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Vocal disorders, injuries, and conditions: considerations for music educators.

As music educators and teachers, our voices are a key instrument in performing our jobs, and as such proper care is required to maintain this important tool. This article explores the four most common voice disorders associated with misuse of the voice: vocal nodes, contact ulcers, vocal polyps, and laryngitis. It also provides the definitions, causes, and symptoms of each of these disorders, as well as possible treatment and prevention techniques that teachers, singers, and music therapists can incorporate in their daily self-care practices.

Vocal Nodes

Prevalence, Definition and Symptoms.

The American Speech-Language Hearing Association (2013) has found that vocal nodes occur most frequently in women between the ages of twenty and fifty. A review of 1156 patients found that the most common population to experience vocal fold nodules were boys and middle aged women (Nagata, Kurita, Yasumoto, Maeda, Kawasaki, & Hirano, 1983). Owens, Metz, and Haz (2007) explain that vocal nodes are immovable localized growths on the vocal folds that appear on the anterior 1/3 and posterior 2/3 of the vocal folds. The locations of these growths indicate the place where the vocal cords strike each other most forcefully during vocal production (Anderson & Shames, 2011). The small pinkish or garish white growths are usually bilateral, meaning that they appear on both vocal cords, but they can also appear unilaterally (Anderson & Shames, 2011). These growths result in devastating vocal symptoms for people involved in speaking or singing professions, and include: hoarseness, breathiness, sore throat, and a loss of the upper third of a person's vocal range.


Commonly referred to as "singer's or screamer's nodes", nodules usually develop in people who use their voice excessively, with the most common population being women between the ages of twenty and forty (Owens, Metz, & Haz, 2007). Although the specific development of vocal nodes is not quite understood, Jiang (1998) suggests that overuse of the voice causes swelling of the vocal folds. The excess fluid and pressure triggers a loss of flexibility in the fold, and the contact between the folds increases. This increased contact can damage the skin of the folds resulting in a hemorrhage or edema, or may create a thickening of the vocal fold epithelium (Jiang, 1998). A fitting analogy of vocal nodes is the formation of callouses on fingers from increased friction from a guitar string. Extreme and acute overuse will cause a rupture such as a blister, which in turn forms a callous, whereas prolonged friction will eventually cause the same callous.

Treatment and Prevention.

Depending on the severity of the nodules, different treatment techniques may be implicated. If nodules have recently developed, they are often effectively treated by resting the voice. This proves challenging for music educators and educators in general given their work environment, and may require taking time off. For nodules that have been left untreated for an extended period of time, surgery is often the only option for removal (Owens, Metz, & Haz, 2007). The most important prevention method is avoiding harsh use of the voice such as yelling or screaming. It is also recommended that educators consult a speech language pathologist for voice therapy and education.

Contact Ulcers

Prevalence, Definition, and Symptoms.

A lesser known voice disorder is contact ulcers, reddened lesions that tend to appear on the posterior surface of the vocal folds in the arytenoid region. Contact ulcers are a pair of cartilaginous structures located at the back of the larynx (Emami, 1999). As with nodules, contact ulcers tend to be bilateral. However, unlike nodules, the symptoms of contact ulcers tend to be far more noticeable. One of the main symptoms is significant pain that occurs unilaterally, and in some cases pain that radiates to the ear and upon swallowing. Another indication of contact ulcers is frequent throat clearing, as the ulcers make it feel as though there is something in the throat. Traditional symptoms that contact ulcers manifest are hoarseness, breathiness, and vocal fatigue and ulcers are most prevalent in men and women over the age of 40 (Koufman, 2000).


The arytenoids are predisposed to developing ulcers because the cartilage is covered by a tight mucoperichondrium and a thin layer of mucosa, (Emami, 1999) and because there are not many protective layers it takes very little trauma to cause damage to the area. There are two theories for what causes this trauma. The behavioural theory proposes that trauma to the mucosal covering is the result of vigorous glottal closure that may occur when people are yelling, screaming, or practicing poor singing habits (Anderson, & Shames, 2011). The psychological theory suggests that people suffering from gastric reflux might experience the stomach acid regurgitate into the esophagus and throat. This stomach acid irritates the fold tissue which causes excessive throat clearing that ultimately harms the vocal cords (Owens, Metz, & Haz, 2007).

Treatment and Prevention.

Typical treatments for contact ulcers include voice rest and surgical excision. However, recent studies suggest that surgery should be avoided because of high recurrence rates. Currently, medical techniques such as proton pump inhibitor therapy for two to four months are now the primary form of treatment (Emami, 1999). Voice therapy is still used and purports to have the same outcome as patients receiving medicinal therapy (Emami, 1999). For people suffering from gastric reflux looking to prevent the development of contact ulcers, managing the symptoms by using antacids and seeking medical assistance is suggested. As with vocal nodes, professionals should take care to not abuse their voice by avoiding shouting, yelling, and excessive throat clearing.

Vocal Polyps

Prevalence, Definition, and Symptoms.

According to Anderson and Shames (2011) vocal polyps are benign tumours usually found on parts of the larynx. These growths are either attached directly to the larynx (sessile), or by a stalk; (pedunculated) and tend to be unilateral, vascular, and therefore prone to haemorrhage (Anderson & Shames, 2011). The symptoms generally reflect the placement and type of the vocal polyp, and a person with a polyp may experience the sensation of having something caught in his/her throat (Owens, Metz, & Haz, 2007). If the polyp protrudes from the glottal boarder, it can impede contact needed between the folds which causes breathiness as excess air passes through during speech (Anderson & Shames, 2011). If the polyp is large enough that it rests partially on the other vocal fold, it can interfere with vibration causing hoarseness or roughness.


Kambic (1981) explains that vocal polyps develop from excessive use of the voice causing vasodilation, which is an increase of blood flow that eventually leads to a period where there is a flow stoppage. This makes the vessel walls more permeable, and in return causes an increased level of fluid in the tissue leading to the fibrosis (a thickening of tissues) or the degeneration of hyaline or basophil, which form the vocal polyps. It is significant to note that polyps can form after only one traumatic incident.

Treatment and Prevention.

Vocal polyps are usually treated with surgical methods with modern technology allowing for an increase in the use of effective laser removal procedures. However, once a polyp develops, invasive procedures seem to be the only methods of treatment (Anderson & Shames, 2011). Smoking, alcohol, and caffeine should be avoided as they contribute to vocal polyp development (Kim, 2008).

Acute and Chronic Laryngitis

Prevalence, Definitions, and Symptoms.

Laryngitis manifests in two categories: acute and chronic. Acute laryngitis is a temporary inflammation or swelling of the vocal chords; and chronic laryngitis is a much more severe and long lasting swelling that causes the vocal folds to become thick, swollen, and reddened (Ehrlich, 2011). If left untreated, chronic laryngitis can cause the vocal chords to atrophy or waste away. The symptoms of laryngitis include a persistent cough, throat aches, mild hoarseness to the inability to speak (Owens, Metz, & Haz, 2007). Reflux laryngitis in particular accounts for 4-10% of the population that are referred to an otolaryngologist (Vaezi, 2004).


Acute laryngitis is most commonly caused by a cold or flu, however, it can also be caused by exposure to noxious agents such as tobacco smoke and alcohol. As with contact ulcers, laryngitis may be caused by irritation from acid reflux (Ehrlich, 2011). Chronic laryngitis is the result of vocal abuse during a period of acute laryngitis--for example, a teacher going to work and speaking/singing while he/she has a cold. Since the folds are already irritated and prone to damage, vocal abuse at this time can create considerable deterioration of the vocal tissue (Owens, Metz, & Haz, 2007).

Treatment and Prevention.

Treatment of acute laryngitis typically includes considerable vocal rest recommending people rest and not use their voices at all during acute laryngitis phases, as the progression to chronic laryngitis can be very severe. For chronic laryngitis, treatment usually includes surgery followed by voice therapy (Owens, Metz, & Haz, 2007). Similar to prevention techniques listed above avoiding smoke, alcohol, and keeping well hydrated are suggested.

A Word about Voice Therapy

Throughout this article voice therapy has been referred to as a form of treatment for voice disorders. The goals of voice therapy treatment are to restore and preserve the quality of the voice either by itself or in conjunction with medical treatment. Some of the specific techniques include electromygraphic biofeedback or laryngeal muscle activity, progressive relaxation, yawn-sigh, laryngeal massage, Accent method, chewing method, vocal intensity reduction, cough reduction, vocal function exercises, and resonant voice therapy. Speech language pathologists also use vocal hygiene approaches, and educate patients about proper voice care, effective use of the voice, and eliminating abusive voice habits (Ramig, 1998). Voice therapy is generally continued until a person's symptoms are improved and additional therapy would not advance or improve the voice further. In Ylitalo's (2000) study, patients attended anywhere from 10 to 40 voice therapy sessions spanning from four months to one year.


As music educators our voices are a primary tool in our day to day work. This article has reviewed the four main types of vocal problems: vocal nodes, contact ulcers, vocal polyps, and laryngitis. All four of these disorders manifest in physically different ways, but have common causes. These common causes include: vocal abuse (yelling, screaming), overuse, smoking, and drinking. Other causes of voice disorders include acid reflux, cold, and flu. Teachers in general are a group of persons prone to develop vocal issues due to the amount of speaking they do per day, but music educators face a more serious threat as they also may be required to sing for several hours a day and to speak or shout over instrument sounds.

Treatment of voice disorders usually involves invasive surgical methods or voice therapy. Music educators rely heavily on their voice, and therefore if surgery or therapy is required, it impedes their ability to work. It is for this reason that proper prevention methods should be practiced by people who rely on their voice. These include proper hygiene, avoidance of vocally abusive behaviours, and avoidance of drugs and alcohol. With these pre-emptive acts, music educators can avoid the onset of vocal injuries, and can continue to use their voice safely and effectively in the workplace.

Final Thought

For myself I did not really think about voice disorders seriously until I had issues as a young professional which thankfully were resolved, but it was a scary experience. Recently several colleagues have contacted me regarding vocal issues that are most likely the result of their work environments. I want to encourage you all to really consider making vocal care a priority!


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Ehrlich, S. (2011, September 25). University of center. Retrieved from

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Owens, R., Metz, D., & Haas, A. (2007). Introduction to communication disorders: A lifespan perspective. Boston: MA: Pearson Education, Inc.

Ramig, L O. (1998). Treatment efficacy: Voice disorders. Journal of Speech, Language, and Hearing Research, 41(1), S101.

Vaezi, M. F. (2004). Laryngitis and gastroesophageal reflux disease: Increasing prevalence or poor diagnostic test and quest. The American Journal of Gastroenterology 99(5), 786.

Ylitalo, R. (2000). Voice characteristics, effects of voice therapy, and long-term follow-up of contact granuloma patients. Journal of Voice, 14(4), 557.

Dr. Amy Clements-Cortes is Assistant Professor, University of Toronto; Senior Music Therapist/Practice Advisor, Baycrest, Instructor and Supervisor, Wilfrid Laurier University. Amy has extensive clinical experience working with clients across the lifespan. She has given over 80 conference and/or invited academic presentations, is published in peer reviewed journals and books, and has supervised over 30 music therapy internships, 30 undergraduate research studies, and 3 Masters students MRPs. She is the Clinical Commissioner for the WFMT, Vice-Chair and BOD Member Room 217, and Past President, (CAMT), Amy is co-editor of the Canadian Association for Music Therapy 40th Anniversary Journal, Chair of the 40thAnniversary Conference and Co-Chair of the 3rd IAMM Conference 2014. Amy is on the editorial review board of the WFMT Journal and Music Therapy Perspectives; Co-investigator in the AIRS SSHRC Project; and coordinator MaHRC Alzheimer Study
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Title Annotation:music makers: music and health
Author:Clements-Cortes, Amy
Publication:Canadian Music Educator
Date:Jan 1, 2013
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