SINGERS' NODES. 
BT 
FREDERICK I. KNIGHT, M. D., 
BOSTON. 
REPRINTED EROM THE 
Neto ¥orfc IHeUical journal 
for December 1, 1894- Reprinted from the New York Medical Journal 
for December 1, 189^. 
SINGERS' NODES * 
By FREDERICK I. KNIGHT, M. D., 
BOSTON.-* 
The affection of which I wish to say a few words con- 
sists, as I have seen it, of a small ovoid nodule situated on 
the edge of one or both vocal cords at about the junction 
of the anterior and middle thirds, and can usually be attrib- 
uted to extraordinary or improper use of the voice. It 
has been described as one of the conditions found in 
chronic laryngitis, but also as " trachoma of the vocal 
cord " and " chorditis tuberosa." It occurs, however, as 
has been pointed out by Rice,f as a primary affection, with 
or without subsequent general laryngitis. I described a 
case as " trachoma " in the Archives of Laryngology for 
1883. The cases of Turek, who suggested this name, pre- 
sented multiple granulations not only on the edge but on 
the upper surface of the cords, and the name seems most 
appropriate for these cases. The single nodule on one or 
both cords, although it may be pathologically the same, 
* Read before the American Laryngological Association at its six- 
teenth annual congress. 
f Transactions of the Am. Laryngological Assoc., 1890. 
Copybight, 1894, by D. Appleton and Company. 2 
SINGERS' NODES. 
constitutes clinically a distinct affection, and is, I think, 
entitled to a separate designation. Whether the term 
" chorditis tuberosa," which Dr. Rice adopts, is entirely 
satisfactory is doubtful, as there may be little or no chor- 
ditis, and this term has been also unfortunately applied to 
the diffuse form. Singer's node is not exactly appropriate, 
because the subject, though usually, is not always a singer. 
To be exact, we can only at present say that we find a 
node on the vocal cord in the above-mentioned site. This 
is usually whitish or yellowish-white in appearance, of the 
size of a millet seed or larger. There may be a depression 
in the edge of the opposite cord in the corresponding spot, 
or a little nodule here also. The mucous membrane of the 
adjacent parts of the cord may show signs of inflammatory 
action, but in the beginning this is often absent. The 
cause of this condition will almost always be found to be 
strain or wrong use of the voice in singing or speaking. 
It is said that friction of the edges of the cords is greatest 
at this point, hence the pathological change. The nature 
of this development has been but little studied histo- 
logically. Kanthack * examined three specimens from 
Krause's clinic, and found in one a simple local hyper- 
plasia ; in the second, cornification; and in the third, such 
a growth as comes from chronic irritation. No glands or 
vestiges of such were found. 
The examinations were made on account of a statement 
by B. Fraenkel that these nodes were of glandular origin. 
Kanthack also examined twenty larynges, and found no 
glands in the vocal cords. 
Rice had sections examined from two nodules which he 
removed from the vocal cord by a small snap guillotine, and 
the result in both cases was connective tissue and epithelial 
* Internationales Centralblatt fur Laryngologie, etc., 1890. SINGERS' NODES. 
3 
elements in largely increased numbers. M. Sabrazes and 
M. Freche* report on the microscopic examination of three 
specimens, that they are to be considered as circumscribed 
hypertrophies of the epithelium and chorion of the mucous 
membrane. Sometimes the thickening of the epithelium 
predominates, sometimes it is rather the papillary pro- 
longations of the chorion; mostly both participate in the 
hypertrophy. Wedl f made an examination of post-mortem 
sections of a "trachomatous" vocal cord in a patient of 
Turek, and found only hypertrophied connective tissue and 
proliferation of nuclei. This patient had the diffuse granu- 
lar condition of both cords. She died of tuberculosis. 
It will be noted that histologically the nodules were of 
the same character as the single ones which we are dis- 
cussing. 
The symptoms produced by these little nodes vary from 
slight hoarseness to complete loss of voice. In the latter 
case there is usually a considerable amount of laryngitis, or 
paresis of the tensors. 
The prognosis depends largely on the duration of the 
condition, and the ability and willingness of the patient to 
carry out instructions. When seen early, and the patient 
is able to rest the voice, the prognosis is, in my experience, 
good; but if the patient is obliged to use the voice, espe- 
cially if his method is wrong, it is serious, and under these 
circumstances the growth will probably continue and gradu- 
ally increase, leading to the various secondary conditions, 
and, as in the case of all such developments, the older it is 
the harder is it to cause absorption or get a good result 
from operation. 
The treatment of these nodules must vary with their 
* Internationales Centralblatt Jur Lar^ngologie^ etc., 1893. 
f Turek, Klinik der Kehlkopfkrankheiten, 1866. 4 
SINGERS' NODES. 
size and form. Those which I have seen have been so 
small and sessile, so thoroughly incorporated with the cord, 
that any operative procedure seemed inadvisable, not only 
on account of the difficulty of extirpating the growth, but 
for fear of injuring the vocal cord. Sabrazes and Freche 
state that the nodule may be pediculated, in which case the 
operation would be comparatively trivial. I have never 
seen such, and should doubt their identity with the kind I 
have described. I should have hesitated to cut into the 
vocal cord in any of the cases I have seen, unless the voice 
seemed ruined forever, as it was, and this gave the only 
hope, for the integrity of the singing voice depends on the 
integrity of the edge of the vocal cord. Tn the few com- 
ments published on the treatment of this condition there 
has been a great confusion of this and the diffused tracho- 
ma of Turek, from which it must be distinguished, notably 
in the discussion at Baltimore on Dr. Rice's paper. Dr. 
Rice himself, in the illustration of his article and in his re- 
marks on treatment, evidently had in mind the single 
nodule on the edge of one or both cords, but at the begin- 
ning of the article he says that Tiirck's description of this 
condition is comprehensive, whereas Turek describes only 
the diffused condition occurring on the surface as well as 
edge of the vocal cord. Dr. Westbrook describes a nodule 
on the vocal cord of one of his patients growing from the 
vocal process forward. Dr. Daly said that the condition 
was not uncommon in tuberculous families, evidently re- 
ferring to a diffuse granular condition of the cords. Dr. 
Delavan spoke of the recommendation of forcing a probang 
covered with cotton through the glottis in the hope that 
the granulations might thus be scraped away, and that he 
had not found this method a success. This method was 
suggested by Voltolini for papillomata, which are often fri- 
able, but I can not conceive how any one could recommend SINGERS' NODES. 
5 
it for the hard, closely incorporated nodule such as I have 
described. Neither should I expect to accomplish any- 
thing in this form but irritation-by scraping with the 
finger nail-as done in one case by Dr. Daly, even if I 
could reach the vocal cord. The epiglottis and tips of the 
cartilages of Santorini are as far as I can reach with my 
forefinger in most cases, and the vocal cords are consider- 
ably further off. 
Dr. John N. Mackenzie said we should distinguish be- 
tween a mere granular condition and the genuine chorditis 
tuberosa, evidently meaning by this latter term the diffuse 
form, as he says the whole cord is converted into a band 
like a granular hd, and is usually incurable. 
Tn my cases so far I have found that by rest and as- 
tringents, if there was also inflammation of the surrounding 
mucous membrane, the voice has been so far restored that 
I did not feel justified in risking cutting operations; but if 
after this treatment there was still no useful voice, I should 
not hesitate to employ Dr. Rice's guillotine and remove the 
protruding portion of the growth, if it could be engaged, 
hoping that the remainder would be more readily absorbed. 
I have not been able, from Dr. Rice's published paper or 
his remarks in the discussion, to find out just how much 
of a voice the patients whose nodules he e-xcised ever ac- 
quired after the operation. Neither have I been able to 
learn how the nodules were removed nor the resulting con- 
dition of the voice in the cases of MM. Sabrazes and Freche 
(Lichtwitz's clinic) nor in the cases of Kanthack (Krause's 
ciinic). 
The object of this brief paper is, first, to call attention 
to the imperfect nomenclature of this affection, and to 
recommend the abandonment of the term " trachoma of 
the vocal cord " for the form of the affection which I have 6 
SINGERS' NODES. 
described, and the restriction to that form of the term 
" chorditis tuberosa," if it should seem best to retain it; 
and in the second place to elicit reports of operations on 
single nodules (unilateral or bilateral) situated as T have 
described, and especially the effect of their excision on the 
singing voice. The New York Medical Journal. 
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