Follow-up Trends in Patients Undergoing Modified Wendler Glottoplasty.

OBJECTIVES: After modified Wendler glottoplasty (mWG), close follow-up with laryngologist and speech-language pathologist (SLP) is thought to be essential to achieve best outcomes. This study presents a case series of patients undergoing mWG at a single institution to identify factors associated with trends in post-operative follow-up. METHODS: Retrospective review of trans women patients who underwent mWG between March 2018 and July 2023 was performed. Demographic data, pre-operative care, and post-operative course were reviewed. Lost to follow-up (LTFU) was defined as a failure to return to the office or schedule a follow-up appointment as recommended, for ≥2 months after last visit. Logistic regressions were utilized to identify possible factors associated with being LTFU. RESULTS: Eight (50%) of 16 patients met LTFU criteria. Patients were considered not LTFU if they completed care (n = 3, 19%) or were still undergoing care (n = 5, 31%). Patients with chronic diseases were less likely to become LTFU (p = 0.03). Those lost to follow-up had more no-show visits (p = 0.04). Total number of gender-affirming surgeries, distance from hospital, socioeconomic status of residential zip code, race/ethnicity, other psychological history, and patient-reported outcome measure scores did not affect LTFU rates. CONCLUSION: Fifty percent of patients were LTFU after modified Wendler glottoplasty. Even one no-show visit increased risk of being LTFU, whereas the presence of chronic diseases was protective against this. This study illustrates that increased efforts are needed following mWG to better understand the factors associated with being LTFU and to facilitate patients' ability to complete post-operative care successfully. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

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, 2024.

Psychiatric Diagnoses and Psychotropic Drug Usage in Gender-Affirming Voice Surgery Patients.

OBJECTIVES: To describe the burden of psychiatric illness and psychotropic medication usage among the subset of transgender patients who undergo gender-affirming laryngeal surgery and describe some of the most commonly encountered conditions experienced by this population. METHODS: An Institutional Review Board-approved chart review was conducted for the 18 patients who have undergone gender-affirming laryngeal procedures from August 2019 to June 2022 performed at a single institution. Patient demographic data, treatment details, and psychiatric diagnoses and prescriptions for psychotropic medications were recorded. RESULTS: Of the 18 patients who underwent gender-affirming laryngeal surgery at this institution, 16 patients underwent these operations as part of a transition from male to female gender, while 2 patients were transitioning from female to male gender. In this cohort, 13 patients were diagnosed with a psychiatric comorbidity (72.2%). Of these patients, 11 were prescribed at least 1 psychotropic medication (61.1%). The most common psychiatric illnesses encountered in these patients were depression, anxiety, and post-traumatic stress disorder. Ten patients were diagnosed with more than 1 psychiatric comorbidity (55.6%). The most commonly prescribed psychotropic drugs were selective serotonin/norepinephrine reuptake inhibitors. Three patients in this cohort had a recorded history of at least one prior suicide attempt. CONCLUSIONS: Multiple studies have demonstrated increased rates of mental illness in transgender individuals, however, this is the first study to describe the burden of these conditions specifically in the subset of patients who undergo gender-affirming laryngeal surgery.

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.

Gender-Affirming Voice Modification for Transgender Women: Characteristics and Outcomes.

Objective: The primary aim of this study was to define characteristics of transgender women seeking gender-affirming voice modification at our voice center. The secondary aim was to evaluate outcome measures, comparing (a) behavioral voice training alone, (b) surgery alone, and (c) combination of behavioral voice training+surgery. Methods: Patients seen in a 30-month period, who sought care for gender-affirming voice modification, were included if they were assigned male at birth and identified as female. Patient demographic information, patient quality of life index scores, Trans Woman Voice Questionnaire (TWVQ), and acoustic data were collected before and after intervention. Results: Sixteen patients met inclusion criteria. The majority of patients were (a) undergoing hormone replacement therapy at initiation of treatment, (b) were presenting in public for over 2 years as female, and (c) had a history of psychological disorders (i.e., gender dysphoria, anxiety, depression, and attention deficit hyperactivity disorder [ADHD]). Increased f0 and decreased TWVQ scores were evident and statistically significant within behavioral voice training cohort and behavioral voice training+surgery cohort. Treatment groups appear similar with respect to average changes; pre- and post-data were not available for surgery only patients. Greater change in f0 was directly correlated with increased number of voice training sessions. Conclusion: There is variability in treatment course for patients seeking gender-affirming voice modification; however, treatment type may not impact outcomes. Increased patient quality of life and increased speaking fundamental frequency were found in this patient cohort.

Assessing the concern for airway complications introduced by Wendler's glottoplasty.

Objective: Wendler's glottoplasty (WG) is a pitch-elevating surgery performed by laryngologists providing gender-affirming care. The surgery creates an anterior glottic web that could theoretically cause airway concerns, either perioperatively or at the time of future procedures; such concerns are not well-described in the literature. We seek to assess surgeon opinions on airway concerns regarding WG. Method: A survey of laryngologists assessing opinions on airway considerations in glottoplasty. Results: A total of 19 physicians responded, representing approximately 193 surgeries. 52.6% performed glottoplasty and the remainder responded based on experience with anterior glottic webs. Two perioperative airway complications were reported, both mild stridor that did not prevent same-day discharge. No long-term sequela was reported. All surveyed laryngologists endorsed an altered general anesthetic approach for future procedures, with 73.7% advocating for use of a smaller endotracheal tube. 72.2% did not have "major concerns" about future intubations, and only 5.3% thought the immediate risk of airway compromise was a "real concern." 91.9% counsel their patients routinely but briefly on airway concerns. Open-ended comments conveyed themes of concern for post-operative disruption of the web more than of airway compromise. Conclusion: Because glottoplasty is performed in the anterior glottis and does not significantly impact airway patency, the risk of serious airway complications appears to be minimal. Laryngologists believe future intubations require a modified approach with a smaller tube, partly due to concern for glottic web trauma. Based on this pilot study, the topic deserves greater work to standardize care and anesthetic alterations for patients with WG. Level of Evidence: 5.

Modification of Wendler Glottoplasty for Male to Female Gender Transition.

INTRODUCTION: Transgenderism is a condition regarding the gender identity of an individual where their psychological gender is discordant with their anatomic gender. For patients transitioning from Male to Female, voice changes are created predominantly with voice therapy, with vocal surgery as an adjunct if the patient desires it. A common surgical technique is the Wendler Glottoplasty. A CO2 laser is used to de-epithelialize the anterior third of the vocal folds and the anterior one-third of the folds are sutured together. This shortens the vibratory folds and increases the fundamental frequency (F0) of the voice. We present a novel modification that incorporates use of injectable aqueous carboxy-methyl-cellulose gel (Prolaryn) to medialize the anterior aspect of the vocal folds and apply fibrin glue sealant (Tisseal) in lieu of sutures, simplifying the operative technique and a thyroarytenoid myectomy for debulking of the cords in select cases. METHOD: We present ten patients treated with our modified Wendler Glottoplasty technique. Voice assessment was based on F0 and frequency range pre and post-operatively measured via MDVP and Real-Time Pitch on the Computerized Speech Lab. RESULTS: The 10 patients had an average age of 34.0 years (range 22.2-64.3 years). The average preoperative F0 was 136.1 Hz, with an average frequency range of 108.3-282.4 Hz. Postoperatively, the average F0 was 245.9 Hz, with an average frequency range of 197.3-300.7 Hz. This led to an average F0 increase of 106.3 Hz. CONCLUSION: Our modification to the Wendler Glottoplasty successfully resulted in a significant increase in the postoperative F0. In addition, there was improved satisfaction in vocal character after the procedure, compared to their preoperative vocal character.

Voice Outcome of Glottoplasty in Trans Women.

PURPOSE: This study investigates the short- and longer-term effects of glottoplasty up to six months after surgery on acoustic voice parameters, listener perceptions, and client's satisfaction in trans women. Secondly, the impact of chondrolaryngoplasty and voice therapy on the glottopasty outcomes was investigated. METHOD: A prospective longitudinal non-controlled trial was used. Thirty-five trans women undergoing glottoplasty or a combination of glottopasty and chondrolaryngoplasty were included in this study. A voice assessment was conducted before surgery and 1 week, 1 month and 6 months after surgery. The following outcome parameters were measured: fundamental frequency (fo), intensity, frequency and intensity range, Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI), Voice Handicap Index (VHI), Trans Woman Voice Questionnaire (TWVQ), and visual analogue scales (VAS) measuring client's satisfaction. Listener perceptions of masculinity-femininity were collected using a listening experiment. RESULTS: Significant differences over time were found for all fo and intensity parameters, DSI, AVQI, VHI and TWVQ scores. Listener perception and self-perception of femininity was higher after surgery. Significant differences in evolution of listener perceptions were found between the groups with and without voice therapy. CONCLUSION: Glottoplasty improves voice related quality of life and is an effective method to increase the fo and associated perceptual femininity. After glottoplasty an immediate and short-term decrease in voice quality, vocal capacity and frequency range was measured with a progressive recovery on the longer term. Long term side effects of glottoplasty are a reduction in speaking intensity and intensity range. Voice therapy seems to improve the outcomes of glottoplasty, but should be further investigated in future studies.

Effect of Wendler glottoplasty on voice and quality of life of transgender women.

OBJECTIVE: To investigate the effect of Wendler glottoplasty on voice feminization, voice quality and voice-related quality of life. METHODS: Prospective interventional cohort of transgender women submitted to Wendler glottoplasty. Acoustic analysis of the voice included assessment of fundamental frequency, maximum phonation time formant frequencies (F1 and F2), frequency range, jitter and shimmer. Voice quality was blindly assessed through GRBAS scale. Voice-related quality of life was measured using the Trans Woman Voice Questionnaire and the self-perceived femininity of the voice. RESULTS: A total of 7 patients were included. The mean age was 35.4 years, and the mean postoperative follow-up time was 13.7 months. There was a mean increase of 47.9 ±â€¯46.6 Hz (p = 0.023) in sustained/e/F0 and a mean increase of 24.6 ±â€¯27.5 Hz (p = 0.029) in speaking F0 after glottoplasty. There was no statistical significance in the pre- and postoperative comparison of maximum phonation time, formant frequencies, frequency range, jitter, shimmer, and grade, roughness, breathiness, asthenia, and strain scale. Trans Woman Voice Questionnaire decreased following surgery from 98.3 ±â€¯9.2 to 54.1 ±â€¯25.0 (p = 0.007) and mean self-perceived femininity of the voice increased from 2.8 ±â€¯1.8 to 7.7 ±â€¯2.4 (p = 0.008). One patient (14%) presented a postoperative granuloma and there was 1 (14%) premature suture dehiscence. CONCLUSION: Glottoplasty is safe and effective for feminizing the voice of transgender women. There was an increase in fundamental frequency, without aggravating other acoustic parameters or voice quality. Voice-related quality of life improved after surgery.

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.

Effect of Wendler glottoplasty on voice and quality of life of transgender women

Abstract Objective: To investigate the effect of Wendler glottoplasty on voice feminization, voice quality and voice-related quality of life. Methods: Prospective interventional cohort of transgender women submitted to Wendler glottoplasty. Acoustic analysis of the voice included assessment of fundamental frequency, maximum phonation time formant frequencies (F1 and F2), frequency range, jitter and shimmer. Voice quality was blindly assessed through GRBAS scale. Voice-related quality of life was measured using the Trans Woman Voice Questionnaire and the self-perceived femininity of the voice. Results: A total of 7 patients were included. The mean age was 35.4 years, and the mean postoperative follow-up time was 13.7 months. There was a mean increase of 47.9 ± 46.6 Hz (p = 0.023) in sustained/e/F0 and a mean increase of 24.6 ± 27.5 Hz (p = 0.029) in speaking F0 after glottoplasty. There was no statistical significance in the pre- and postoperative comparison of maximum phonation time, formant frequencies, frequency range, jitter, shimmer, and grade, roughness, breathiness, asthenia, and strain scale. Trans Woman Voice Questionnaire decreased following surgery from 98.3 ± 9.2 to 54.1 ± 25.0 (p = 0.007) and mean self-perceived femininity of the voice increased from 2.8 ± 1.8 to 7.7 ± 2.4 (p = 0.008). One patient (14%) presented a postoperative granuloma and there was 1 (14%) premature suture dehiscence. Conclusion: Glottoplasty is safe and effective for feminizing the voice of transgender women. There was an increase in fundamental frequency, without aggravating other acoustic parameters or voice quality. Voice-related quality of life improved after surgery.

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.

Anterior glottoplasty: the effect of inclusion of the vocal fold lamina propria to frequency elevation.

BACKGROUND: Anterior glottoplasty is a commonly used treatment for voice feminization. But it remains in dispute over whether to suture of the ligament as part of the procedure. OBJECTIVES: This study aimed to explore the effect of inclusion of the vocal lamina propia. MATERIAL AND METHODS: Anterior webs were created in 8 excised canine larynges by sutures placed at 10%, 20%, and 30% of the vocal fold length, respectively. The suture depth was divided into two groups: epithelium layer (Shallow Suture, SS group) and deep layers of vocal fold lamina propia (Deep Suture, DS group). RESULTS: For anterior webs between 0% and 30%, the frequency elevation ranged from 3% to 151% of the pre-web fundamental frequency (fo) in SS group and from 13% to 222% in DS group. No significance was found between two groups at three different sutures (p = .486 for suture at 10% of vocal fold length, 0.686 for 20%, 0.886 for 30%, respectively). CONCLUSIONS AND SIGNIFICANCE: The frequency in excised canine larynx increased continuously as the anterior glottic webs ranged from 0% to 30%. The inclusion of the vocal fold lamina propia does not affect the frequency elevation.

Changes in Breathing Patterns after Surgery in Severe Laryngomalacia.

BACKGROUND: Most of the studies regarding the surgical treatment of severe laryngomalacia (LM) have been aimed at describing the efficacy of the treatment in terms of improvement of clinical symptoms or anatomical findings. There are no studies specifically aimed at analyzing the changes in breathing patterns following surgical treatment for severe LM. OBJECTIVE: To review the breathing pattern changes before and after corrective surgery in infants with severe LM. STUDY DESIGN: A series of retrospective cases at a tertiary referral children's hospital. METHODS: Retrospective chart review of 81 infants who underwent supra-glottoplasty (SGP) for severe laryngomalacia between 2011 and 2020 at Bambino Gesù Children's Hospital of Rome, Italy. Among the patients, 47 (58%) were male and 34 (42%) were female. Twenty-one patients (26%) had one or more comorbidities condition. The data collected included age, symptoms, a polysomnography/pulse oximetry study, growth rate, the findings from flexible endoscopy, pre- and post-supra-glottoplasty (SGP) pulmonary function tests (PFTs) and, when indicated, 24 h pH-metry. Breathing patterns were studied during restful, normal sleep, using an ultrasonic flow-meter (Exhalyzer, Viasys) which measured: Tidal Volume (Vt), Respiratory Rate (RR), time to peak expiratory flow/expiratory time ratio (tPTEF/Te, an index of the patency of the lower airways) and mean expiratory/mean inspiratory flow ratio (MEF/MIF, an index of the patency of the upper airways) evaluated before surgical procedure (T1) and 3-6 weeks after (T2). Pre- and post-operative mean data were calculated and comparisons made with a Student T-test. RESULTS: The surgical procedure was well tolerated by all infants and no intraoperative or post-operatory long-term complications were noted. In T1, breathing patterns were characterized by low tidal volume and high tPTEF/Te and MEF/MIF ratios, suggesting a severe reduction in the patency of the upper airways in all patients. After surgery (T2), all the previously mentioned variables significantly improved, reaching normal values for the child's age. CONCLUSIONS: Supra-glottoplasty, as already described in several studies, is a safe and efficient procedure to treat severe laryngomalacia during infancy. The improvement in breathing patterns after surgery was reliably confirmed by a lung function test in our study, which showed the diagnostic value of testing respiratory functionality in the laryngomalacia and comparing them to clinical and endoscopic data. Moreover, considering the results obtained, we also propose the use of this available, dependable test to verify its therapeutic effects (post-surgery) and to monitor future respiratory development in these infants. Moreover, we believe that further studies will provide detailed grading guidelines for gravity of the LM, based on these functional lung tests.

Predictive Factors Affecting the Outcomes Of angiolytic Laser-Assisted Glottoplasty for Sulcus Vocalis.

OBJECTIVE: Glottoplasty using an angiolytic laser is an option for the surgical treatment of sulcus vocalis. In this study, we sought to evaluate the clinical outcomes of using a 532-nm diode laser in sulcus vocalis patients and to identify predictive factors of improved voice outcomes after angiolytic laser-assisted glottoplasty. METHODS: A total of 66 patients with sulcus vocalis who underwent laser-assisted glottoplasty with a 532-nm diode laser were included in this study. RESULTS: 3 months after surgery, GRBAS scores, patient-reported outcome measures, fundamental frequency (F0), jitter percent, and noise-to-harmonic ratio decreased significantly, while cepstral peak prominence (CPP) of vowel and sentence production increased. Patients with auditory-perceptual improvements showed greater improvement in the Voice Handicap Index (VHI) scores, F0, and CPP of vowel and sentence production compared to those with no improvement. While young male patients with preoperatively high F0 were predicted to have favorable outcomes, the type of sulcus vocalis was not predictive of treatment outcomes. Patients treated with lower laser power showed better improvement in the VHI scores postoperatively than those who received higher laser power per vocal fold. Combined injection laryngoplasty with laser glottoplasty was effective in lowering the F0, especially in male patients with high F0. CONCLUSION: A 532-nm diode laser is useful for treating sulcus vocalis. Young male patients and individuals with preoperatively high F0 showed better voice outcomes after laser glottoplasty. Laser power and combined injection laryngoplasty are considered to affect improvement in the VHI and lowering F0 after laser glottoplasty in sulcus vocalis.

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.

Effect of Wendler Glottoplasty on Acoustic Measures of Voice.

OBJECTIVES: Voice therapy has been the primary treatment for voice feminization in transfemale patients due to concerns that surgery worsens voice quality. We aim to determine the impact of Wendler glottoplasty on acoustic measures of voice. STUDY DESIGN: Retrospective case series. METHODS: Transgender female patients treated for vocal feminization with Wendler glottoplasty at a single tertiary care center were identified. Pre- and postoperative measures were taken with the Kay Elemetrics Real-Time Pitch, Analysis of Dysphonia in Speech and Voice, and Multidimensional Voice Program. RESULTS: Twenty-eight patients were included in this study. There were no statistically significant changes in fundamental frequency variation, peak amplitude variation, soft phonation index, noise-to-harmonics ratio, cepstral peak prominence, or cepstral spectral index of dysphonia at a significance level of P < .05. Average speaking fundamental frequency (SF0) increased from 143 Hz after voice therapy to 163 Hz after surgery (P = .0009). Lower range decreased in 61% and increased in 26% of patients. Upper range decreased in 52% and increased in 48% of patients. CONCLUSIONS: Wendler glottoplasty does not worsen voice quality based on acoustic measures. Although most patients experience an increase in average SF0, effects on vocal range are variable with approximately half of patients experiencing a reduction and half experiencing an increase in upper pitch limit. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:583-586, 2021.

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 (fo ) 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 fo , SPL, and glottal flow waveforms. RESULTS: fo 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 fo . 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.

Applying concurrent multidisciplinary care to gender affirmation in transgender women: A case series.

Gender affirmation surgeries, though important for many transgender persons, can be numerous. Combining surgeries, as presented in this case series, affords many benefits to patients without increasing risk or complications.

An ex vivo porcine model of the anterior glottoplasty for voice feminization surgery.

OBJECTIVE: Perceived gender identity is correctly assigned when a combination of physical and vocal attributes become congruent. Several voice feminization procedures have gained popularity, but current evidence of their impact on vocal feminization is limited to case series. This study establishes an ex vivo porcine phonatory model to evaluate the ideal extent of anterior glottic web formation in relation to frequency elevation and airway patency. METHODS: Six fresh porcine larynges were obtained and fitted with arytenoid adduction sutures. Compressed air was passed through the larynges, and the vocal folds were adducted to induce phonation. Vocal fold length, posterior glottic width, fundamental frequency, and sound pressure intensity were measured as the vocal folds were progressively shortened as per the anterior glottic web surgical technique. RESULTS: The average fundamental frequency prior to web formation was 109.7 Hz. The maximum frequency achieved after web formation was 403.7 Hz, and the web proportions varied from 11.8% to 61.0% of the length of the membranous vocal folds. The glottic cross-sectional area showed an expected inverse linear relationship to the length of the glottic web. Creation of an anterior glottic web caused consistent elevation of pitch, but there was a gradual plateau of effect with increased length of the web. CONCLUSION: The ex vivo porcine larynx is demonstrated as an effective, available, and low-cost model for further study of vocal pitch elevation surgical techniques. We demonstrate that in addition to progressively reducing the cross-sectional area of the airway, additional benefit from increased web length is limited. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E206-E212, 2020.