The human vocal folds are uniquely structured to withstand repeated stresses associated with phonation. For example, vocal fold microscopic anatomy is layered and complex, potentially offering protection from injury and facilitating the ongoing repair of subclinical microtrauma. Recent advances in the areas of vocal fold cellular and molecular components, as well as excised larynx work, have begun to reveal the nature of vocal fold tissue stresses during phonation and the pathophysiologic basis for benign laryngeal lesions. This review focuses on the emerging view of vocal nodules as a response to recurring mechanical trauma that disrupts the basement membrane zone and superficial lamina propria. Also reviewed is the preferred treatment for vocal nodules: voice therapy that alters speaking habits from those that contribute to microtrauma and protects both the basement membrane zone and underlying lamina propria from further recurring damage. In the future, more complete understanding about matrix constituents in the lamina propria and basement membrane may lead to better restorative or preventive therapies.
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