Pathogenesis of vocal fold nodules: new insights from a modelling approach.

OBJECTIVE To give new insights into the pathogenesis of vocal fold nodules: (a) why the female/male ratio is so extreme, (b) how an hourglass-shaped vibration pattern - eliciting a localized microtrauma - originates, and (c) what the roles of muscular tension imbalance and of behavioral aspects are. MATERIALS AND METHODS Simulations with a 3-dimensional computer model of the vibrating vocal folds. RESULTS AND CONCLUSION (1) A slightly incomplete dorsal vocal fold adduction is a first condition for inducing an hourglass vibration pattern. (2) A limited collision zone is only possible with a small degree of curving of the rest position of the vocal fold edges in their ventral portion. This is an anatomical characteristic of the adult female larynx. Muscular fatigue and resulting hypotonia seem to enhance this curving. (3) If both these conditions are fulfilled, a sufficient vibration amplitude is required to achieve a localized impact. (4) This third condition can be obtained by an increased subglottal pressure and/or by a decrease in active stress of the tension forces between the neighboring vocalis masses. These last aspects incorporate muscular tension imbalance (dyskinesia) and behavioral aspects in the modelling process. Decrease in active stress is a possible effect of fatigue, and increase in subglottal pressure a result of effort compensation.