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ORIGINAL ARTICLE

Laryngeal aerodynamic
analysis of vocal nodules

S. Sheela
Department of SpeechLanguage Pathology,
All India Institute of Speech and Hearing, Manasagangotri,
Mysore, Karnataka, India

ABSTRACT
The present study is aimed to investigate the effects of vocal nodules on the aerodynamic analysis of the
voice. The study included twelve females with normal laryngeal and respiratory functions and twelve age,
gender and language matched females with bilateral vocal nodules within the age group of 1840years.
All participants were subjected to noninvasive aerodynamic analysis using Aeroview 1.4.4 version(Glottal
Enterprises Inc, USA). The participants were instructed to produce the CV syllable train papapapa into
the circumvented mask at comfortable pitch and loudness. The recorded stimuli were analyzed to obtain
laryngeal aerodynamic measures such as estimated subglottic pressure, mean airflow rate, laryngeal
airway resistance, and laryngeal airway conductance. Mean and standard deviation for all the four laryngeal
aerodynamic measures were calculated separately for both control and clinical groups. The results revealed
significant effect of voice on laryngeal measures such as estimated subglottic pressure and mean airflow
rate. Thus, results suggest that indirect measurement of laryngeal aerodynamic parameters are effective
and essential investigative tools in assessment of vocal nodules.

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DOI: 10.4103/2230-9748.118705
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Key words: Subglottic pressure, laryngeal airway conductance, laryngeal airway resistance, mean air
flow rate, vocal nodule

INTRODUCTION
Vocal nodules, also called as nodes, singers nodes, screamers
nodes are localized benign masses, located within the
superficial layer of the lamina propria. They typically occur at
the midpoint of the membranous vocal folds at the junction of
the anterior third and posterior twothirds of the full length
of the vocal fold[1] with an excessive deposit of collagen IV
and fibronectin.[2,3]
Vocal nodules are caused by repeated trauma to the
vocal folds during talking or singing. The midpoint of the
membranous vocal folds, where the extra mass growths
occur, receives the maximum impact during production of
voice. Other factors such as the presence of dehydration,
respiratory infections, inflammatory factors(smoking,
alcohol use, caffeine intake, drug effects, allergies,
exposure to noxious chemicals, laryngopharyngeal reflux)
may be predisposing or aggravating factors for nodules
development.[1]
Address for correspondence:
Ms. S. Sheela, Research officer, Department of SpeechLanguage
Pathology, All India Institute of Speech and Hearing,
Manasagangotri, Mysore570006, Karnataka, India.
Email:sheela.mslp@gmail.com
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In adults, vocal nodules are more frequent in women(94.5%)

than in men.[3,4] Specifically, lesions occur most frequently in
women between the ages of 2040years.[1] Small extra mass
growths that develop at the site of the trauma are usually
known as soft nodules. They interfere with the adduction
and vibration of the vocal folds. If soft nodules are ignored,
persistent damage may begin to produce fibrous scar tissue,
referred to as hard nodules. Vocal nodules cause a minimal
disruption of the mucosal wave on stroboscopy.[1]
Patients with vocal fold nodules usually complain of
dysphonia. Vocal fatigue is common. Perceptually, the voice
usually has a strained/leaky quality. Often, the voice also
includes perceptual features that indicate irregularities in
vocal fold vibrations, such as roughness(irregular voice) as
well as vocal fry.[5,6] Due to the increased mass of the vocal
folds, fundamental frequency(f0) tends to be lower than
normal.[7] Problems with the upper vocal pitch range are often
the first symptom noticed by individuals with vocal nodule.
Furthermore, the quality of the voice worsens with use,
particularly if there is extensive, loud, pressed voice use.[1]
Assessment of voice production routinely includes perceptual
evaluation of voice quality and measures of laryngeal
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Sheela: Laryngeal aerodynamics in vocal nodules

function using acoustic, aerodynamic and videostroboscopic

instrumentation. Aerodynamics is a branch of science that
is concerned with the study of gas motion in objects and
the forces that are created. Laryngeal aerodynamics(LA) is
a specific field within this branch of science that studies the
airflow and pressure changes that are produced within the
larynx. LA analysis is based on the fact that voice production
is essentially an aerodynamic phenomenon, whereby the
glottis transforms aerodynamic power into acoustic power.
For phonation to take place, both a suitable quantity of air
and a suitable air pressure are needed. The aerodynamic
forces working at the glottis seem to be responsible for
the creation of the sustained vibration of the vocal folds.[8,9]
LA analysis assess the interaction of both respiratory and
laryngeal functions,[10] which provides information related to
the valving efficiency of the glottis during phonation.
LA measures include mean air flow rate(MAFR), estimated
subglottal pressure(ESGP), laryngeal airway resistance(LAR)
and laryngeal airway conductance(LAC), etc. These measures
are briefly explained below.
MAFR is the volume of air flow across the vocal folds during
the phonation in 1 s. It is generally measured in liters or
milliliters or cubic centimeters per second(l/s or ml/s or cc/s).
ESGP is one of the LA parameters that has been proposed
to be measured for voice evaluation.[11] It is the amount of
pressure exerted on the vocal folds during adduction and is
measured in cm H2O.
LAR and LAC are derived parameters. LAR is the ratio
of ESGP to MAFR.[12] It is the quotient of peak intraoral
pressure(estimated from production of an unvoiced
plosive/p/) divided by the peak flow rate(measured from
production of a vowel/i/) as produced in a repeated train
of/pi/syllables. This measurement is intended to reflect the
overall resistance of the glottis and by extension serves
as an estimate of the valving characteristic, whether too
tight(hyperfunctional), too loose(hypofunctional) or normal.
Laryngeal resistance has been used in experimental settings
to further analyze the covarying relationship between
pressure and flow in vocal fold vibration. Aword of caution is
useful, however, because derived measures pose some limits
to interpretability. The magnitude of a particular derived
value is not meaningful without examining the separate
contributions of pressure and flow. For example, a measure
of increased LAR values might be attributable to excessive
ESGP, insufficient transglottal flow or both. LAC is the ratio
of MAFR to the ESGP. It is the converse of LAR and reflects
the conductance for airflow at the level of glottis.
Early investigators have found that aerodynamic studies are
Journal of Laryngology and Voice | January-June 2013 | Vol 3 | Issue 1

helpful in etiological classification of voice disorders,[8,13] while

later studies showed that the diagnostic value of aerodynamic
measurements is low in identifying the exact etiology, but
they may point to a tendency to the hyperfunction or
hypofunction styles of vocal production.[14,15]
However, the main purpose of aerodynamic measures is to
evaluate the degree of some aspects of vocal function and
to monitor the posttherapeutic changes.[11]
Tanaka and Gould[16] studied vocal efficiency in order to explain
LA aspects in voice disorder. Vocal efficiency is defined as the
ratio of sound power at the mouth opening(or the opening
end of a tube if inserted in the mouth) to aerodynamic power
calculated as mean flow rate times, mean ESGP.[17] They had
selected ten normal adult subjects and variety of clients with
unilateral and/or bilateral vocal nodule(small/large), unilateral
and/or bilateral vocal polyp(small/large), Reinkes edema,
recurrent laryngeal nerve(RLN) paralysis and glottal cancer.
The body plethysmography was used to obtain LA measures
such as ESGP(cm H2O) and MAFR(cc/s). Each subject sat in
the airtight box with a mouthpiece and a clip placed on the
nose. Then, the subject was instructed to sustain the vowel/a/
for a few seconds at a comfortable loudness and pitch level.
Specifically, in subjects with bilateral vocal nodules, MAFR
values were 0.258L/s and SGP 8.3 cm H2O. They suggested
an aerodynamicbiochemical classification based on vocal
fold lesion type associated with low vocal efficiency. Firstly, a
large glottal chink(RLN paralysis) associated with high MAFR
value. Secondly, mass on vocal folds(vocal nodule, vocal polyp
and Reinkes edema), associated with a high level of MAFR
and ESGP values. Thirdly, highly stiffened vocal fold(Glottal
cancer), associated with high SGP value.
Sapienza and Stathopoulos[18] studied laryngeal measures in
female subjects with bilateral vocal nodules. Their clinical
group consisted of ten females with bilateral vocal nodule
and control consisted consists of ten females with normal
voice. The pneumotachograph(Glottal Enterprises, Model
MS 100 A2) was used to obtain SGP(cmH2O) LA measure.
The subjects were instructed to produce a syllable string
consisting of/pa/at their comfortable pitch and loudness
at a rate of 1.5 syllables/s.[12] The ESGP value in females
with bilateral vocal nodule was 8.05 cmH2O(2.46) and in
females with normal voice was 6.07 cmH2O(1.07). The
ESGP value was significantly higher in females with bilateral
vocal nodule compared with females with normal voice
production. The authors have attributed the increase in
ESGP values in females with bilateral vocal nodules indicating
that a greater amount of air is being transferred through the
glottis during voice production and suggests the presence
of glottal incompetence.
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Sheela: Laryngeal aerodynamics in vocal nodules

In summary, few studies showed that aerodynamic studies

of the dysphonic voices of vocal fold nodules usually show
statistically significant increased ESGP values[16,19,20] as well as
statistically significant increased MAFR values[16] as an attempt
to produce phonation in the presence of leaky glottis.
The aim of this study is to evaluate the effect of vocal nodules
on aerodynamic analysis of the voice.

MATERIALS AND METHODS

Subjects
The control group consisted of twelve female subjects with
normal laryngeal and respiratory system and functions in
the age range of 1840years. The clinical group consisted of
twelve age, sex and language matched subjects diagnosed as
bilateral vocal nodules through stroboscopic evaluation.
Instrumentation
The Aeroview 1.4.4 version(Glottal Enterprises Inc, USA)
was used to collect aerodynamic data from each subject.
The Aeroview is a computerbased system that measures the
MAFR and ESGP pressure during the vowel production. The
derived parameters such as LAR(ESGP/MAFR) and LAC(MAFR/
ESGP) using an automated factoryoptimized algorithm
are also displayed. Other measures of voice such as the
sound pressure level and the fundamental frequency of the
measured vowel segment phonation can also be obtained.
Before recording, the transducers for measuring airflow
and air pressure were calibrated on a daily basis as per the
guidelines provided by Glottal Enterprises.
Recording
The subjects were seated comfortably and the procedure was
explained clearly. The subjects were instructed to hold the
mask firmly against the face so that nose and mouth were
covered with the intraoral tube placed between the lips
and above the tongue. The examiner confirmed the correct
placement of the transducer or ensured that the mask is firmly
fitted. The participants were then instructed to produce the
repetitions of consonantvowel syllable/pa/67times into
the circumvented mask at a comfortable pitch and loudness
to obtain six to seven stable peaks of intraoral pressure.
The rate and style of production was demonstrated by the
examiner and two practice runs were given before the actual
recording. Following practice, the actual recordings were
made. The recording with syllable production rate between
2.0 and 3.5/s(recommended by the manufacturer) and with
appropriate pressure peak morphology was considered for
the further analysis. Typical pressure peak and airflow wave
morphology is shown in Figure1.
12

Figure1: Typical wave morphology of appropriate pressure peak and airflow

Analysis
The recorded waveform was analyzed by placing the
cursors on flat portions of two adjacent pressure peaks. The
application software analyzes the waveform and provides
the values of ESGP(cmH2O), MAFR(ml/s), LAR(cmH2O/ml/s),
LAC(ml/s/cmH2O) values. On obtaining three peaktopeak
measurements, the software automatically provides their
average value. In order to facilitate comparison of MAFR
values with earlier studies, MAFR which is obtained in
ml/s was converted manually to L/s. Accordingly, derived
parameters such as LAR and LAC obtained values were
converted to(cmH2O/L/s) and(L/s/cmH2O) respectively.
Statistical analysis
Statistical Package for Social Sciences version17.0 was used
to obtain descriptive statistical measures such as mean
and standard deviation(SD). For both groups, all four LA
parameters were calculated separately.

RESULTS AND DISCUSSION

The present study consisted of two groups. The control group
consisted of twelve female subjects with normal laryngeal
and respiratory system and functions and clinical group of
12female subjects diagnosed as bilateral vocal nodules
through stroboscopic evaluation. Table1 depicts the mean
and SD and p values for LA measures such as ESGP, MAFR, LAR
and LAC. The results show a significant difference between
the control group and clinical group for laryngeal measures
such as ESGP(P<0.01) and MAFR(P<0.01).
The ESGP and MAFR values were higher for clinical group
compared with the control group. This can be attributed
to the fact that ESGP represents the energy immediately
available for the creation of the acoustic signals. Since
vocal nodules hinder proper acoustic signals because of
the glottal air leak, the subjects with vocal nodule try to
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Sheela: Laryngeal aerodynamics in vocal nodules

Table1: Mean and SD for laryngeal aerodynamic

measures ESGP, MAFR, LAR, and LAC measures
Laryngeal
aerodynamic
measures
ESGP(cmH2O)
MAFR(L/s)
LAR(cm H2O/L/s)
LAC(L/s/cm H2O)

Control
group(n=12)

Clinical
group(n=12)

Mean

SD

Mean

SD

5.22
0.19
28.77
0.04

0.89
0.04
9.04
0.01

8.03
0.39
25.21
0.05

2.43
0.18
15.38
0.03

Pvalue

*0.00
*0.00
0.50
0.10

*Indicates P<0.05. SD=Standard deviation; ESGP=Estimated subglottal pressure;

MAFR=Mean air flow rate; LAR=Laryngeal airway resistance; LAC=Laryngeal
airway conductance

compensate for this by increasing ESGP. This finding is

consistent with previous reports from Isshiki and Ringel,
1964;[19] Stathopoulos and Weismer, 1985;[20] and Tanaka and
Gould, 1985.[16] The phonatory glottal gap that results from
vocal nodules leads to air leak as has been explained. This
can explain the increase in MAFR values in the clinical group
compared to control group. This finding is in consonance with
previous reports from Tanaka and Gould, 1985.[16]
The high LAR value was obtained for the control group
compared with the clinical group, but not statistically
significant. However, decrease in LAR in the clinical group can
be attributed to the phonatory glottal gap caused by vocal
nodules, leading to a decrease in the resistance of the glottis.
It can also be attributed to the possibility that the increase
in MAFR was much higher than that of ESGP. The high LAC
value was observed for clinical group compared with the
control group, but not statistically significant. It reflects the
conductance for airflow at the level of glottis. This parameter
was not considered by any of the earlier reported studies.

CONCLUSION
The present study found statistically significant differences in
ESGP and MAFR values in females with bilateral vocal nodules
in comparison with females with normal laryngeal and
respiratory system and functions. The LAR values were lesser
in the clinical group compared with the control group, but
not statistically significant. Non invasive LA measures such
as ESGP and MAFR are effective and may be used as essential
investigative tool in the assessment of vocal nodules.

ACKNOWLEDGMENTS

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I would like to express my sincere gratitude to Dr. S. R. Savitri,

Director, AIISH, Mysore for providing me an opportunity to
carry out this study.

REFERENCES
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Voice DisordersI. London: Lea Publishers; 2008.
Journal of Laryngology and Voice | January-June 2013 | Vol 3 | Issue 1

Cite this article as: Sheela S. Laryngeal aerodynamic analysis of

vocal nodules. J Laryngol Voice 2013;3:10-3.
Source of Support: Nil, Conflict Interest: No.
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