Predictors of poor response to voice therapy in adult vocal fold nodules: a retrospective cohort study

Abstract

Purpose To identify predictors of poor response to standardized voice therapy in adult vocal fold nodules and to evaluate recurrence risk across treatment pathways. Methods We retrospectively reviewed 107 adults with vocal fold nodules treated between 2020 and 2024. Patients were categorized as: (i) voice therapy alone, (ii) delayed surgery after failed therapy, or (iii) primary surgery. Demographics, stroboscopic findings, acoustic and aerodynamic parameters, patient-reported outcomes (Voice Handicap Index-10, Vocal Fatigue Index), and clinician-rated perceptual evaluation (GRBAS) were analyzed. Therapy failure and recurrence were defined according to prespecified clinical criteria. Results Voice therapy was effective in 41/48 patients (85.4%). Compared with Group A, patients proceeding to delayed surgery had longer symptom duration, more professional voice use, and higher baseline shimmer and perceptual strain; 23/25 (92.0%) improved after surgery. Primary surgery patients had worse baseline measures; 30/34 (88.2%) improved but recurrence was higher (26.5%) than in delayed surgery (8.0%) or therapy alone (4.2%). On multivariable analysis, shimmer and VFI independently predicted therapy failure, while shimmer and GRBAS strain independently predicted recurrence. Conclusion Structured voice therapy remains first-line management. Elevated shimmer, perceptual strain, and high VFI identify patients at risk of failing conservative care and may justify earlier surgical consideration; professional voice use and longer symptom duration were associated on univariable analyses. Integrating objective acoustic and patient-reported measures can guide individualized decisions and clarify surgical indications.