Increasing attention has been paid in recent years to the role of the laryngologist in providing gender-affirming care. Within medicine broadly, the goal of clinicians engaged in gender affirmation work is to help alter a patient’s appearance and function to better match their gender. Voice is a crucial aspect of how humans are perceived by others and also by oneself, and a mismatch between one’s natural voice and one’s desired voice can lead to significant quality-of-life and psychosocial impact. Correction of this dysphoria can lead to improvement in health outcomes. Currently, strategies for gender-affirming care within laryngology are centered on two distinct issues: the appearance of the neck and the sound of the voice. The former, while an important component of gender affirmation, is beyond the scope of this chapter.

Voice alteration in nonbinary and transgender patients traditionally has focused on behavioral changes through voice therapy and hormone replacement therapies. Increasingly, gender-affirming laryngeal surgery (GALS) has also been used to address gender dysphoria by achieving a voice and communication style congruent with gender identity. ^{, ,} Systematic reviews have shown these to be successful in achieving certain aspects of voice alteration, particularly pitch. Vocal pitch is a key objective difference between the stereotypical cis male and cis female voice that contributes to gender attribution and is easily measured. Physiologically, these surgeries modify pitch by creating changes in vocal fold length, tension, or mass, or a combination of these parameters. Surgical interventions historically have included feminization of the voice with cricothyroid approximation (alteration in length and tension) and laser tightening (alteration in mass, and perhaps tension), but modern approaches have focused much more on endoscopic glottoplasty, (alteration in length and tension), which appears to have the most consistent and durable results, while maintaining flexibility of the voice. ^, These surgeries have been reported to have high satisfaction, with relatively few long-term complications. ^, Combinations of these procedures have also been described. For masculinizing the voice, surgical therapies are less common, due to the often satisfactory pitch-lowering effects of hormonal therapy through the permanent increase in vocal fold mass. However, a recent metaanalysis of 19 studies assessing the acoustic effects of testosterone on voice after a minimum of 1 year, an estimated 21% of study participants did not achieve cis-gender normal frequencies, and 21% reported incomplete gender-congruent voice; 16% remained unsatisfied with their voice. Type III thyroplasty, with setback of the anterior commissure through framework surgery, is an option for patients desiring durable pitch lowering.

Office-based procedures in laryngology have blossomed over the past 20 years, due in part to improvements in equipment, optimized anesthesia, and the increasing realization of the efficacy and cost-savings of this care delivery approach. Gender-affirming office procedures, however, have not yet become common practice. Herein, we focus on the few office-based treatments for gender-affirmation currently available to otolaryngologists. The indications of these procedures are to alter the pitch of the voice—to date, other components of the voice (resonance, intonation, prosody, etc.) cannot be addressed procedurally.

Two office-based procedures have been described for pitch-lowering in patients desiring a more masculine voice.

Webb et al. described a case report in which office-based injection augmentation of both true vocal folds was used to render a trans-masculine patient’s voice more congruent and more efficient. This office-based procedure is widely utilized for the treatment of glottic insufficiency of various causes, from bilateral presbylaryngeal change to vocal fold paresis/paralysis. The rationale of such an intervention was to increase the total mass of the “body” of both vocal folds by injecting an augmentation agent deep into both thyro-arytenoid muscles, and thus effectively lowering pitch. Additionally, and perhaps more importantly, by increasing the mass of the vocal folds, it potentially allowed improved closure, especially at lower than “physiological” frequencies in a cis-female laryngeal framework, leading to increased glottal resistance, and thus greater glottal power and efficiency ( Fig. 47.1 ). The procedure was performed in an almost identical manner to that of conventional injection augmentation, utilizing local anesthetic topicalization and a trans-thyrohyoid double-bend needle approach. The key specific considerations in this indication are the volume of injectate in each side and the balanced injection between sides. Initially, a short-acting agent was used as a “trial” agent—namely, carboxymethylcellulose (Prolaryn Gel, Merz Aesthetics). Once success was confirmed with this agent, and reabsorption had occurred, a longer-acting agent was used—namely Calcium Hydroxyapatite (Prolaryn Plus, Merz Aesthetics). With each procedure, a balanced, approximately 25% “over-injection” was performed, aiming for symmetrically increased vocal fold bulk. The range of volume injected was between 1 and 2 mL total. Postprocedurally, strict voice rest was encouraged for 24 hours, and then a gradual increase in voice use and postprocedural voice therapy was employed. About 6 months postinjection augmentation, the patient’s mean reading f ₀ (Hz) had decreased from 135 to 108. Stroboscopy revealed a linear complete closure with closed-phase dominance ( Fig. 47.2 ). Overall, they were very pleased with the improved congruency of their voice and reduced vocal fatigue. It is expected, as with conventional injection augmentation for glottic insufficiency, that the injectate will resorb, and that the patient’s original presenting symptoms will return to some degree. Of course, repeat office-based injection can be offered as a “top-up” at any point in time in the future. The authors have since performed similar procedures in 3 other trans-masculine patients, with unpublished results demonstrating similar reductions in speaking frequency and improvements in patient-reported outcome measures.

Trans-masculine patient attempting low-frequency phonation with a significant glottic gap.

(Courtesy Paul Paddle.)

Following augmentation, there is complete closure of the gap at low frequency with closed phase dominance.

(Courtesy Paul Paddle.)

Vahabzadeh-Hagh et al. describe a case report of two patients in whom vocal fold testosterone injections were performed to achieve a deeper pitch and a more gender congruent voice in a trans-masculine patient. Given the sensitivity of the larynx to testosterone, the rationale of this approach was that more targeted administration could facilitate voice change safely and more expeditiously than systemic testosterone. Testosterone cypionate (200 mg/mL) was injected into the bilateral thyroarytenoid muscles of the vocal folds. 25 mg (0.125 cc) of stock testosterone cypionate (200 mg/mL) was drawn into a 1 cc syringe and diluted with preservative-free saline to an injectable volume of 0.3 cc. In their description, a point-touch trans-cricothyroid approach to the larynx was used, but any conventional in-office approach to the vocal folds could, in theory, be utilised. Four injections of 25 mg testosterone were administered to each vocal fold over 5 weeks. The first two injections were spaced 1 week apart. Subsequent injections were spaced 2 weeks apart. Testosterone levels were checked during the treatment period. While testosterone dosing is individualized, typical dosages ranged from 40 to 160 mg daily, weekly, or monthly, depending on the testosterone formulation. Consideration was given to any concurrent traditional intramuscular testosterone exposure in calculating the total dose for each injection. Both patients achieved a reduced mean f ₀ , narrower and reduced pitch range, as well as lower semitones. In contrast to the increased “body” mass with deep injection augmentation, the phonatory change here was theorized to be achieved through increased extracellular matrix protein deposition within the superficial lamina propria, the “cover” of the vocal fold. Long-term follow-up of the durability of these results is yet unpublished.

Procedures for raising pitch have not been explored extensively in the literature. In theory, 532 or 445 nm laser treatments of the vocal folds—which are routinely performed in the modern laryngology office—could be performed in transgender women, akin to the laser tightening procedure undertaken in the operating room. To our knowledge, this has not yet been described in the literature as a primary treatment, though pKTP laser office-based treatment has been described as a revision/refinement procedure after primary “feminization laryngoplasty” procedures. ^, Although reference has been made to steroid injections into the thyroid arytenoid muscles to intentionally cause atrophy of these muscles, ^, which may elevate the pitch, this has been incompletely characterized.

Additionally, transgender patients may benefit from adjunctive office procedures after definitive operative management. Augmentation of the vocal folds can address a small anterior glottic gap and the resulting breathiness that can result from glottoplasty procedures. Other injections, such as steroids, can be considered for scarring, granulation tissue, or inflammation in a patient who is not healing optimally. And, as mentioned above, office laser-based treatments of the vocal folds may be utilized to reduce vocal fold mass and introduce controlled scarring/tensioning of the vocal folds to some degree.

Whereas surgical procedures in the operating room have an established track record of efficacy, ^, there are, as yet, very few outcomes published for the above-described office-based procedures. In general, vocal fold injection and augmentation are well tolerated and successful in improving vocal fold motion issues (e.g., paralysis) as well as patients with glottic insufficiency from other causes (e.g., presbyphonia). There is no certainty regarding their long-term efficacy in pitch modification; however, given the natural history of voice change and injectable substance absorption rates, it seems reasonable to assume a similar duration of action when utilized in voice feminization/virilization contexts. Objective measured pitch (frequency) parameters when performing such procedures should include: mean speaking frequency, lowest frequency, highest frequency, and frequency range.

Whilst the use of serial testosterone injections into the vocal folds also holds promise, long-term follow-up and durability are yet to be reported.

As always in the care of voice patients, the use of specific, validated patient-reported outcome measures (PROMs) can aid in patient outcome tracking and patient voice self-awareness. Examples include the Trans-Woman-Voice Questionnaire (TWVQ, formerly the TVQ ^MTF ), the currently nonvalidated adapted version for trans-men (TVQ ^FTM ), and the Voice-related Experiences of Nonbinary Individuals (VENI). ^{, ,}

It is also important to note that peri-procedural voice therapy is a key component of the gender affirming voice care, not only from a postoperative voice recovery perspective, but also from the perspective of further optimization of an individual’s voice, communication and psychosocial adjustment, especially in areas not directly targeted by the above described procedures, such as resonance, prosody, articulation and other paralinguistic cues. ^,

While there is some emerging data regarding complications for gender-affirming surgeries, ^{, , , ,} there is little regarding the safety and complications of office-based gender-affirming procedures. Extrapolating from similar literature, however, in patients undergoing vocal fold augmentation or therapeutic injection of the vocal folds, the expected complication rate following either of these procedures is low. Complications may include bleeding, technical failure to perform the procedure, material extrusion or misplacement, and, rarely, airway obstruction. Concerning testosterone injections into the vocal folds, there is a degree of detectable systemic absorption reported with each injection, and the additive effect of this to any traditional intramuscular testosterone injection should be considered and accounted for.

As with many other gender-affirming procedures, insurance coverage remains problematic and fraught. Within the United States, gender-affirming voice therapy is unequally covered and reimbursed. Indeed, many office-based laryngeal procedures have only recently gained acceptance and recognition as distinct procedures, and many of the products used for injection augmentation (e.g., hyaluronic acid derivative injections) are used in an off-label manner in the larynx. The relatively recent adoption of gender-affirming procedures is likely to continue to complicate reimbursement, especially as outcomes are still not fully characterized.

Another important component of all gender-affirming laryngeal care is the political and social controversy that surrounds this issue. Transgender health has become a political issue in the United States, with practitioners facing backlash and even the threat of violence for participating in transgender care. While deep political divides may exist around this issue, doctors are encouraged to follow WPATH guidelines ( www.wpath.org/publications/soc ) regarding gender affirming care, and should weigh risks and benefits of any intervention offered to patients, with careful consideration of patient preference.