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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 184-191

Resolution of vocal cord nodules with individualised homoeopathic treatment


Dr. Anjali Chatterjee Regional Research Institute (H), Kolkata, West Bengal, Central Council for Research in Homoeopathy, New Delhi, India

Date of Submission30-Jan-2019
Date of Acceptance16-Sep-2019
Date of Web Publication4-Oct-2019

Correspondence Address:
Dr. Suraia Parveen
Dr. Anjali Chatterjee Regional Research Institute (H), 50, Rajendra Chatterjee Road, Kolkata - 700 035, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_5_19

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  Abstract 


Vocal Cord Nodules (VCNs) are localised benign, superficial growths on the medial surface of the true vocal folds resulting primarily from voice abuse, overuse or misuse and clinically manifested by progressive hoarseness of voice, with increased effort required to produce the voice, vocal fatigue and discomfort or pain in the throat. Conventional treatment methods include conservative voice therapy and surgical intervention. Both treatment methods are required for the resolution of VCNs with improvement of clinical symptoms. Here, a 44-year-old male teacher presented with a history of progressive hoarseness with vocal fatigue, discomfort in the throat during talking and bilateral VCNs since 8 months. There was no improvement after voice rest and voice therapy interventions for 5 months and he was finally advised for surgery, which he denied. He was, instead, successfully treated by individualised homoeopathic single medicine Hepar sulphuricum (30C, 200C and 1M) selected on holistic approach. Over the period of 5 months of homoeopathic treatment, the patient's presenting symptoms of VCNs were improved and with resolution of it. This case report suggests that homoeopathic intervention may be the treatment for the resolution of VCNs with its presenting symptoms.

Keywords: Hepar sulphuricum, Hoarseness, Homoeopathy, Individualisation, Vocal cord nodules


How to cite this article:
Parveen S, Nath R. Resolution of vocal cord nodules with individualised homoeopathic treatment. Indian J Res Homoeopathy 2019;13:184-91

How to cite this URL:
Parveen S, Nath R. Resolution of vocal cord nodules with individualised homoeopathic treatment. Indian J Res Homoeopathy [serial online] 2019 [cited 2019 Oct 19];13:184-91. Available from: http://www.ijrh.org/text.asp?2019/13/3/184/268519




  Introduction Top


Vocal cord nodules (VCNs) are benign, callous-like growths on the medial surface of the true vocal folds that commonly occur from vocal cords tissue trauma due to chronic vocal overuse or misuse. VCNs are usually bilateral and located at the midpoint of the membranous vocal fold and are characterised by hoarseness of voice, vocal fatigue, a sensation of discomfort or pain in the throat because of increased effort required to produce the voice and an unstable voice when speaking. Hoarseness is a common presenting symptom and refers to a rough, raspy, breathy, weak or strained voice or to changes in pitch and perceived effort.[1],[2] This pathological growth of masses in vocal folds is generally caused by excessive and repeated mechanical stress. Vocal cords are subject to collision forces at each vibratory cycle. High-pitched vibration causes mechanical stress confined to the edge of the vocal folds, which is associated with a predisposition to nodule formation by activating subepithelial fibroblasts leading to excessive collagenous fibre deposition. Over the time, the vocal abuses generate firstly soft and swollen spots, which then evolve into nodules and become bigger and stiffer if the incorrect vocal use persists.[3]

Epidemiologic studies of the sociodemographic factors related to vocal nodules in the nationwide surveys are rare. Vocal nodules are common among the general population; with a lifetime prevalence reported at 2.29%–16.9%.[4] Most of the patients with voice complaints are known to have benign vocal fold lesions, with the most common pathology being vocal nodules. Hoarseness of voice is the predominant symptom followed by vocal fatigue.[5] The exact prevalence of vocal fold nodules is not known, but it has been reported that 23.4% of children who attended an ENT clinic for voice hoarseness, 6% of phoniatric clinic attendees and 43% of teachers with dysphonia had nodules. Vocal nodules have been associated with young age. The younger individuals have a greater possibility to overuse or abuse their voice, compared with that of the older age group.[2] The exact aetiology of vocal nodules is not known, but traditionally, the causative factors of VCN are reported to be laryngeal trauma due to long-term voice use, vocal abuse or misuse, long-term exposures to smoke or chemical and other medical conditions such as infection, allergy, gastroesophageal reflux, hypothyroidism, neuromuscular conditions, psychiatric conditions, systemic disorders, neoplasms or other vocal cord lesions. However, the majority of previous studies concerning vocal nodules have involved specific occupation (almost teachers and singers). A study conducted by Herrington et al. found that occupation such as teacher had more voice disorders as a result of voice overuse.[6] Significant occupational voice demands, such as teachers, are at the greatest risk for developing voice problems as well as vocal nodules or vocal polyps. Some reported that over 30%–38% of teachers quit their jobs or have trouble with teaching because of voice problems. The impact stress of phonation appears to be important both clinically and in laboratory models of VCNs. The diagnosis of VCNs based on history, presenting symptoms and endoscopic laryngeal examination (indirect laryngoscopy or fibre-optic endoscopy or microlaryngoscopy) which revealed bilateral vocal fold nodules.[7],[8]

VCNs are treated either by non-surgical voice therapy interventions (e.g., voice retraining or voice therapy, voice rest or hygiene) or by surgical removal of nodules including excision with microsurgical instrument and the laser. Exacerbating factors, such as infection, allergy and reflux, may also be treated with pharmacological interventions. Voice therapy usually requires a prolonged period of treatment while surgery potentially removes the causative lesions restoring the anatomical configuration of the vocal folds. Although voice therapy is principally indicated for the treatment of functional dysphonia without any organic abnormality in the vocal folds, a number of clinicians have attempted to perform voice therapy even in dysphonic patients with benign mass lesions in the vocal folds. Voice therapy is usually chosen as a primary treatment of choice; there is no consensus as to which of the techniques employed by speech therapists are most effective or for how long they should be used. The techniques range from improving vocal hygiene, behaviour modification and 'abuse' reduction, to vocal retraining and psychological support, but it may be hampered voice-demanding profession like teaching or singing for time-consuming. Rates of surgical intervention vary widely, and the exact criteria for surgery are not clearly defined and it is also very costly. However, there are potential risks of surgery, and failures have been reported if the underlying causative factors are not addressed. For complete resolution of vocal nodules, both non-surgical speech therapy intervention and surgery are effective. It is not clear how patients should be selected.[9],[10]

Literature review revealed a case report on homoeopathic treatment of vocal cord polyp with hoarseness of voice. This case was treated with indicated homoeopathic medicines Arsenicum album and showed a resolution of vocal cord polyp.[11],[12]

A case of hoarseness of voice with bilateral VCNs, where voice therapy could not improve the presenting symptoms with failure to resolution of nodule, is presented here. Then, he was advised for surgical intervention by an ear, nose, and throat (ENT) surgeon but he rather chose to take homoeopathic medication.


  Patient Information Top


On 11 April 2018, a 44-year-old male presented to the Outpatient Department of Dr. Anjali Chatterjee Regional Research Institute for Homoeopathy (DACRRIH), Kolkata, with hoarseness of voice, vocal fatigue and discomfort or pain in the throat during speaking for the past 8 months. There was a history of vocal overuse which gradually preceded the onset. The hoarseness was accentuated in the morning and evening after overuse (teaching) of voice and in cold weather.

History of present complaints

The patient had been suffering from hoarseness of voice for near about 8 months. Professionally, he was a tutor and used to teach for 8–10 hours (4–5 coaching classes) per day, resulting in overuse of voice, which, in turn, led to hoarseness of voice. After suffering from hoarseness of voice for 8 weeks, laryngoscopy was done on 15 October 2017 as advised by the ENT surgeon which revealed bilateral VCNs. The ENT surgeon suggested voice rest and voice therapy with voice hygiene and minimises their coaching classes. He took voice therapy intervention (voice rest, voice training and voice hygiene) and discontinued his coaching classes for 20 weeks. However, there was no improvement.

It was difficult for him to continue further voice rest with the voice therapy as this was hampering his occupation. Due to deprivation in his tuition/teaching profession, he became worried, anxious and frustrated and ultimately he restarted his coaching classes on a small scale. Then, he was advised surgical removal of VCNs by the ENT surgeon. To avoid surgery, he decided to take the homoeopathic treatment and came to the Outpatient Department at DACRRIH, Kolkata.

Past history

There was a history of pneumonia at the age of 2 years which was cured by Allopathy medicines. There was a tendency to wards recurrent attacks of cold and cough.

Family history

Paternal grandfather of the patient died due to heart stroke, and maternal uncle is a known case of bronchial asthma.

Personal history

The patient is a private tutor and teaches literature to the students. He started his teaching profession in 2010 and is teaching for 8–10 hours/day.

The living environment of the patient is dry and airy. No other environmental factors except cold weather provokes his recurrent throat infection. There was no history of any addiction like smoking or alcohol and he was not on any ongoing allopathic medicine.


  Homoeopathic Generals Top


Mental generals

The patient was worried and frustrated due to his illness. He is very sensitive and anxious about little matters. He is physically active and speaks hurriedly.

Physical generals

The patient is fair complexioned but looked older than his age. He is chilly and cannot tolerate cold in general and prefers wrapping up his head. There was a history of recurrent attack of cold and cough from exposure to cold weather. He has a tendency to catch cold easily and delayed wound healing. He has satisfactory appetite and moderate thirst with craving for sour things ++ and meat +. He dislikes fatty, spicy food ++ with intolerance to bitter +, salty things +. His bowel habit is regular, clear and soft in consistency, and urine passes normally without any difficulty. There is profuse offensive perspiration all over the body but without any relief. He has a sound sleep pattern, 6–7 h/day.

Particulars

The patient feels pain and discomfort in the throat or larynx during speaking. Hoarseness of voice is aggravated from overuse of voice from teaching and in the morning. He has to put extra effort to speak or to read. His cough aggravated due to exposure to cold wind or weather.


  Analysis of the Case and Repertorisation Top


Proper case taking was done as per the direction of the Organon of Medicines and the Homoeopathic Philosophy. After analysis and evaluation of the symptoms of this case, the totality of symptom was constructed and the case was and repertorised with the help of 'Hompath Classic M.D version-10 software'[13] using Kent's repertory. The repertorial results are shown in [Figure 1].
Figure 1: Repertorisation software chart

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The following symptoms were considered for repertorisation:

  • Feeling of anxiety from little matters
  • Despair of recovery
  • Hasty speech
  • Chilly, cannot tolerate cold in general, patient feels better during wrapping up the head
  • Tendency to take cold
  • History of delayed wound healing
  • Desire – Sour things ++
  • Aversion – Fat/rich food ++
  • Sweat – Profuse all the time without getting any relief and offensive in odour
  • Hoarseness aggravated on overuse of voice and in the morning
  • Pain and discomfort feeling in the throat/larynx during talking
  • Cough aggravated on being cold and exposure to cold air.



  Diagnostic Assessment Top


Diagnosis was made by presenting symptoms such as hoarseness of voice, pain with discomfort in the throat and voice fatigue during talking and confirmed by fibre-optic laryngoscopy (FOL) on 15 October 2017 and revealed bilateral, symmetrical VCNs in the medial part of vocal cord [Figure 2].
Figure 2: Before treatment: Both vocal cord nodules

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  Therapeutic Intervention With Follow-Up and Outcome Top


On the basis of totality, individualisation, repertorial analysis and consultation with Materia Medica, Hepar sulphuricum was selected as similimum. On the first visit (11 April 2018), Hepar sulphuricum 30C was prescribed with four doses for two consecutive days. Homoeopathic medicines were procured from Hahnemann Publishing Company Pvt. Ltd. (Good Manufacturing Practice certified ISO 9001:2008 unit) and was dispensed from DACRRIH dispensary. Clinical follow-up of the patient was assessed fortnightly or as per requirement for 5 months. During follow-ups, the change in potency and repetitions of doses were done as per guidelines of the homoeopathic philosophy.[14],[15]

A detailed account of follow-up with prescription is shown in [Table 1].
Table 1: Timeline including follow-up of the case

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Hepar sulphuricum with raising potencies (30C, 200C and 1M) improved the presenting symptoms of VCNs, hoarseness of voice, voice fatigue and discomfort in the throat during talking with resolution of bilateral VCNs, which was confirmed by FOL on dated 24 September 2018 [Figure 3]. The other associated symptoms such as cough and tendency towards cold were also improved. Finally, his voice returned to normal with improvement in his quality of life and continuation of his teaching.
Figure 3: After treatment: Vocal cord nodules resolved

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The final outcome and possible causal attribution of the changes in this case were assessed using the 'modified Naranjo criteria' as proposed by the clinical data working group of the Homeopathic Pharmacopoeia of the United States.[16]


  Discussion Top


VCNs are localised, benign, callous-like masses, present on both folds and located within the lamina propria and represent a pathological condition for which the growth of unnatural masses on vocal folds affects the patients. More specifically, progressive hoarseness is the presenting symptom of all types of VC lesions that impairs communication or reduces voice-related quality of life. A number of studies have considered the association between voice disorders and a specific occupation group, for example, teacher and student which correlate this case report.[7],[17],[18]

With regard to management of VCNs, smaller nodules were managed conservatively by voice therapy, but larger ones required surgery and also post-operative care voice therapy equally plays a vital role for better prognosis which was more cost-effective.[19] According to the current literature, a substantial proportion of vocal polyps certainly tend to shrink after voice therapy, but regarding vocal nodules, no studies have investigated the effectiveness of voice therapy using proper experimental methodology. Evidence at present are, therefore, still insufficient to support the use of voice therapy for the treatment of benign vocal fold lesions and require surgery.[20]

There is no doubt that vocal nodules are a difficult condition to study and treat because the aetiology is not fully understood. The study suggested that patients with VCNs who showed no improvement after 6 weeks of voice therapy either subjectively or objectively were subjected to surgery.[21],[22] In this case report, the patient was in proper voice therapy by a speech therapist for near about 20 weeks, but there was no improvement in presenting symptoms of VCNs (hoarseness, voice fatigue and discomfort in the throat) and was advised for surgery.

Homoeopathy can take care of chronic problems in an individual, where surgery is otherwise advised. In previous study [23] and case studies,[24],[25] homoeopathic treatment had shown positive results on surgical cases such as breast lesions and benign squamous laryngeal papillomatosis. In this case, the patient was treated with single Homoeopathic medicine Hepar sulphuricum in increasing potencies (i.e. 30C, 200C and 1M), over a period of 5 months, which brought about the improvement and final resolution of it. Moreover, there was no recurrence of symptoms of VCNs till date (near about 8 months).

Hepar sulphuricum not only presented as a 1st-grade medicine under the rubric 'hoarseness of voice' in Kent's and Synthesis repertory, but also, it has been selected on the basis of holistic approach and individualisation of general symptoms. Hepar sulphuricum with 30C and 200C potencies improved the presenting symptoms of VCNs to some extent, but Hepar sulphuricum 1M completed the cure, i.e., the patient gained his normal voice with resolution of VCNs confirmed by laryngoscopy [Figure 3] on 24 September 2018.

In this case, the total outcome score, as per the modified Naranjo criteria was +9, which was close to the maximum score 13 [Table 2]. This explicitly shows the positive causal attribution of the individualised homoeopathic treatment towards this case of bilateral VCNs with associated symptoms.[16]
Table 2: Assessment of outcome with modified Naranjo algorithm

Click here to view


A study conducted by Verdolini et al., Nerriere et al. and Mattiske et al. found that voice disorders such as hoarseness of voice, vocal fatigue and discomfort or pain in the throat during speaking often arise in one's career as a teacher. This confirms that teaching is a profession with very high vocal demands. With proper individualised homoeopathic treatment, these problems can be solved.[26],[27],[28]

Strengths and limitations in approach to the case

Homoeopathy can take care of chronic problems in an individual, where surgery is otherwise advised. The, homoeopathic approach towards the VCNs is holistic, rather than restricted to the pathological problem. Proper diagnosis, voice therapy and individualised homoeopathic treatment has proven to be useful in the management of patients with VCNs. Individualised homoeopathic treatment has a positive effect in the resolution of VCNs with its presenting symptoms and also returns the voice to normal with improved quality of life. However, it is not possible to exclude the chances of recurrence of VCNs in future resulting from using the voice excessively.

Future perspectives

This case illustrates the improvement of a chronic problem like VCNs with hoarseness of voice, vocal fatigue and discomfort or pain in the throat during speaking. Homoeopathy should be considered before a surgical intervention. Well-designed research studies are required for establishing the effectiveness of Homoeopathy in treating VCNs with associated symptoms. A comparative study can be carried out to assess whether treatment results vary with individualised medicines or with specific medicines for a clinical condition.

Acknowledgements

The authors are grateful to Dr. D. B. Sarkar, Officer In-Charge, DACRRIH, Kolkata, for editing this case report and acknowledge the patient for his compliance in continued follow-ups.

Declaration of patient consent

The authors declare that they have obtained all appropriate patient consent forms. In the form, the patient has given written consent for his images and other clinical information to be reported in the journal. The patient understands that his name will not be published and due efforts will be made to conceal his identity.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

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2.
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Akif Kiliç M, Okur E, Yildirim I, Güzelsoy S. The prevalence of vocal fold nodules in school age children. Int J Pediatr Otorhinolaryngol 2004;68:409-12.  Back to cited text no. 4
    
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Bastian RW. Benign vocal fold mucosal disorders. Cummings Otolaryngol Head Neck Surg 2005;4:2150.  Back to cited text no. 5
    
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Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Description of laryngeal pathologies by age, sex, and occupation in a treatment-seeking sample. J Speech Hear Disord 1988;53:57-64.  Back to cited text no. 6
    
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8.
Won SJ, Kim RB, Kim JP, Park JJ, Kwon MS, Woo SH, et al. The prevalence and factors associate with vocal nodules in general population: Cross-sectional epidemiological study. Medicine (Baltimore) 2016;95:e4971.  Back to cited text no. 8
    
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Pedersen M, McGlashan J. Surgical versus non-surgical interventions for vocal cord nodules. Cochrane Database Syst Rev 2012;6:CD001934.  Back to cited text no. 9
    
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11.
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Shah J. Hompath Classic M.D Repertory. Ver. 1.0. Mumbai, India: Mind Technologies Pvt. Ltd.; 2002  Back to cited text no. 13
    
14.
Boericke W. Pocket Mannual of Homoeopathic Materia Medica & Reprertory. 50th Impression. New Delhi: B. Jain Publisher (P) Ltd.; 2010. p. 325-8.  Back to cited text no. 14
    
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16.
van Haselen RA. Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline. Complement Ther Med 2016;25:78-85.  Back to cited text no. 16
    
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Sapir S, Keidar A, Mathers-Schmidt B. Vocal attrition in teachers: Survey findings. Eur J Disord Commun 1993;28:177-85.  Back to cited text no. 17
    
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Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, et al. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1-31.  Back to cited text no. 18
    
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21.
Bakat B, Gupta A, Roy A, Roychoudhury A, Raychoudhury BK. Does voice therapy cure all vocal fold nodules. Int J Phonosurg Laryngol 2014;4:55-9. [DOI: 10.5005/jp-journals-10023-1083].  Back to cited text no. 21
    
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McCrory E. Voice therapy outcomes in vocal fold nodules: A retrospective audit. Int J Lang Commun Disord 2001;36 (Suppl):19_24.  Back to cited text no. 22
    
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Gupta G, Naveen G, Madhu C. Fibroadenoma of breast: A sonomammographical supported clinical study on the effect of homoeopathic drugs. Homoeopathy 2013;4:37-45.  Back to cited text no. 23
    
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25.
Nanda SK, Galagali JR, Guruprasad V. Thuja-in management of laryngeal papillomatosis. Med J Armed Forces India 2000;56:87.  Back to cited text no. 25
    
26.
Verdolini K, Ramig LO. Review: Occupational risks for voice problems. Logoped Phoniatr Vocol 2001;26:37-46.  Back to cited text no. 26
    
27.
Nerrière E, Vercambre MN, Gilbert F, Kovess-Masféty V. Voice disorders and mental health in teachers: A cross-sectional nationwide study. BMC Public Health 2009;9:370.  Back to cited text no. 27
    
28.
Mattiske JA, Oates JM, Greenwood KM. Vocal problems among teachers: A review of prevalence, causes, prevention, and treatment. J Voice 1998;12:489-99.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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