Consent forms > Cricothyroid Approximation and Laryngeal reduction

• The procedure
• Weak voice
• Raspiness
• Reduction of vocal range
• Painful swallowing
• Crackling under skin
• Infection
• Abnormal pitch
• Relapse of previous low pitch
• Scar problems
• Poor result

The Procedures

Cricothyroid approximation.
Thyroid cartilage reduction.
Feminization Larynoplasty

Weak Voice

The vocal cords may be tightened to the point that the work of speech may be increased. You may notice an increased fatigability of the voice, characterized as a weakness of the voice after periods of prolonged speaking. The vocal cords may be held slightly apart and excess air will leak out.

Raspiness

When you first start talking the voice is weak and may be coarse, actually getting worse for several weeks. This is a result of swelling from the procedure and will gradually improve. I have also had granulomas form. These are pieces of flesh that can form out of blood vessels growing into a raw area that is healing. If a granuloma grows between the vocal cords, it keeps them from closing fully and air leaks out causing quite a bit of hoarseness and weakness. Usually, these will fall off, but it can be several months. Injection with a steroid can speed up their falling off.

Diminished range

The mechanism of the surgery is to actually prevent you from reaching the lowest notes of your range. CTA does not augment the upper range while FemLar might. In general, your overall pitch range (the distance between the highest and lowest notes that you can reach) will likely be diminished.

Painful swallowing

It is common for patients to have pain with swallowing for up several weeks after voice modification.

Subcutaneous emphysema

Air may leak out of the windpipe into the surrounding skin. This would appear as a temporary puffiness of the skin and the sensation of crackling under the skin when it is pressed. This is called crepitation. It can advance to the point of putting pressure on your neck and limiting your breathing. You must call if you develp this symptom.

Infection

Infection can range from a mild redness around a drain site, to a painful swelling in the neck, to a severe swelling of the voice box that impairs breathing. Any redness, swelling, increasing pain or difficulty breathing should be reason to contact me at once. If this occurs, it seems to do so between 2 to 5 days after the surgery.

Abnormal pitch

With CTA, when you first start talking after surgery the voice may be weak and too high. With FemLar it will almost certainly be too low from vocal cord swelling. This will change quite a bit over the first six weeks and there will be some continued small change even over many months. 

Relapse of your old pitch

While the surgery has always been initially very successful in my experience in everyone, the pitch elevation has remained permanently in about 2/3 of patients, so that when the surgery is successful in raising the pitch for several months, it seems to result in a permanent elevation in pitch. However up to about a third of patients seem to have vocal cords that stretch out several weeks to a few months after the surgery. Though no worse than before the surgery, they have returned to the presurgical voice.

When I first began the surgery, I felt it was possible that the stitches in the cartilage might not hold or pull out and the voice could lower again. However, to date in fact, I have never seen it happen either in my own nor in the patients of other surgeons. I presume that it is still a possible complication. By around 6 weeks, your body's own scar tissue will add support to the sutures making this complication even less likely.

The voice may naturally lower with age as elasticity is lost in the vocal cords - much like the elasticity of the skin of an 80 year old is compared to a baby's skin. Although the procedure should be permanent, it is a fairly new procedure and really long term post-operative analysis is not yet available. There may be new supplemental procedures developed in the future.

Scar tissue

The surgery is done through a cut that parallels your own natural skin folds. As it heals it may initially become more pink for several months. During this time, the scar tissue will easily pigment permanently from a sun tan. When out in the sun you should keep the scar covered with the highest sun block available during the first year of healing. The scar on the neck in some people may become adherent to the underlying cartilage and may move with swallowing. Massaging the scar will usually release this, but if it fails to resolve, the scar may need to be revised.

Poor result

Resonance mismatch - There is more to sounding feminine than just the pitch of the voice. Articulation patterns and resonance are not changed with this surgery and thus even the best result does not, on its own, produce completely feminine speech.

The vocal cords are attached directly to the thyroid cartilage (Adam's Apple). If the thyroid cartilage is reduced during the procedure to change the appearance of the overlying skin, there is a risk of lowering the voice, perhaps permanently. This is a rare occurrence.

Date: ___ / ___ / 200__

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James P. Thomas, MD