Quantitative voice outcomes from vocal feminization surgery: A single case study with high-speed videoendoscopy and patient perspective

Background: Transgender patients may pursue vocal surgery to align their voice with their gender. One common vocal feminization surgery is Wendler’s glottoplasty, resulting in positive increases in pitch and voice-related quality of life (QOL). Currently, long-term objective outcome measures related to vocal physiology (i.e., aerodynamics and laryngeal kinematics) and their correlation to patient perspectives on their new voices are lacking. Therefore, the purpose of this study was to perform comprehensive long-term tracking of vocal physiology and patient experience following feminizing laryngeal surgery.

Methods: A 50-year-old transgender woman underwent a comprehensive voice evaluation that included: acoustic and aerodynamic analysis, high-speed videoendoscopy, and voice-related QOL measures. The protocol was completed prior to receiving vocal surgery (baseline), as well as 6-weeks, 3-months, 6-months, and 9-months post-surgery.

Results: Surgery was completed without complication and the patient adhered to voice rest recommendations and all follow-up visits. A granuloma formed at the anterior commissure during wound healing that was removed in month 7 using an office-based laser. Starting with an f0 of 187 Hz, the patient was able to maintain a mean vocal pitch between 174-230 Hz during recovery, with a simultaneous reduction in cognitive effort from 93 mm to 53 mm needed to produce voice (as measured on a visual-analog scale). Moreover, measures of vocal incongruence decreased, while measures of voice-related QOL increased. Laryngeal high-speed biomechanical measures of open quotient and peak velocity of closure showed similar trends as the QOL outcomes, showing promise as correlates to vocal femininity. However, the patient experienced a reduction in vocal loudness by ~5 dB SPL following surgery, as well as a persistent reduction in vocal efficiency (subglottal pressure/dB SPL). The patient reported a resultant negative impact of voice on her social life due to challenges being heard in social environments (e.g., restaurants).

Conclusion: The surgery led to reduced cognitive effort and a shift towards a more feminine vocal pitch (> 174 Hz). However, there were important reductions in vocal loudness and efficiency, which could impact individuals with vocally demanding professions or lifestyles. Comprehensive patient education on both positive and negative outcomes remains necessary.