Pitch altering surgeries: Cricothyroid approximation

• Definition
• Indications
• Alternatives
• Presurgery
• Risks
• Procedure
• Recovery
• Instructions during healing
• Benefits

The following is typical for my patients. There certainly are regional and individual surgeon variations in style.

Definition

Cricothyroid approximation is a procedure designed to mimic the function of one set of your vocal muscles, the cricothyroids. This pair of muscles is one of the main groups of muscles that raises your pitch. They are the group that puts your voice up into falsetto. When they are relaxed your pitch is lower or in the chest register.

Indications

The surgery is for patients whose voice pitch is consistently interpreted as male, despite concerted efforts at altering pitch. For instance, patients who are perceived as males when on the telephone.

Pre and post-operative voice practice and therapy is essential as the surgery only truncates the lowest pitches, it does not change speech patterns, intensity, resonance or inflection characteristics of the male voice into a female pattern.

In fact, your original voice in falsetto will sound the same after surgery as before surgery. The surgery prevents or limits dropping back down into the chest voice but doesn’t alter the quality of the falsetto voice. The surgery then doesn’t change the voice, it limits it. This can be a desirable limitation by relieving the effort of always trying to keep the voice up in falsetto. It also generally prevents an inadvertent drop into a deeper voice at an inopportune moment.

Alternatives

This surgery doesn’t work or meet the needs of everyone. Other surgeries are being tried and perhaps other better surgeries will be developed in the future. Some may be used in conjunction or compliment the gains from cricothyroid approximation.

Other approaches include reducing the size of the vocal cord, perhaps with a laser. The theory is that the thinner vocal cord will vibrate at a higher pitch. Women’s vocal cords are both thinner and shorter than mens.

I have tried shortening the distance between the thyroid cartilage and the hyoid bone to shorten the length of the resonating portion of the throat. This seems to change the quality slightly without raising the pitch much.

One can remove the front of the voice box and make the voice box smaller and the vocal cords shorter which I am calling a Feminization Laryngoplasty. In addition to being shorter, they can be placed on a tighter stretch. This is a more complex operation and has more risk of impairing the voice than the cricothryoid approximation, but might hold the potential for further pitch elevation.

As pitch elevation in both males and females involves reducing the diameter of the throat to match resonance with increasing pitch, there may be a way to surgically reduce the diameter of the throat (or pharynx) that would change the resonance of the voice. I have only considered such an approach in theory, but have not tried it.

In general, I have moved away from performing this surgery because of it's unpredictability. It is one of the easiest surgeries to perform, but I cannot predict who will be too squeaky and who will be too low. In general, it is a very standardized surgery and perfomed similarly by different surgeons.

Presurgery

Before the surgery/procedure, a PARQ conference is held with you. This is an acronym for Procedures, Alternatives, Risks and Questions. It means that your surgeon has discussed with you in full detail the reasons for the procedure, the alternative treatments to the procedure, the risks of the procedure and that you have been given ample time to ask questions and are satisfied with those reasons and answers. In addition, an evaluation and examination of your voice box is essential. This involves a skilled examiner listening to and measuring a number of characteristics of your voice. A visual inspection of your voice box is also performed. This takes about an hour.

Risks

The general risks of surgery are discussed on the informed consent page. The risks specific to this procedure are discussed at http://old.voicedoctor.net/surgery/consentform/pitchconsent.html.

The procedure

The surgery is performed in an outpatient setting under local anesthesia. You may have sedation if desired. A one to two inch incision is placed parallel to or in a skin crease of your neck over the Adam’s Apple. Sutures are placed through the two main cartilages of the voice box, the thyroid and cricoid cartilages. They are then tightened to remove some of the lower pitches from your voice. You will be asked to talk at some points during the surgery which is one reason to do the procedure awake. This procedure will often accentuate the tracheal contour of the Adam’s Apple and a Laryngeal reduction or contouring may be done simultaneously.

Recovery

Your voice will often seem a quite tight or effortful at the end of the procedure. It will likely get worse for a few days to a week until any swelling starts to subside. There will be initial discomfort from the procedure. It is common to describe a sore throat sensation and to have some difficulty with swallowing for a few days.

Instructions during healing

Complete voice rest is very helpful for one week after the procedure. All forms of verbal communication should be avoided, including whispering. Remember, there are only a few sutures in there and until your bodies own scar tissue helps support the procedure, the sutures could pull out. Sedentary work can be resumed in a few days. Speaking may begin gradually after a week. Aerobic activity may be resumed after two weeks. Weight lifting should be deferred for a month.

Benefits

The actual pitch has been initially raised in everyone. It has remained long lasting in most people, but not all. In at some of my patients, it has returned completely to the pre-surgery pitch, despite the sutures remaining in place. In a few patients who were not satisified with the gain in pitch, I have tried approximating the thyroid cartilage and the hyoid bone to shorten the distance in the cavity above the vocal cords. I am not ready to say whether this additional shortening of the pharynx has long term benefit.

Most people tend to be able to remain higher full time, including such vegetative sounds as throat clearing and cough.

You may listen to some pre and post surgical voices at http://old.voicedoctor.net/media/cases/index.html. Here is also a short video of 4 sample cases who have benefited from the surgery.

For a different viewpoint see Anne Lawrence who reviews a number of surgeries. I would certainly agree that practice in feminizing the voice is the number one approach. Still, cricothyroid approximation, when successful, certainly makes maintaining a given pitch much easier.