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Vocal Nodules - Preventing Injuries

April 28, 2020

vocal nodules

By Camille van Niekerk 

Because your voice is part of your body, it’s sensitive and susceptible to damage in ways that other instruments are not! And, unlike any other instrument, it’s irreplaceable.  

This article will provide valuable information on how to keep your voice healthy and prevent injury, including signs and symptoms to pay attention to.  

The most important takeaway is: if you are hoarse for two weeks or longer, make an appointment with your doctor. No amount of vocal exercise will help you if there’s an underlying issue; in fact, continuing to use your voice when it’s hoarse can lead to further damage. 

How and why does vocal damage occur? 

Most vocal damage occurs as the result of misuse, overuse, or abuse.

Misuse can include any unhealthy technique resulting in vocal strain. The most common unhealthy techniques to avoid are unhealthy belting and singing with an overly breathy tone. Unhealthy belting is strained, pushed “yell”-singing in which you drag your chest voice up well past your natural break. You’ll know you’re belting unhealthily if it’s really hard to do and it hurts your throat (during or afterwards). With an overly breathy tone, you can hear air leaking through the vocal folds. It’s counterintuitive to some, because it doesn’t seem like air should cause damage; but constantly singing with a breathy tone trains your vocal folds to never come together fully, causing them to compensate by building extra tissue. It’s also believed that the excess air being pushed through your cords with a breathy tone dries them out, which makes them more injury prone. Adele had vocal surgery after belting too much; John Mayer had vocal surgery after singing breathily for too long. Either extreme is to be avoided. 

Overuse is singing (or speaking) too much, for too long, without adequate vocal rest. You may be overusing your voice if your throat feels tired and sore at the end of the day, or if you feel pain and swelling the next day. 

Abuse includes yelling, screaming, and inhaling smoke - all of which cause irritation and swelling, which can contribute to long-term damage. 

Learn all about daily practice routines with this lesson!

What if I’m sick?

If you currently have a cough or sore throat, chances are you have vocal swelling and irritation, causing temporary changes to your vocal quality and ability. All singers will experience the effects of vocal swelling at some point, and although it’s very frustrating, it’s not permanent! If you are able, go on complete vocal rest while you’re sick so your swelling can go down and your vocal folds can heal faster.

I’m not sure if I have vocal damage. How can I tell?

The most common sign of vocal damage is hoarseness. Hoarseness refers to “an abnormal vocal quality that may be manifested as a voice that sounds breathy, strained, rough, raspy, tremorous, strangled, or weak, or a voice that has a higher or lower pitch” (‘Hoarseness in Adults’, American Family Physician). Other common symptoms include:

• Loss of range

• Pain or discomfort when talking and/or singing

• Inability to sing quietly

• Inability to sing in head voice/falsetto

• Chronic vocal fatigue

If you’ve been hoarse or experienced any of the above symptoms for 2 weeks, go on complete vocal rest (no singing or talking) and call your doctor to make an appointment. Tell them you’re a singer and ask if they’ll refer you to an otolaryngologist, who specializes in the voice. 

I’ve heard about nodes. What are they, and what are some other vocal injuries?

The following info comes from Dr. Reena Gupta of the Osborne Head + Neck Institute’s division of laryngology. See the references at the bottom of this article for her website!

Vocal nodules (nodes) are callous-like thickenings on the vocal folds, due to vocal misuse, abuse, or overuse. Symptoms include:

• Hoarseness in your speaking voice

• Hoarseness, meaning an irregular or inconsistent quality, in your singing voice

• Decreased range (no longer hitting higher notes easily)

• Inability to sing quietly

• Inability to hold a pitch steady

• Decreased color or vibrancy of tone

• Vocal fatigue (feeling worn out after a performance)

• Throat discomfort, pain, or tightness

• Neck pain


Laryngopharyngeal reflux is similar to acid reflux, but it reaches your larynx, due to a weakness or malfunction in your esophageal sphincter. Symptoms include:

• Hoarseness

• Chronic cough

• Throat clearing

• Sensation of an object in your throat (globus sensation)

• Post-nasal drip


Vocal fold hemorrhage: blood that has leaked into the vocal fold from a damaged blood vessel. Symptoms include:

• Acute loss of voice or vocal range. Singers often describe it as a “curtain” suddenly dropping over their voice.

• Hearing two pitches at the same time when you sing or speak

• Hearing a flutter in your voice

• Hoarseness in your voice (may be mild or severe)

• Decreased range (no longer hitting higher notes easily)

• Inability to sing quietly

• Inability to hold a pitch steady

• Neck pain


Cyst: fluid collection inside the vocal fold, as the result of injury. Symptoms include:

• Chronic hoarseness

• Pitch change in your speaking voice

• Significantly decreased range (no longer hitting higher notes easily)

• Inability to sing quietly

• Inability to hold a pitch steady

• Throat pain

• Voice fatigue


Less common issues include vocal fold paralysis, spasmodic dysphonia, and psychological disorders causing speech dysfunction. 


How can I prevent vocal injury?

1. Always warm up to prepare your voice to sing. Consider warming down, too, if you’ve had a long and taxing rehearsal or performance. 

2. When you’re sick with a sore throat, go on complete vocal rest (or reduce your vocal use as much as humanly possible). When your vocal folds are swollen or irritated, they’re much more injury-prone, so do NOT “push through”. If you’re sick, that’s also a good time to avoid going out in the cold, inhaling smoke, or being in a loud environment where you have to talk louder. 

3. Avoid the two main causes of vocal injury: unhealthy belting and breathy tone.

4. Speaking of extremes, avoid them even when you’re not singing. That means: don’t yell or scream a lot, and don’t whisper a lot! Know when you’re “breaking the rules” and do that sparingly. 

5. Use vocal pacing to avoid overuse. This includes taking vocal breaks, avoiding long phone conversations, and “marking” in rehearsals. Pro singers save their voices by resting their voice during the day, and not singing “full out” during some or most of rehearsal. 

6. Keep your body healthy with good sleep, exercise, and a healthy diet.

7. Take special care of your voice by staying hydrated, using a humidifier, saline sinus rinses, gargling with warm salt water, and keeping lozenges handy. 

With proper technique and voice care, hopefully you’ll never need to see the doctor for your voice! But if you’re experiencing troubling symptoms, don’t ignore them or try to push through pain and discomfort. Call your doctor, and rest assured that they’ll get you back to singing as soon as possible. 


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