zeitels said. Until this recent study, there was little data to determine the success of surgical management in vocalists. Using an approach called stroboscopy, the surgeon can assess the vibratory function of the vocal cords. A strobe light creates the illusion of slowing down the rapidly vibrating cords and allows the observer to watch them move together and apart. Voice outcomes of the surgeries in both studies were evaluated by Robert Hillman, HMS associate professor of otology and laryngology and a voice scientist who leads the voice lab at MEEI. Hillman's group primarily tested two general metrics of the voice: acoustic measures such as loudness, pitch, and regularity of tone, and aerodynamic measures--how much air the person must push from the lungs to get the vocal cords to vibrate.

Singers, like athletes, offer a model for studying how different behaviors affect the vocal cords: a musical-theater singer who belts out Broadway numbers is creating a different kind of stress than an opera singer. "If you can understand how these individuals function, you can master restoring most other voices," Zeitels said. He has found that singers can often perform with long-term trauma because their activity has induced more elastic normal tissue to compensate--their vocal cords even appear larger. The team has a partnership with Robert Langer, an HMS senior lecturer on surgery at Children's Hospital and the Kenneth J. Germeshausen professor of chemical and biomedical engineering at MIT, to develop biomaterials that could be used to reconstruct this elastic tissue. The trick, Zeitels said, is to find a material that does not degrade and is pliable, since stiffness is the cause of the majority of hoarseness. Zeitels believes that maintaining or even supplementing the healthy tissue may become just as important in vocal surgery as removing the abnormalities. --by Courtney Humphries


- Steven Zeitels, HMS associate professor of otology and laryngology and director of the Division of Laryngology at the Massachusetts Eye and Ear Infirmary, has been a leader in developing increasingly precise phonosurgical techniques. Much of the past decade of these innovations is detailed in two papers in the December Annals of Otology, Rhinology & Laryngology, looking at two groups of patients: those with early vocal cord cancer and singers and orators who develop lesions on the vocal folds.


Vocal cord nodules - are bilateral benign growths on the vocal cords that are usually thought to be the result of voice overuse or misuse. The first line of treatment is usually voice therapy with a speech-language pathologist. Voice therapy can very often successfully reduce or eliminate nodules, although large, fibrous, or more chronic nodules may require surgical removal to improve the voice. Even in cases of surgical removal, pre- and post-operative voice therapy is strongly encouraged to address the initial behavioral causes of the vocal cord nodules so that they do not re-develop and so that vocal quality successfully returns to normal.

A vocal cord polyp - is a benign, fluid-filled lesion that is often thought to be the result of a period of acute voice abuse, such as you've described. Many ENTs will recommend surgical removal of a vocal cord polyp because a polyp generally does not resolve with voice therapy alone. Ideally, individuals who opt for surgical removal of a vocal cord polyp should receive pre- and post-operative voice therapy. Pre-operative voice therapy is helpful in establishing a comprehensive vocal hygiene program to encourage optimal post-surgical recovery, including education as to post-surgical vocal guidelines. Post-surgical voice therapy typically involves vocal exercises designed to encourage healing, improve vocal quality, and prevent future lesions from occurring. The best diagnostic test to look at these types of lesions is called a video laryngeal stroboscopic examination. This exam provides a magnified view of the larynx with clear visualization of the vocal cord edges, allowing the doctor to differentially diagnose the lesion. If the diagnosis is a laryngeal cyst or polyp, then surgical removal is recommended for voice improvement. Post-operative voice therapy is often helpful during the healing process.



Vocal Cord Surgery (including CO2 laser)

VOCAL CORD surgery - Vocal cord surgery is a general name for many different types of procedures that can be performed on the vocal cords.
Vocal Cord surgery is performed when the vocal cords have growths, such as, polyps, tumors, or other masses that need to be removed for biopsy or to improve function. The child will usually exhibit a hoarse or raspy voice.

Vocal Cord surgery is also indicated to normalize vocal cord functioning when the vocal cords are scarred from various causes, paralyzed, or are otherwise abnormal. These conditions may interfere with the complete opening and/or closing of the vocal cords, which is necessary for normal speech and breathing.

How is vocal cord surgery performed?

Surgery on the vocal cords can be performed either directly in an open surgical approach (making an incision in the neck) or indirectly through an endoscopic approach (through a tube inserted into the mouth and throat). Either procedure is performed under general anesthesia (the patient is fully asleep).

An open surgical approach is most often performed after trauma or fracture of the larynx (upper front of neck) has occurred. Please see REPAIR OF FACIAL AND NECK TRAUMATIC INJURIES in "Surgeries We Perform".

Although the open surgical approach allows somewhat better control of the vocal cords during the procedure, the endoscopic approach may be more successful in restoring more normal voice sound. The endoscopic approach also has the advantage of allowing extremely close observation of the vocal cords, therefore resulting in a precise and accurate cut or removal of tissue. However, not all surgeries can be performed endoscopically. Be sure to discuss this option with your doctor.

Recovery after either an open or endoscopic approach includes minimizing damage to the larynx during surgery, as well as reducing inflammation after the surgery. Therefore, your surgeon will recommend the procedure he/she feels will minimize these complications.


What is involved with endoscopic vocal cord surgery?

Endoscopic vocal cord surgery is basically MICROLARYNGOSCOPY (magnified examination of the vocal cords) in addition to a corrective procedure performed on the vocal cords.

As mentioned above, this surgery is performed with the patient under general anesthesia (fully asleep). The patient is lying on the back and a laryngoscope is inserted in the mouth to hold down the tongue and visualize the vocal cords. A special telescope or operating microscope is used to get very close and detailed views of the vocal cords and surrounding areas.

There are many different methods used to correct vocal cord abnormalities. These can include using forceps (like tweezers) to hold a bump or nodule and small scissors or the CO2 laser (see below) may be used to remove it. Powered instruments may also be used to remove lesions. These rotating blades remove growths such as papillomas with very little damage to normal tissue.

Defects on the vocal cords or surrounding areas may be repaired by injections, flaps of tissue, or grafts depending on the size of the defect.

The surgery itself usually lasts about an hour, but is highly variable. Removal of nodules or bumps or more simple reconstructive procedures may not require an overnight stay in the hospital. More complex procedures may require a hospital stay.


What is the CO2 laser?

Laser stands for "light amplification by stimulated emission of radiation". The CO2 laser device increases the intensity of light waves using CO2 (carbon dioxide) and concentrates them in an intense, penetrating beam of light. This is similar in a way to using a magnifying glass to concentrate the sun's rays; the "concentrated" sun rays underneath the magnifying glass get hot enough to burn paper for example. Similarly, the CO2 laser beam can be used to very accurately "burn off" areas of tissue that need to be removed, (vaporized).

Why is the CO2 laser used in vocal cord surgery?

The CO2 laser can be passed through the glass of the operating microscope, allowing for very accurate placement of the laser beam on the vocal cords. This method of tissue removal is much more precise than surgical scissors, and results in less bleeding and inflammation to the surrounding tissues. As mentioned previously, the less traumatic the surgical procedure, the more favorable the outcome, including faster recovery.

What are the risks of using the CO2 laser?

Although the laser can precisely vaporize the desired tissue, it can also accidentally burn basically anything else it may come in contact with. Therefore, safety precautions have been made to avoid this complication. These safety precautions include protective eye gear for both the patient and the operating team. A wet cloth may also be placed over the patient's face and eyes. Also, as the breathing tube can catch on fire, these surgeries are usually performed without a breathing tube in place while the laser is in use. In addition, the lowest amount of oxygen needed is used during the procedure.

What are the risks and complications of vocal cord surgery?

The risks with the use of the CO2 laser are described above. The short-term risks of vocal cord surgery in general include chipped teeth (protective teeth guards are used during surgery to help prevent this), bleeding, breathing difficulties, hoarseness, change in voice quality, or infection.

Long term risks include a less than desired outcome in regaining normal voice or scarring from the surgery that may need additional surgical repair in the future.
Your surgeon will discuss these with you in detail.

What is involved with recovery after vocal cord surgery?

Recovery after vocal cord surgery is dependent on the surgical procedure, as well as how well inflammation and swelling are controlled after the surgery. Your surgeon will give you guidelines on how to start reusing your voice. It is important to follow to these guidelines and keep all recommended follow up appointments to regain optimal vocal cord function.

Famous singers who have had problems

Julie Andrews performed while “singing over a cold” a few years ago, with the result of nodule formation. She had surgery in 1998, but it was unsuccessful, reducing a four-octave range to that sung by a choral alto. She is still not singing.

Maria Callas had an operatic career spanning from 1941 to the mid-1960s. She developed vocal problems in the late 1950s, which her accompanist Robert Sutherland said were due to her overworking her voice. She did manage, however, to reprise Tosca in the 1960s, probably her signature role and her first role at La Scala in 1941.

Jose Carreras has survived lymphoblastic (lymphocytic) leukemia, of which the first symptom was persistent bleeding and infection in his gums. This was discovered in 1987; he spent four months in a Barcelona hospital, and then several months more in Seattle where he received a bone marrow transplant. The latter was successful; he made a triumphant return in 1988, and continues his career to this day.

Enrico Caruso had several health problems. A notable incident took place on December 11, 1920, in which he suffered bleeding, either from the throat or the lungs, while on stage singing in “L’Elisir d’Amore”. His health deteriorated after that and his final performance was two weeks later on December 24, 1920.

Beverly Sills is very highly regarded as one of America’s divas. She retired in 1980 at age 50, saying that she “wanted to go out on a high note”. She was a coloratura, the lightest soprano voice. During the 1970s she decided to go beyond the usual coloratura repertoire, and tackled heavier roles such as Violetta in Verdi’s “La Traviata”. Consequently she developed a “wobble”, with thin an undependable high notes.


Natalie Dessay developed vocal nodes after 2001. Her technique was so secure and her breath support so prodigious that she was able to alter dynamics on a high E without a waver, and overall her control of her instrument was that of a master, her singing always notable for its solid consistency. During the first decade of her career, she had the coveted ability to thrust into the vocal stratosphere to sustained Gs and A-flats. In a conversation with Natalie Dessay said "My technical approach of singing is to try to achieve the greatest results with as little effort and air pressure as possible. Like most singers, especially female singers, my voice has been naturally developing into a warmer register. I follow and monitor this natural process with the different teachers and coaches who help me in my vocal and musical work. My first and second vocal troubles were the same problem that was just dealt with in two steps. We thought operating on the first cord would be enough but we didn't know that a polyp was also on the second cord. Because I couldn't recover really well during the 2 years after the first operation, I then decided to go through a second operation of the second cord. Having only two cords, I may expect it's over now!

Le Monde reported that Dessay, underwent surgery to have a polyp removed from the right vocal cord. It was just a little over two years ago that she had a pseudocyst removed from the other cord. She came back from that one in great form. She told Le Monde that both problems had existed all along but that the doctors had hoped after the first one was removed the second one would go away, but no such luck.

She was featured in the cover story of December's Diapason, a French music mag, which quoted her as saying she was thinking about retiring because of her vocal problems. But she told Le Monde that she gave that interview at a moment when she was feeling very down, a few weeks before the operation, and that now, the surgery having gone very well, she's optimistic: "I figure I have another good 10 years ahead of me, now that I've had a 'facelift' on both vocal cords." The paper says she's due to start working with a voice therapist in mid-January.