By: Brenda Earle Stokes, BFA, M.MusIn 2016, after a bad bout of reflux, I noticed that my voice was getting hoarse. Assuming that it was some combination of my allergies and fatigue from life in general, I did a little voice rest and drank extra water. One week, two weeks, three weeks went by and it wasn’t getting better. That’s when I panicked. What if something was really wrong??Luckily, I had a great relationship with my Laryngologist Dr. Michael Pitman, who was able to squeeze me in for an appointment the next day. He could tell just by speaking with me that something was not right. After a quick stroboscopy he confirmed my worst fear: I had nodules.
What are vocal fold nodules?
Voice pathology can take many different shapes, including polyps, nodules and a hemorrhage. While polyps typically occur on one side of the vocal fold, nodules typically occur bilaterally. A hemorrhage is like a bruise in the vocal fold, where there is bleeding occurring somewhere inside the vocal fold. All three of these pathologies can be caused by vocal overuse, inefficient vocal production or other underlying health concerns or illness. School teachers, coaches and other professionals who use their voices a lot in loud settings are at a higher risk of vocal injury than a person who uses their voice less. And, it’s not just rock singers that have vocal issues – plenty of classical singers have had vocal pathology!Nodules and other vocal fold pathologies can only be diagnosed by a Laryngologist or a SLP after performing a stroboscopy. Going to a regular ENT is not enough as you cannot be diagnosed with any vocal pathology unless you are scoped properly. Voice teachers cannot diagnose voice pathology, but they can help to recognize when there may be a problem and refer you to a specialist.Being diagnosed with a vocal fold injury is not a death sentence, and nowadays surgery is generally a last resort. Depending on the diagnosis and severity of the pathology, voice therapy and addressing underlying medical concerns are generally the first line of defense against injury.
The good news was that my nodules were small and soft and since I went for an annual scope, I knew that they had been there for a short time. We also discovered a lot of thick mucus on my vocal folds, which Dr. Pitman suggested was either the result of allergies and/or reflux. After reassuring me that I will get my voice back again, he gave me a list of steps to take, which included treating my potential allergies/reflux and having several sessions with an SLP (Speech Language Pathologist). I walked out of his office in a daze.I was so upset with myself that this happened. First of all, I am a professional singer with supposedly impeccable technique. How could this happen to me?!? And, I’m a voice teacher. What if my students find out? They’ll think terrible things about me and my studio will crumble! How am I ever going to be able to recover?!? I have a young son and it’s summer vacation and we’ll be together all the time. How am I going to rest and rehabilitate my voice?!?! I shed a lot of tears and felt very angry at myself. How could I let this happen?I reached out to several trusted friends, including (lucky me!) two friends who happen to be SLPs. My friend Kathleen Curatolo helped to explain in great detail what my diagnosis meant and my friend Jan Potter Reid who specializes in working with singers at the Chicago Institute for Voice Care who wrote me a long email sharing her experience in the field and assuring me that I was not alone. I then breathed a heavy sigh of relief.
Cause and Treatment of Nodules
So how did I get the nodules then? The biggest culprit for me was reflux aka GERD. (This is also known as LPR – Laryngealpharyngeal Reflux). I had suffered with terrible reflux during my pregnancy back in 2011/2012, and since my son was born it would show up once in a while. That caused some inflammation and excess mucus on my vocal folds, which made them need to work harder. Factor into that a very busy schedule of teaching and performing, and the rigorous demands of motherhood. Since I live in NYC, it is loud everywhere and having a young son riding a scooter around and playing in crowded playgrounds meant that I was often shouting at him. This was the recipe for my vocal fold injury.The first thing I did was get started treating my reflux. Since I don’t respond well to PPI’s or any of the traditional medications, I went back to my usual routine: smaller meals, no eating at least 3 hours before bed, no spicy or greasy good, cut back on sugar and get back to taking my natural remedies. I was also careful to manage my stress and get a lot more sleep.
Voice Therapy and Lifestyle Change
I sought treatment from Leanne Goldberg, an SLP on staff at the Grabscheid Voice and Swallowing Center at Mount Sinai Hospital in New York City. She came highly recommended from several people, and it turns out we actually knew each other from a few social gatherings. It felt like kismet!My SLP Leanne Goldberg helped me to identify the many ways I was using my voice and helped me to figure out some solutions to my voice use. She showed me how to use “forward placement” to project my voice to call to my son in the playground. I took it another step further and trained my son to stop when he heard me whistle. That meant that he could enjoy his scooter or running a bit ahead of me without my having to yell. HE also knows where he hears my whistle that he is to stop and look for me. Even some of his friends stop dead in their tracks when they hear me whistle!She told me to take vocal naps throughout the day, by assigning breaks between students where I wouldn’t talk at all. She helped to define a way to warm up and cool down my voice. She also challenged me to spend a lot less time demonstrating exercises during voice lessons, in order to save my voice. While teaching piano lessons, she suggested that I find ways to minimize talking (by making my students count aloud, rather than doing it for them) and to never try to speak over someone playing. I applied all of these solutions immediately and still use them to this day.My SLP helped me to find an easier way to pitch my voice so that it would carry better without putting so much stress on my vocal folds. She had me do a variety of therapeutic exercises (SOVT – semi occluded vocal tract) that helped to stretch the folds and to encourage healing. We also worked a lot on forward resonance, so that I would have enough brightness in my sound in order for it to carry without putting so much stress on my vocal folds. She helped me “find” my voice again, after so many weeks of hoarseness and weakness.Now that I was considering my voice use, I started thinking about how I used my voice during the non-teaching times of my week. I thought of the times I would holler “it’s time to go” to my family. Could I walk into the room instead to say it, to save my voice? When my husband or son ask me a question for another room, I could choose not to yell back to them. Instead I asked them both, if they needed me that they can come and find me, because I’m not able to yell any more. I also started thinking about all the times I would intervene when my husband was having difficulty with me son. Now, I let them work it out, which also gives my voice a much-needed break.
Back to SingingI took a full four weeks off from singing. Luckily, it coincided with a down time in my schedule, so I didn’t have a lot going on. When it was time to get back to it, I enlisted the help of my longtime voice teacher Jeanie LoVetri. Jeanie is an expert voice teacher, who has years of training and experience working with the finest singers around, and she is uniquely skilled in working with injured voices. She has been very forthcoming publicly about her own experience with vocal fold paresis and had been working hard to get her voice back in working shape. She had been aware of my entire nodules journey and had been both supportive and encouraging.Our first few lessons after I was cleared by my SLP consisted of a lot of SOVT exercises, especially with a tube in a water bottle. She had me explore my range again and helped me to secure my lower pitches in an easy chest register. The entire time, my voice was wobbly and would often cut out, but she always reassured me that we were working in the right direction. I worked along with the recordings of our session, often breaking the session into 10-minute chunks. Over time, we were able to get some strength on the lower and middle pitches and eventually my head register started to show up with more and more clarity.All in all, it took about 6 weeks of voice lessons with Jeanie and I felt 80% of the way better. Within three months my voice was all the way back and then some. Going through the experience made me reconsider what I thought was “my sound” and I ended up with a voice that was more balanced and flexible than it had been prior to the injury.
The Stigma of Vocal Injuries
There is such a stigma in the voice community about vocal injuries. Just look at the horrible articles written about Adele and Ed Sheeran and their vocal issues. So many times, these incredible singers will be shamed for having “bad technique” and the word “vocal abuse” starts being used. I have experienced first-hand the judgement that arises even the voice community where voice teachers will make terrible comments about bad singing being the cause of the injuries. The face of the matter is that we are all Monday Morning Quarterbacks when it comes to other people’s voice issues. The only people who know the cause of Adele’s or Ed Sheeran’s voice issues are their medical team and voice therapy providers. How do we know that they don’t have severe reflux, hormone issues, unusual anatomy or that they didn’t have a terrible cold or flu that weakened their singing anatomy?There will always be the potential for injury when someone is doing anything physical on an elite level. When a baseball pitcher gets an elbow injury or a football player injures his knee, is there backlash against them for “bad technique” or is it just a part of playing the game? As singers, we need to stop the blame game and switch our messaging to removing this stigma.When I mentioned my injury in a couple of chat groups I was in, people responded to me, but only in private. Very few singers were willing to share their voice problems out in the open. I wanted to write this article as a way to take the shame and stigma out of voice issues, so we can be more open with our students.
What I learned from my experience
This was one of the most humbling experiences of my career and one that I am amazingly grateful to have had. I first learned that I am human and that the human body doesn’t always work perfectly. The reflux, the fatigue, were all things I had very minimal control or even awareness of. I also learned how crucial it is to have a support team around me. I was so lucky that I already had a relationship with a top laryngologist, and that I was friends with 3 different SLPs. And to top it off, my voice teacher is one of the top voice specialists on the planet and because we have such a strong relationship, she was able to make space in her calendar to help me.The biggest gift that I got from this experience is that it has made me a better teacher. Since I know what it feels like to lose my voice, I have so much for empathy and connection for my students who find themselves struggling. I know what the struggle is and what it takes to get through it. I’ve also managed to help other singers to get the help they need, by suggesting that they go get scoped or treat other medical issues that may be causing difficulty in their singing. I have started working with several singers who have been referred to me after being diagnosed with voice issues. I know how to help them rehabilitate their voices (once they’ve been cleared by their doctor and SLP!) and retrain to get back what they had and train their voices to be stronger and more functional than ever. I have been told by more than a few singers that they appreciate my openness about my vocal fold issues and my rehabilitation. Even in this day and age, there is so much secrecy surrounding vocal fold issues, which leads to more shame and more secrets.Writing this article is an attempt to break that silence and to encourage others to share their stories, so that we can further the voice field even more and help people to seek treatment. I hope by coming forward and sharing such an in-depth discussion of my entire experience, that others will also be willing to share their stories. Let’s take the shame out of vocal health issues!
Epilogue: My post-nodule life
Nowadays, it is rare that I will have a bad voice day. Sure, I get colds like everybody else does. (I have a school age child, remember!) If I feel like my voice is feeling tired, I immediately modify my speech in order to protect my speaking voice and not make the issue worse. If I’m feeling under the weather, I have PMS or vocally tired, I go back to some of the exercises that I used to recover from my injury (hello singing through a tube in a bottle of water!). I am always careful to warm up before I perform or have a heavy teaching day, and I know exactly the sweet spot of where I want to be vocally. I have a much lighter mix in the middle than I did before, and I am very particular about making sure my register transitions are as smooth as possible. I am also better overall at having healthy boundaries around my time and voice so I’m not wasting my vocal “dollars” unnecessarily.I am open with all of my students about my vocal issues, and share my experience as a way to inspire them to keep working on their voices, no matter what they are struggling with. Our voices are here to share our truths just as much as they are to sing our songs.