Journal of Voice

Vol. 13, No. 1, pp. 128-142

© 1999 SingularPublishingGroup, Inc.

Vocal Fold Nodules in Adult Singers:

Regional Opinions About Etiologic Factors, Career Impact,
and Treatment. A Survey of Otolaryngologists,
Speech Pathologists, and Teachers of Singing

*tNorman D. Hogikyan, tScott Appel, *~Leslie W. Guinn, and *tMarc J. Haxer

*University of Michigan Vocal Health Center; ~University of Michigan Department of Otolaryngology; and
¢University of Michigan School of Music, Division of Vocal Arts

Summary: This study was undertaken to better understand current regional

opinions regarding vocal fold nodules in adult singers. A questionnaire was sent
to 298 persons representing the 3 professional groups most involved with the
care of singers with vocal nodules: otolaryngologists, speech pathologists, and
teachers of singing. The questionnaire queried respondents about their level of
experience with this problem, and their beliefs about causative factors, career
impact, and optimum treatment. Responses within and between groups were
similar, with differences between groups primarily in the magnitude of positive
or negative responses, rather than in the polarity of the responses. Prevailing
opinions included: recognition of causative factors in both singing and speaking
voice practices, optimism about responsiveness to appropriate treatment, enthu-
siasm for coordinated voice therapy and voice training as first-line treatment,
and acceptance of microsurgical management as appropriate treatment if be-
havioral management fails. Key Words: Vocal fold nodules (VFN)--Survey
opinions--Etiology--Treatment.

Vocal fold nodules (VFN) are a common form of
laryngeal pathology.I, 2 Voice overuse, misuse, and
abuse are felt by most authors to be the primary
causative factors. 1-4 The degree of dysphonia experi-
enced secondary to VFN is quite variable, and de-
Accepted for publication December 10, 1997.
Address correspondence and reprint requests to Norman D.
Hogikyan, MD, University of Michigan Medical Center, Depart-
ment of Otolaryngology, 1904 Taubman Center, 1500 E. Med-
ical Center Drive, Ann Arbor, Michigan 48109-0312, U.S.A.
Presented at the 26th Annual Symposium: Care of the Pro-
fessional Voice, Philadelphia, Pennsylvania, June 5, 1997.
pends to a significant degree on the size of the nod-
ules, as well as on the patient and his or her vocal de-
mands. Laryngoscopic appearance is also not uni-
form, but typical findings include bilateral elevations
of the free margins of the midmembranous true vo-
cal folds, which are whitish to pink, and may be ses-
sile to conical in shape.l, 2
For singers, both the vocal limitations and emo-
tional consequences of VFN can be devastating. Sat-
aloft writes, "When nodules are present, the patient
should be informed with the same gentle caution
used in telling a patient that he/she has cancer." 3

128
 VOCAL FOLD NODULES IN ADULT SINGERS
While the speaking voice is often only mildly if at
all abnormal, the singing voice is usually character-
ized by limitations of upper range, onset delays with
high soft phonation, reduced vocal endurance, a
sense of increased effort to sing, a need for longer
warm-up, and more day-to-day variability in the
voice than expected. 5
Treatment options for VFN in general include
voice therapy by a speech-language pathologist
(SLP) and laryngeal microsurgery by an otolaryn-
gologist (OTO). A review of current textbooks of
otolaryngology finds that most authors endorse
voice therapy as the primary treatment, with surgery
as a secondary alternative should vocal limitations
and laryngeal pathology remain after behavioral
management. 5-9 A minority of authors do not feel
that behavioral management is helpful, l0
For singers, another dimensiofl of treatment can
include the teacher of singing (TS). The rationale for
inclusion of the TS in a treatment plan stems from
the widespread belief that faulty singing practices
contribute to onset and propagation of VFN. A joint
technical report by the American Speech-Language-
Hearing Association (ASHA) and the National Asso-
ciation of Teachers of Singing (NATS) about remedi-
ation of singers with voice disorders acknowledged
that "the most effective path to vocal recovery will
often include an integrated approach to optimal
voice care and production that addresses both speech
and singing tasks. ''11
The purpose of the current study was to determine
prevailing regional opinions of professionals from
otolaryngology, speech-language pathology, and
voice training about VFN in adult singers. The cur-
rent literature does contain published data from
questionnaires on the subject of VFN that were sent
to practitioners from otolaryngology and speech-lan-
guage pathology. 12,13 To our knowledge, though, no
such survey has ever been published that specifically
addressed VFN in singers or included all 3 profes-
sional groups as respondents.
MATERIAL A N D M E T H O D S
A questionnaire about issues related to VFN in
adult singers was developed (see Appendix). It was
129
designed to query respondents regarding their level
of experience with VFN in adult singers, possible
etiologic factors, responsiveness to appropriate treat-
ment, and treatment options. The definition of singer
included students of the vocal arts, as well as ama-
teur or professional singers. Choice of content for
the questionnaire was based on the literature and on
the authors' combined experiences from the fields of
otolaryngology, speech pathology, and voice train-
ing. A scale was outlined for graded responses to
questions about possible etiologic factors, response
to treatment, and choice of treatment options.
The primary referral area for a multidisciplinary
voice clinic staffed by the 3 authors includes the
states of Michigan, Ohio, and Indiana. Professionals
from this region who are involved with care of
singers with VFN were the target audience for the
survey. Questionnaires were mailed to the 71 region-
al members of the voice and voice disorders special
interest division of ASHA, a random sample of 117
regional otolaryngologists taken from the member-
ship directory of the American Academy of Oto-
laryngology--Head and Neck Surgery (AAO-HNS),
and a random sample of 110 regional members of
NATS. As the goal of the study was to determine
prevailing opinions, and not just the opinions of the
most qualified members of these groups, a random
sampling method was used for the NATS and AAO-
HNS members. The whole of the voice and voice
disorders special interest division of ASHA was sur-
veyed due to the relatively small size of this group.
Questionnaires were returned anonymously via self-
addressed, stamped envelopes.
While the region surveyed probably has a lower
density of singers overall compared to several other
parts of the United States, it was the logical choice
for this study. The current authors wanted to better
understand the prevailing opinions in their region of
practice regarding this subject, and these states con-
stitute that region. We do not know whether opinions
from the Midwest differ significantly from those in
other parts of the country.
Demographic data and level of experience with
VFN in singers were tabulated, and means and ranges
calculated. For possible etiologic factors, a mean and
standard deviation of the scaled responses were cal-
culated for all respondents and by professional group.
Journal of Voice, Vol. 13, No. 1, 1999
130 NORMAN D. HOGIKYAN ET AL
Responses regarding responsiveness to treatment
and choice of treatment options were evaluated in 2
ways. A mean and standard deviation of the scaled
responses were calculated for all respondents and by
professional group. It was felt, though, that these
values or data generated from several other consid-
ered statistical treatments failed to truly depict the
opinions or differences of opinion that were sought
in this study. Therefore, responses are also presented
in graphical format where the trends toward positive
(a 4 or 5), negative (a 1 or 2), or uncertain (a 3) opin-
ion can be determined by group for each statement.
Use of a response scale that included an uncertain or
"don't know" option was felt to be necessary due to
the diverse professional backgrounds of respondents,
and the fact that some may be unfamiliar with issues
related primarily to the others' disciplines.
RESULTS
Response Rate and Demographics
The overall response rate to the questionnaire was
43% (128 returned of 298 mailed). Response rates
by group were OTO 24% (28 of 117), SLP 58% (41
of 71), and TS 54% (59 of 110). The mean age of re-
spondents was 49 years (range 26 to 82), and the
gender mix was 44% male and 56% female.
Amount of Professional Experience
The average numbers of years in their respective
professions were OTO 13 years (range 0 to 36), SLP
16 years (range 2 to 35), and TS 26 years (range 4 to
56). The average numbers of singers with VFN treat-
ed and/or taught in the past year were OTO 4 (range
0 to 25), SLP 10 (range 0 to 60), and TS 1 (range 0
to 4). Lifetime mean professional experience with
this problem were OTO 56 (range 0 to 350), SLP 94
(range 0 to 1000), and TS 7 (range 0 to 144).
Etiologic Factors
Mean scores and standard deviations for each pro-
posed etiologic factor are presented for all respon-
dents and by professional group in Table 1. Respons-
es of O, indicating that the respondent was unsure
about the factor, were not included in tabulations. A
response of 1 indicated that the respondent felt that
Journal of Voice, Vol. 13, No. 1, 1999
the factor was not related to VFN, while 2 to 5 indi-
cated a progressively increasing causal relationship.
The factors are listed in descending order of the
mean score tabulated for all respondents. The order
within professional groups varied somewhat.
In each group shouting and screaming were rated
highest, with poor singing technique and trying to
sing too loudly among the 5 highest rated risk fac-
tors for each professional group. Caffeine use and
genetic predisposition were rated the lowest across
all groups. Proposed factors that were added to the
list by respondents with enough frequency to be not-
ed were general statements about poor speaking
voice, cheerleading, and smoking.
Responsiveness to Treatment
Mean scores and standard deviations of responses
to questions about responsiveness to treatment are
presented for all respondents and by professional
group in Table 2. For clarity in understanding the
trends in opinions, data from this portion of the
questionnaire are also presented in Figs. 1A and lB.
Results of this section indicated optimism about
prognosis for voice recovery. The nature of treat-
ment was purposely not specified beyond the de-
scription "appropriate treatment."
Treatment Options
Mean scores and standard deviations of responses
to questions about treatment options are presented
for all respondents and by group in Table 3. For clar-
ity in understanding trends in opinions, data from
this section are also presented in Fig. 2.
Combined treatment employing voice training by
a TS and voice therapy by an SLP was the treatment
option rated highest by each professional group (Table
3, Fig. 2E). Speech therapy alone was the second
highest rated treatment option, while surgery was not
felt by a large percentage of any group to be the best
treatment for VFN in a singer (Table 3, Figs. 2A and
2C). A majority of each group disagreed with the
statement that surgery should never be performed for
this problem. A majority of each group also felt that
surgery was appropriate treatment in cases where be-
havioral management was not successful (Table 3,
Figs. 2F and 2G).
 VOCAL FOLD NODULES IN ADULT SINGERS 131

T A B L E 1. Mean Ratings for Proposed Etiologic Factors for All Respondents and by Professional Group*
Proposed M e a n + SD M e a n _+ SD M e a n _+ SD M e a n _+ SD
Etiologic Factor (ALL) (OTO) (SLP) (TS)

Shouting and screaming 4.43 _+0.78 4.48 + 0.58 4.30 _+0.97 4.51 + 0.70
Poor singing technique 4.18 + 0.84 4.07 + 0.83 3.89 -+ 0.94 4.45 + 0.69
Trying to sing too loudly 3.84 _+ 0.94 4.15 + 0.77 3.79 + 1.11 3.73 + 0.88
Style of singing 3.64 _+ 1.11 3.78 + 0.70 3.21 _+ 1.15 3.88-+ 1.16
Singing outside of natural range 3.56 _+ 0.99 3.93 + 0.87 3.69 -+ 0.99 3.29 _+0.98
Excessive throat clearing 3.46 _+ 1.06 3.48 + 0.94 3.91 +1.1l 3.12 + 0.96
Excessive coughing 3.43 + 1.12 3.44 _+0.93 3.89 + 1.02 3.10 _+ 1.16
Rehearsing when fatigued 3.35 + 0.89 3.52 _+0.75 3.24 _+0.88 3.34 + 0.96
Very talkative personality 2.80 _+ 1.27 3.22 + 1.05 2.89 + 1.23 2.54 + 1.35
Gastroesophageal reflux 2.45 _+ 1.51 3.00 -+ 1.44 3.06 + 1.17 1.74 + 1.47
Allergies 2.33 _+ 1.16 2.00 + 1.04 2.86 + 0.78 2.10 + 1.32
Caffeine use 1.86 _+ 1.23 1.60 + 1.12 2.69 _+ 0.99 1.39 + 1.14
Genetic predisposition 1.40 _+ 1.28 1.41 + 1.15 1.73 _+ 1.17 1.14 _+ 1.37

*Factors are listed in descending order of mean rating by all respondents.

Rating scale: 1 = No Contibution; 2 = Small Contribution; 3 = Moderate Contribution; 4 = Large Contribution; 5 = Very Large
Contribution.

T A B L E 2. Mean Ratings for Statements About Responsiveness to Treatment

for All Respondents and by Professional Group
Responsiveness M e a n _+ SD M e a n __. SD M e a n _+ SD M e a n _+ SD
To T r e a t m e n t (ALL) (OTO) (SLP) (TS)

Very responsive 4.15 _+ 0.72 3.96 + 0.74 4.46 + 0.50 4.02 + 0.77
Difficult to treat 2.00 + 0.85 2.07 _+0,77 1.64 _+ 0.67 2.24 + 0.93

*Rating scale: 1 = Strongly Disagree; 2 = Disagree; 3 = Don't Know; 4 = Agree; 5 = Strongly Agree.

DISCUSSION the same as for the survey of OTO by Moran and

With any survey, the response rate and appropri-
ateness of the populations surveyed must be as-
sessed. The response rates of 58% and 54% for SLP
and TS, respectively, were good for an unsolicited
questionnaire, and these were felt to be satisfactory
samples. For OTO, the rate of 24% was somewhat
disappointing, and it is uncertain whether this was a
representative sample of this population. Interesting-
ly, the current OTO response rate was almost exactly
Pentz. 12
The professional experience data indicated that
each group was acquainted with the problem of VFN
in singers. Our own clinical experience in a universi-
ty voice care program is significantly higher than
most of these numbers, but our facility is recognized
as unique in our region and has a wide referral base.
The question of how much experience is necessary
before an opinion can be considered "learned" or

Journalof Voice, Vol.13, No. 1, 1999

132 N O R M A N D. H O G I K Y A N E T A L

"...[VFNare generally responsive to appropriate tx, and normal singing activities can be resumed after tx]..."

70, ~-

to
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40
mm
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O
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,,, 30
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s,,I
SLP I

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1 2 3 4 5
Strongly Disagree Don't Agree Strongly
A Disagree Know Agree

"..[VFN are generally very difficult to treat, and usually end or severely limit a singing career]..."
¢q
70 ~ ,~
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60
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Strongly Disagree Don't Agree Strongly
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FIG. 1. Bar graphs showing the percentage of respondents who indicated agreement or disagreement with statements regarding re-
sponsiveness to treatment. Data for all respondents and by professional group are shown, with the response scale listed below figures A
and B,

Journal of Voice, Vol. 13, No. 1, 1999

 VOCAL FOLD NODULES IN ADULT SINGERS 133

T A B L E 3. Mean Ratings for Statements About Treatment Options for All Respondents*

M e a n _+ SD M e a n + SD M e a n _+ SD M e a n _+ SD
Treatment Option (ALL) (OTO) (SLP) (TS)

Voice therapy by a speech 3.62 -+ 1.08 3.96 _ 0.79 3.93 _+ 1.11 3.21 _+ 1.06
pathologist is usually best
Voice training by a voice 2.80 _+ 1.15 3.57_+ 1.00 2.36_+ 0.94 2.74_+ 1.18
teacher is usually best
Surgery is usually best 1.81 -+ 0.85 2.21 -+ 0.92 1.55 -+ 0.71 1.81 _+0.85
Surgery followed by voice 2.07 _+ 1.08 2.39 -+ 1.20 1.83 _+0.86 2.09 _+ 1.14
therapy or voice training
is usually best
Combination of voice 4.46 _+ 0.83 4.28 _+ 1.01 4.78 _+ 0.72 4.32 _+0.74
training and voice therapy
is usually best
Surgery should never be 2.34 _+ 1.08 1.75 _+ 0.64 2.19 _+0.89 2.75 _+ 1.21
performed
Surgery is appropriate if 3.79 _+ 0.99 4.26 _+ 0.71 3.84 _+0.86 3.54 _+ 1 . l l
voice training and/or
voice therapy fail

*Rating scale: 1 = Strongly Disagree; 2 = Disagree; 3 = Don't Know; 4 = Agree; 5 = Strongly Agree.

"Voice therapy by a SLP is usually the best treatment for vocal fold nodules in a singer"

70,

60
I- LO
Z 50
1,1,1
Z
0
Q.
!,1.1
re
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0
40

30

20
(D CO
li°T°I
SLP
TS
ALL

10

0
1 2 3 4 5
Strongly Disagree Don't Agree Strongly
A Disagree Know Agree

FIG. 2. Bar graphs (A-G) showing the percentage of respondents who indicated agreement or disagreement with statements regarding
choice of treatment options. Data for all respondents and by professional group are shown, with the response scale listed below figures.

Journal of Voice, Vol. 13, No. 1, 1999

 134 NORMAN D. HOGIKYAN ET AL

"Voice training by a singing teacher is usually the best treatment for vocal fold nodules in a singer"
m.
¢O
60 =

¢/) 50
I-
Z
uJ 40
z [] OTO
O l" SLP I
a. 30
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Strongly Disagree Don't Agree Strongly
B Disagree Know Agree

"Surgery is usually the best treatment for vocal fold nodules in a singer"

70

60
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zuJ 50

z 40
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m 30
re BALL I
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C Disagree Know Agree

FIG. 2. (continued)

Journal of Voice, Vol. 13, No. 1, 1999

 VOCAL FOLD NODULES I N A D U L T SINGERS 135

"Surgery followed by voice therapy and~or training is usually the best treatment for vocal fold nodules in a singer"

60

(/) 50
Z
uJ 40
Z • OTO I
O
¢1. • SLP I
(/) 30 eaTS
nl
rr [] ALL
O
20

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0
1 2 3 4 5
Strongly Disagree Don't Agree Strongly
D Disagree Know Agree

"A combination of voice training and voice therapy is usually the best treatment for vocal fold nodules in a singer"

90
80
70
z 6o
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O 50 • SLP
40 ~- eaTS
n- ~ [] ALL
',6 30
o~ 20 ~.

lO

1 2 3 4 5
Strongly Disagree Don't Agree Strongly
E Disagree Know Agree
FIG. 2. (continued)

Journal ofVoice, Vol. 13, No. 1, 1999

 136 N O R M A N D. HOGIKYAN ET AL

"Surgery should never be performed for vocal fold nodules in a singer"

tO
70

60
I--
z 50
U.I
C1
z 40 ]• OTO I
O
a. • SLP I
©
(/) BTS I
,,, 30
rr • ALL I
tim

o 2O ~Z
E~
to

1"
@
10
I

0 i

1 2 3 4 5
Strongly Disagree Don't Agree Strongly
Disagree Know Agree

"Surgery is appropriate tx if voice therapy and~or training have failed to successfully treat the nodules"

70
04
(D

60 U')
¢O
Z 50
LU
t~
Z
40 mOTO I
0 • SLP J
n
tl) =TS
IJJ 30
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[BALL I
leJ
0 20

10

0
1 2 3 4 5
Strongly Disagree Don't Agree Strongly
G Disagree Know Agree

FIG. 2. (continued)

Journal ofVoice, Vol. 13, No. 1, 1999


VOCAL FOLD NODULES IN A D U L T SINGERS
"expert" is not readily answered, but answering this
is not pertinent to the present study, which sought to
simply characterize the prevailing experience and
opinions in this region.
The opinions of respondents regarding possible
etiologic factors (Table 1) were generally in keeping
with writings in current textbooks. Practices that
constitute either abuse or misuse of speaking and/or
singing voices were felt by all groups to be of great-
est importance in causing VFN in singers. SLP tend-
ed to consider behaviors such as coughing and throat
clearing to be somewhat more important causal fac-
tors than did other professional groups. Style of
singing was felt on average to be a moderate to large
contributor to VFN formation. Classical style sing-
ing was notable as the only style listed in the survey
that was not felt to be a contributor except by a very
small number of respondents.
Voice overuse, or simply a very talkative personal-
ity, was considered on average to be a moderate con-
tributory factor by respondents. Based on discus-
sions with colleagues and observations in his own
practice, the senior author considers this personality
factor to be of prime importance in the development
of vocal fold nodules. Risk factors for benign vocal
fold mucosal disorders are the subject of an ongoing,
prospective research effort.
Voice-related health professionals are familiar
with the outward expression of despair and hopeless-
ness that typically follows the initial discussion of
VFN with a patient who is a singer. This is in re-
markable contrast to the optimistic viewpoint of re-
sponsiveness to treatment expressed by most respon-
dents to this survey (Table 2, Figs. 1A and 1B),
espoused by the current authors, and found in pub-
lished accounts of treatment outcomes.I, 14-16 One
possible explanation for this disparity is the fact that
the singers who are most likely to develop vocal dif-
ficulties are also more likely to have had little or no
formal voice training. When first presenting with vo-
cal difficulties, they would not have had the benefit
of education about such problems by TS or other
voice-related professionals who are represented in
this survey. This underscores the need for thoughtful
and deliberate incorporation of education into any
discussion of this problem with a singer.
Determination of the optimum treatment for a dis-
ease or disorder is best accomplished by a prospec-
)
137
tive randomized trial of the known treatment op-
tions. It is probably safe to say that such a study will
never be performed for VFN in singers. Retrospec-
tive or nonrandomized prospective studies are the re-
maining options for outcomes measures for this clin-
ical entity. Such limitations are part of the rationale
for the current questionnaire study. While this study
does not represent outcomes research, it does pro-
vide valuable insights into the prevailing opinions of
appropriate professional groups about VFN in sing-
ers. Indeed, after noting the disparity between text-
book treatment recommendations for treatment of
VFN and prior survey results, Murry and Woodson
concluded that "treatment of vocal fold nodules in
adults is based to a large extent on personal prefer-
ence rather than objective data based on treatment
outcomes.''14 It should be clearly noted that they did
not advocate this approach to determining treatment,
but rather were recognizing it as a consequence of
the lack of good objective data for therapeutic deci-
sion making.
The portion of the questionnaire related to treat-
ment options (see Appendix):was in the form of
statements to which respondents were asked to indi-
cate their agreement or disagreement on a graded
scale. It was intended that each statement be consid-
ered independently of the other statements, and it
was clear from the data that most respondents treat-
ed the statements in this way. In some cases, though,
it is possible that people felt that an agreement
about one treatment option necessitated disagree-
ment with all others, and this may have influenced
their responses.
The data about treatment options are presented in
Table 3 and Figs. 2A through 2G. Because of the na-
ture of the data, it is believed that representation in
bar graph format is most illustrative of the opinions
sought in the study. There was an overwhelming en-
dorsement of combined voice therapy by an SLP and
voice training by a TS as the best treatment for VFN
in a singer (Fig. 2E). This is in keeping with the po-
sition statement by ASHA and NATS regarding the
remediation of singers with voice disorders, and the
fact that causal factors are recognized in both speak-
ing and singing voices. 11 It also, we believe, under-
scores the need for centers of excellence in profes-
sional voice care to embrace this combined approach
to treatment.
Journal of Voice, Vol. 13, No. l, 1999
138 NORMAN D. HOGIKYAN ET AL
A majority of all respondents also responded fa-
vorably to voice therapy alone as the best treatment
(Fig. 2A), although the opinion trend was not as uni-
form or of the same magnitude as with combined be-
havioral management. The most notable exception to
the overall trend was that 37% of TS disagreed with
this statement, while 48% agreed or strongly agreed.
Voice training alone was not favored by a majority
of all respondents (Fig. 2B) but did have a majority
agreement in the OTO group.
Consideration of possible vocal fold surgery in a
singer is never taken lightly and is typically a very
emotion-charged subject in discussions with voice
professionals or patients. Results from the survey
statements regarding surgical management were un-
ambiguous. Surgery was clearly not Considered first-
line treatment by any professional group (Figs. 2C
and 2D). This reflects the overwhelming majority of
the current literature on this subject, and was no sur-
prise. Bastian writes about VFN in general (not just
in singers):
Surgical removal of vocal nodules is a good option in a
highly selected minority of patients with this disorder.
Essentially the only indication for surgery is persistence
of a visible lesion with symptoms that are unacceptable to
the patient, after a long trial of conservative measures. 7
A majority of each professional group did agree or
strongly agree that surgical management of VFN in
singers is appropriate if behavioral management fails,
and disagreed with the statement that surgery should
never be performed for this problem in a singer
(Figs. 2F and 2G). Although there is no definitive
reference for what the opinions of each of these pro-
fessional groups have been in the past regarding this
subject, this uniformity of opinion did come as some-
what of a surprise. Cornut and Bouchayer wrote in a
1989 article that discussed their excellent results
with vocal fold microsurgery in singers: '~k few years
ago, surgical intervention on the vocal folds most of-
ten represented a disaster for singers and the end of
their careers" 16The opinions expressed in this study
regarding surgical management reflect the advances
in vocal fold microsurgery and the enhanced ex-
change of information and coordination of care be-
tween all of the voice-related professionals involved
with the care of singers with voice disorders.
Journal of Voice, Vol. 13, No. 1, 1999
CONCLUSIONS
In this questionnaire study, the opinions of individ-
uals from 3 voice-related professions were sought
regarding VFN in singers. Causative factors related
to overuse~misuse~abuse of the speaking and singing
voices were identified by each group. In the region
studied, optimism about responsiveness to treatment
prevails, and combined behavioral management by
an SLP and TS was enthusiastically endorsed as the
best treatment option. Microsurgical management
was considered appropriate treatment in patients for
whom behavioral management has failed.
Acknowledgment: Supported in part by a Spring/
Summer Research Grant from the University of Mi-
chigan Office of the Vice President for Research.
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Journal of Voice, Vol. 13, No. 1, 1999
140 NORMAN D. HOGIKYAN ET AL

APPENDIX

VOCAL FOLD NODULE QUESTIONNAIRE

Dear Colleague,

Vocal fold nodules ("nodes," "singer's nodules") are relatively common causes of vocal difficulties
in singers. There are varying opinions about the cause of vocal nodules, their treatment, and the im-
pact that they have on a singing career. In order to better understand existing beliefs about these issues,
this questionnaire is being sent to professionals involved with this subject: teachers of singing, speech-
language pathologists, and otolaryngologists. The questions refer to adult singers of all types, includ-
ing amateurs and professionals, and voice students.
The questionnaire will take about five to ten minutes to complete. Please answer the following ques-
tions as candidly as possible. There is no single correct answer for each question, and all responses will
remain anonymous. We are interested in your opinion regardless of your level of experience with this
problem. Please return the survey in the enclosed self-addressed, stamped envelope, prior to Septem-
ber 20, 1996. Thank you very much.
Sincerely,

Norman D. Hogikyan, M.D. Leslie W. Guinn Marc J. Haxer, M.A.,CCC-SLP

Assistant Professor, and Professor, and Director Clinical Speech Pathologist
Director Vocal Health Center Division of Vocal Arts University of Michigan
Department of Otolaryngology School of Music
University of Michigan University of Michigan

NB The identifying data and experience questions were routine, but slightly different for each professional
group. The 3 sets of specific questions are not repeated here for sake of space, but results are summarized in
the body of the paper.

I. IDENTIFYING DATA
(see comment above)

II. EXPERIENCE WITH VOCAL NODULES IN SINGERS

(see comment above)

Journal of Voice, Vol. 13, No. 1, 1999

 VOCAL FOLD NODULES IN ADULT SINGERS 141

IlL BELIEFS ABOUT CAUSATIVE FACTORS

For each factor listed below, please rate using the following 6-point scale the extent to which you be'
lieve that the factor contributes to the formation of vocal fold nodules in singers.

SCALE
0 1 2 3 4 5
Unsure Does Not Small Moderate Large Very Large
Contribute Amount Amount Amount Amount

FACTORS RESPONSES

1. Allergies 1.

2. Poor singing technique 2.

i

3. Style of singing 3.

If you believe this is a factor, please circle the style or styles that you
believe most contribute

classical pop rock belt musical theater other

4. Singing outside of natural range 4.

5. Very talkative personality 5.

6. Shouting and screaming 6.

7. Trying to sing too loudly 7.

8. Excessive throat clearing 8.

9. Excessive coughing 9.

10. Caffeine use 10.

11. Genetic predisposition (family inheritance) for nodules 11.

12. Gastroesophageal (stomach acid) reflux 12.

13. Rehearsing when fatigued 13.

14. Other: 14.

Journal of Voice, Vol. 13, No. l, 1999

142 N O R M A N D. H O G I K Y A N E T A L

IV. BELIEFS ABOUT EFFECTS OF VOCAL NODULES ON CAREERS

Please indicate your opinion about each of the following statements using the 5-point scale listed below.

SCALE
1 2 3 4 5

Strongly Disagree Don't Know Agree Strongly

Disagree Agree

STATEMENTS RESPONSES

1. Vocal fold nodules in singers are generally very responsive to 1.

appropriate treatment, and the singer can usually return to their
normal singing activities following a completed course of treatment.
2. Once vocal fold nodules develop in a singer, they are generally very .
difficult to treat, and usually end or severely limit a career.

V. BELIEFS ABOUT TREATMENT

Please indicate your opinion about each of the following statements using the 5-point scale listed below.

SCALE
1 2 3 4 5

Strongly Disagree Don't Know Agree Strongly

Disagree Agree

STATEMENTS RESPONSES

1. Voice therapy by a speech pathologist is usually the best 1.

treatment for vocal fold nodules in a singer.
2. Voice training by a singing teacher is usually the best .
treatment for vocal fold nodules in a singer.
3. Surgery is usually the best treatment for vocal fold .
nodules in a singer.
4. Surgery followed by voice therapy and/or voice training is .
usually the best treatment for vocal fold nodules in a singer.
5. A combination of voice training and voice therapy is .
usually the best treatment for vocal fold nodules in a singer.
6. Surgery should never be performed for vocal fold .
nodules in a singer.
7. Surgery is appropriate treatment if voice therapy and/or .
voice training have failed to successfully treat the nodules.

Journal of Voice, Vol. 13, No. 1, 1999