Laryngeal surgical treatment in transgender women: A systematic review and meta-analysis

Effects of Fundamental Frequency and Vocal Tract Resonance on Sentence Recognition in Noise

PURPOSE

This study examined the effects of change in a talker's sex-related acoustic properties (fundamental frequency [F0] and vocal tract resonance [VTR]) on speech recognition in noise.

METHOD

The stimuli were Hearing in Noise Test sentences, with the F0 and VTR of the original male talker manipulated into four conditions: low F0 and low VTR (LF0LVTR; i.e., the original recordings), low F0 and high VTR (LF0HVTR), high F0 and high VTR (HF0HVTR), and high F0 and low VTR (HF0LVTR). The listeners were 42 English-speaking, normal-hearing adults (21-31 years old). The sentences mixed with speech spectrum-shaped noise at various signal-to-noise ratios (i.e., -10, -5, 0, and +5 dB) were presented to the listeners for recognition.

RESULTS

The results revealed no significant differences between the HF0HVTR and LF0LVTR conditions in sentence recognition performance and the estimated speech reception thresholds (SRTs). However, in the HF0LVTR and LF0HVTR conditions, the recognition performance was reduced, and the listeners showed significantly higher SRTs relative to those in the HF0HVTR and LF0LVTR conditions.

CONCLUSION

These findings indicate that male and female voices with matched F0 and VTR (e.g., LF0LVTR and HF0HVTR) yield equivalent speech recognition in noise, whereas voices with mismatched F0 and VTR may reduce intelligibility in noisy environments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.29052305.

Mapping Procedures Used by Brazilian Speech-Language Pathologists in Vocal Assessment and Gender-Affirming Voice Therapy of Transgender Women

OBJECTIVE

To map the procedures used by Brazilian speech-language pathologists (SLPs) in vocal assessment and gender-affirming voice therapy of transgender women.

METHODS

The survey included 52 SLPs, with a mean age of 39.50 years, who worked with voice in Brazilewing method, vowel-only reading, and who had treated transgender women in the previous 12 months. They were recruited through social media and answered a digital form via Google Forms, with questions about their professional profile, the care provided to transgender women, and the procedures and strategies used in vocal assessment and gender-affirming voice therapy. Data were collected between August 2022 and March 2023.

RESULTS

Most SLPs were cisgender women specializing in voice, with a mean experience of 15.67 years. Transgender women seen by SLP were predominantly adults. Multidimensional vocal assessments are most common, but they do not necessarily include aerodynamic assessments. Gender-affirming voice therapy sessions were primarily individualized. The SLPs' most used therapeutic strategies were diaphagmatic-abdominal breathing, fricative sounds, tongue or lip trill, humming, resonance tube phonation in water-low resistance, chewing technique, jaw opening exercise, tongue mobility exercise, tongue rotation in the oral vestibule with humming, tongue snap with humming, yawn-sigh technique, auditory repetition, in-ear monitors, pitch and loudness modulation, overarticulation, chant speech, chewing method, vowel-only reading, guidance, awareness and proprioception, supportive approach, and vocal hygiene. There was good satisfaction among SLPs with the therapeutic strategies used in gender-affirming voice therapy, except for respiratory level, where satisfaction was average.

CONCLUSION

The most used assessment procedures, satisfaction, and therapeutic strategies are related to the main vocal characteristics that contribute to gender identification through the voice.

Update of Vocal Fold Shortening With Retrodisplacement of Anterior Commissure for Voice Feminization

OBJECTIVES

To assess the efficacy and long-term durability of the enhanced technique of Type II Vocal Fold Shortening and Retrodisplacement of the Anterior Commissure (VFSRAC) for voice feminization compared with the preceding Type I method.

METHODS

A retrospective analysis encompassed 506 patients drawn from a cohort of 1025 MtF transgender women who underwent VFSRAC between 2003 and 2021. The study period included cases from 2015 to 2021, during which the Type II update technique was implemented, involving a modification to the suture technique. Subjective and perceptual evaluations, aerodynamic and acoustic assessments, real-time pitch analysis, and videostroboscopic reviews were conducted pre- and postoperatively in the MtF transgender women cohort. Comparative statistical analyses were performed to discern differences between the earlier Type I method (2003-2014) and the more recent Type II method (2015-2021).

RESULTS

The preoperative mean speech fundamental frequency (sF0) for Type II VFSRAC was 134.5 Hz. Postoperatively, the mean sF0 increased to 196.7 Hz, 212.3 Hz, and 207.5 Hz at 3 months, 6 months, and beyond 1 year, respectively, exceeding outcomes observed with the Type I method. Postoperative subjective and objective assessments indicated an augmentation in voice femininity. Acoustic and aerodynamic indices were within the normal range, and the regularity of the vocal fold mucosal wave was preserved within normal parameters. These results suggest that patients achieved a natural phonation pattern after surgery.

CONCLUSIONS

The application of our updated type II VFSRAC has demonstrated feasibility and consistently yielded favorable results for individuals desiring a naturally feminine voice.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:5054-5061, 2024.

Comparison Between two Surgical Techniques for Increasing Vocal Pitch by Endoscopic Shortening of the Vocal Folds

OBJECTIVE

To compare two surgical techniques, the Wendler glottoplasty (GP) and its modification, the vocal fold shortening, and retrodisplacement of the anterior commissure (VFSRAC) associated with laser assisted voice adjustment (LAVA) cordotomy, used to feminize the voice of transgender women by increasing the fundamental frequency (F0).

METHODS

A retrospective study of 22 trans-women (20-62 years-old) was carried out. 12 of them were treated with GP and 10 with the VFSRAC+LAVA technique. They were evaluated before surgery and 6 months after surgery and the postoperative speech therapy. Laryngostroboscopy examination, F0 measurements, Transgender Woman Voice Questionnaire (TWVQ) assessment and the perceptual assessment using a visual analog scale (PA-VAS) were obtained from all patients.

RESULTS

Laryngostroboscopic findings showed normal vocal folds before surgery and a shortening of the vocal folds, due to the anterior glottic synechia, after surgery. Significant increases of F0 were found in both groups but they were higher in the VFSRAC+LAVA group (47.75Hz in GP group vs 69.70Hz in VFSRAC+LAVA group). TWVQ scores showed a significant decrease in both groups although the difference was greater in the VFSRAC+LAVA group. Similarly, PA-VAS scores lowered significantly in both groups but VFSRAC+LAVA group presented the biggest decreases.

CONCLUSION

Both surgical techniques produce the shortening of the vocal folds through an endoscopic approach and result in voices with higher vocal pitch. Of the two techniques presented, the VFSRAC+LAVA produces better results although when compared with previous studies it seems that the LAVA technique may not significantly contribute to the postoperative results. So, the VFSRAC technique followed by postoperative speech therapy could be recommended for trans-women who wish to feminize their voice.

Trans Woman Voice Questionnaire Scores Highlight Specific Benefits of Adjunctive Glottoplasty With Voice Therapy in Treating Voice Feminization

BACKGROUND

Treatment options to assist patients to produce a more perceptually feminine voice include voice therapy (VT) and surgeries to elevate pitch such as the Wendler glottoplasty (WG). The Trans Woman Voice Questionnaire (TWVQ) is a validated quality of life measure for trans women's self-reported perceptions of their voice and is frequently administered before and after such interventions. The 30 statements broadly pertain to how feminine a patient feels their voice is, how effortful it is to produce their voice, and how their voice impacts them psychosocially, making it a useful and specific outcome measure when treating trans females for voice concerns.

OBJECTIVE

To compare quality of life outcomes between VT and VT with adjunct WG (VT+WG) based on changes in ratings of individual statements on the TWVQ.

MATERIALS AND METHODS

A retrospective case series of 31 trans female patients treated was completed. A total of 17 patients underwent VT and 14 underwent VT with adjunctive WG. Ratings for each of the 30 TWVQ statements were compared before and after treatment for each group. Wilcoxon rank-sum tests were used to compare rating changes before and after treatment. Spearman rank-order correlation tests were used to assess the association between total TWVQ score and "current voice" rating.

RESULTS

WG was associated with statistically significantly improved ratings for every statement on the TWVQ except one. In contrast, VT was associated with statistically significant improvements in 16 of the 30 statements, which largely pertained to patient emotions surrounding their voice rather than physical aspects such as pitch and dysphonia. Furthermore, while both WG+VT and VT improved the "current voice" rating significantly, WG improved the score by nearly 1 unit more. Lastly, we found a positive association between the total TWVQ score and current voice rating, indicating that lower scores were associated with more self-perceived feminine-sounding voices (P < 0.01).

CONCLUSIONS

Both VT and VT+WG result in improvements in the TWVQ. The specific statements on the TWVQ offer insight into specific quality of life treatment outcomes, with VT associated with improvements in mostly psychosocial aspects of voice production and VT+WG with both psychosocial and physical aspects.

Vocal Outcomes Following Pitch Alteration Surgeries

Our study aims to ascertain the results of speech therapy and surgery in patients who desire pitch alteration. Typically, patients desirous of an increase in their vocal pitch are male-to-female transpersons, and patients desirous of a drop in their pitch are puberphonia patients. This is a 3-year retrospective study of patients who have been operated for pitch alteration. This is a study of seven patients each of Wendlers glottoplasty (WG) and relaxation laryngeal framework surgery (RLFS). The records were reviewed for the preoperative and the 1-year post-operative fundamental frequency (FO), patient subjective satisfaction score (PSSS), and healing time. A total of 7/35 patients of puberphonia underwent RLFS in which the average preoperative F0 was 216 Hz and 1-year post-operative F0 was 114 Hz (p 0.004). The average pre- and post-operative PSSS was 4 and 9 (p 0.0004). Patients of WG had an average preoperative F0 of 153 Hz and 1-year post-operative F0 of 223 Hz (p 0.0005). The average pre and 1-year postoperative PSSS was 4 and 8 (p 0.002). The average healing time was 3 weeks 4 days in the RLFS patients and 8 weeks 5 days for WG patients. The results of RFLS yielded a high PSSS with a pitch drop of more than 100 Hz. The results of WG yielded an increase in the pitch of 70 Hz with a good PSSS. The average healing time taken following WG was double the time taken for RFLS.

1-Year Results of Combined Modified Wendler Glottoplasty with Voice Therapy in Transgender Women

BACKGROUND

To date, 1-year evaluation of pitch elevation in patients undergoing modified Wendler glottoplasty (WG) in combination with VT has not been assessed.

OBJECTIVES

To determine whether 1-year pitch elevation is sustained in patients who undergo modified WG in combination with VT for voice feminization.

METHODS

A retrospective review of patients who underwent WG in combination with voice therapy (VT) was performed from 2016 to 2020. Charts were reviewed for sustained vowel fundamental frequency (F0/a/), speaking fundamental frequency (SF0), and Trans Woman Voice Questionnaire (TWVQ) at preoperative, initial postoperative (3-6 months after surgery), and 12-month postoperative visits.

RESULTS

Change in average F0/a/, SF0 and TWVQ was 50.25 Hz, 32.96 Hz, and 32.6 at 12-months postoperatively compared to preoperative values. Initial and 12-month postoperative SF0 were significantly higher than preoperative SF0 (Mann-Whitney U test p = 0.0042, p = 0.0010). There was no difference in initial postoperative and 12-month postoperative SF0 (p = 0.50). TWVQ at 12 months was significantly lower than preoperative TWVQ (ANOVA p < 0.001, Tukey honestly significant difference HSD p < 0.05).

CONCLUSIONS

Pitch elevation remains sustained at one year in patients undergoing modified WG in combination with VT. Modified Wendler glottoplasty combined with VT results in relatively long-term improvements in voice-related quality of life and is possibly a beneficial addition in the long-term management of patients who desire voice feminization.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:615-620, 2023.

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention

The purpose of this article is to provide an overview of the current state and available evidence surrounding surgical voice care for the transgender and/or gender expansive population. The term "gender expansive" has been proposed as an inclusive term to classify those who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience. We aim to review indications and candidacy for surgery, surgical procedure options for altering vocal pitch, and typical postoperative expectations. The role of voice therapy and considerations for perioperative care will also be discussed.

Novel Use of Feminization Laryngoplasty

INTRODUCTION

Wendler glottoplasty is a voice feminization surgical procedure designed to increase the fundamental frequency (F0) in male-to-female transsexual patients with gender dysphoria. On average, Wendler glottoplasty has the most significant effect on F0 among voice feminization surgical procedures.

CASE REPORT

We present the case of a young female patient with a testosterone-producing adrenocortical adenoma who underwent irreversible vocal changes secondary to virilization, which impacted her self-esteem and quality of life (QOL). Voice feminization surgery using Wendler glottoplasty was performed with significant improvement in F0 and QOL.

DISCUSSION

Sex hormones have a profound impact on the voice. Increased testosterone and dihydrotestosterone are known to cause hypertrophy of the laryngeal muscles and ligaments, which leads to a drop in F0. However, women who present androphonia rarely require surgical management and improve with vocal therapy alone. Few cases of voice feminization procedures for the treatment of androphonia have been described in the literature. Our patient presented with severe masculinization of her voice with a F0 lower than the average adolescent male, which led to the requirement of surgical management.

CONCLUSIONS

Patients with severe androphonia that significantly affect their QOL and show no improvement after the management of the underlying pathology and intense vocal therapy are candidates for voice feminization surgeries. These procedures offer positive results both in terms of F0 and in improving patient's self-esteem and QOL.

Voice and Speech Training for the Transgendered Patient: What the Otolaryngologist Should Know

Vocal dysphoria is present for many transgender individuals. Voice goals are defined by each individual client. Voice modification work can be challenging for both clinicians and clients, involving both direct and indirect aspects of intervention. The latter are likely to be less known to otolaryngologists but can form a significant part of clinical practice for experienced speech pathologists. Varying experience levels of treating clinicians can in turn have a bearing on the vocal outcomes achieved by clients. Those who do seek surgical assistance benefit from appropriate presurgery speech and language therapy evaluation and postsurgical voice rehabilitation and treatment.

Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique

OBJECTIVES

Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period.

STUDY DESIGN

Level III, retrospective study and description of technique.

SETTING

A single-institution transfeminine voice clinic.

METHODS

Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented.

RESULTS

The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up.

CONCLUSION

FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

Vocal Tradeoffs in Anterior Glottoplasty for Voice Feminization

OBJECTIVES/HYPOTHESIS

Anterior (Wendler) glottoplasty has become a popular surgery for voice feminization. However, there has been some discrepancy between its theoretical pitch-raising potential and what is actually achievable, and downsides to shortening the glottis have not been fully explored. In addition, descriptions of the surgery are inconsistent in their treatment of the vocal ligament. This study aimed to determine 1) how fundamental frequency (f_o ) is expected to vary with length of anterior glottic fixation, 2) the impact of glottic shortening on sound pressure level (SPL), and 3) the effect of including the ligament in fixation.

STUDY DESIGN

Computational simulation.

METHODS

Voice production was simulated in a fiber-gel finite element computational model using canonical male vocal fold geometry incorporating a three-layer vocal fold composition (superficial lamina propria, vocal ligament, and thyroarytenoid muscle). Progressive anterior glottic fixation (0, 1/8, 2/8, 3/8, etc. up to 7/8 of membranous vocal fold length) was simulated. Outcome measures were f_o , SPL, and glottal flow waveforms.

RESULTS

f_o increased from 110 Hz to 164 Hz when the anterior one-half vocal fold was fixed and continued to progressively rise with further fixation. SPL progressively decreased beyond 1/8 to 1/4 fixation. Inclusion of the vocal ligament in fixation did not further increase f_o . Any fixation increased aperiodicity in the acoustic signal.

CONCLUSIONS

The optimal length of fixation is a compromise between pitch elevation and reduction in output acoustic power. The simulation also provided a potential explanation for vocal roughness that is sometimes noted after anterior glottoplasty.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1081-1087, 2021.

Unexpected difficult airway management in a transgender female patient

A transgender female patient, who had previously undergone gender-confirming feminisation surgery to the face and larynx, was scheduled for thoracic surgery requiring one-lung ventilation. We encountered unexpected difficult airway management and difficulty inserting an appropriately-sized double-lumen tube. A size 41Fr double-lumen tube, which is selected commonly for biological males, was used eventually for lung isolation and subsequently exchanged for a size 6.5 single-lumen tracheal tube at the end of the case, before successful extubation with a staged extubation set. It is important to highlight the challenges faced, as the care of transgender patients is likely to be unfamiliar to most anaesthetists, despite the increase in the number of gender-confirming procedures performed. Many of these procedures involve the face and airway and can result in significant challenges for airway management, including appropriate sizing of tracheal tubes and their correct placement. It is also possible that patients may not volunteer a history of these procedures and it should be enquired about specifically as part of the anaesthetic pre-assessment.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Endocrinology of Transgender Medicine

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Intervención logopédica en la feminización de la voz en transexuales: revisión bibliográfica

La transexualidad es un trastorno en el cual entran en conflicto el sexo fisiológico y el género de una persona. Las personas transexuales sienten el deseo de pertenecer al sexo con el que realmente se identifican y esto les lleva a realizar ciertas acciones para cambiar su apariencia. La mujer transexual no alcanzará la feminización de su voz mediante el tratamiento hormonal, siendo sus opciones: la cirugía de las cuerdas vocales y/o la intervención logopédica.La presente revisión bibliográfica tiene como objetivo exponer aspectos relevantes y proporcionar información amplia sobre el trabajo logopédico en el tratamiento de la feminización de la voz, en transexuales de hombre a mujer, como intervención única, no complementaria a la intervención quirúrgica. Para llevar a cabo una revisión bibliográfica descriptiva se realiza la búsqueda de artículos científicos en las fuentes secundarias PubMed y Scopus. Utilizando una metodología cualitativa, se obtiene un listado de 25 artículos, en cada una, que se acota con filtros y criterios de inclusión y exclusión, dando como resultado una lista de 7 artículos finales. En cuanto a los resultados, todos los artículos concluyen con resultados positivos de la terapia vocal en mujeres transexuales, destacando especialmente los objetivos relativos al aumento de la frecuencia fundamental y al aumento de las frecuencias formantes.En conclusión, se halla información que demuestra que la terapia logopédica puede ser eficaz en la feminización de la voz en la población transexual. Sin embargo, el escaso número de artículos impide hacer generalizaciones universales.