Gender-Affirming Laryngoplasty: Complications Relatively Common

Daniel M. Keller, PhD

September 15, 2022

Philadelphia — More than half of patients undergoing gender-affirming laryngoplasty to alter their voice experienced complications, according to a retrospective study of 41 patients presented at the annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS).

People transitioning from man to woman often want to alter their voices to match their new gender, which is where otolaryngologists come in. Over time, vocal care for transgender patients has evolved from behavioral therapy to hormone-replacement therapy, to voice therapy, and now, to laryngeal surgery. Most published data on this newest modality tends to focus on voice outcomes, such as phonation time and intensity. Few studies have reported on complications and suboptimal outcomes.

Matthew Naunheim, MD, MBA, of Massachusetts Eye and Ear Infirmary and Harvard Medical School in Boston, and colleagues explored these issues as they apply to two key gender-affirming laryngeal surgeries — Wendler glottoplasty (connecting the anterior one third of the vocal folds with sutures to raise voice pitch) and chondrolaryngoplasty (often called "tracheal shave," employed to reduce the size of the Adam's apple).

"Complications related to healing granulation tissue and web length are not uncommon, and patients and surgeons should be aware of these and secondarily, that discussions around glottic insufficiency are important, and voice changes should be discussed. preoperatively," Naunheim said.

The patient study cohort (N = 41) was compiled from three tertiary care centers in the Northeastern United States. The investigators performed a retrospective chart review of patients with a billing code for gender dysphoria as a diagnosis during the single year of 2020-2021. Their average age was 39 years (range, 16-68 years).

Twenty-eight of the patients had undergone previous surgery, of whom, 15 had complications. (Any one patient may have had one or both surgeries, and more than one complication was possible in any one patient.)

Among 13 patients with chondrolaryngoplasty, none had any short-term complications, but three (23.1%) experienced long-term complications of skin tethering (n = 2), and one had each infection/fistula or voice change.

"For glottoplasty, we saw that there were significantly more short-term complications, things like granulation tissue issues and the sutures that have been placed," Naunheim told attendees. "And then in the long-term complication group...a relatively high rate of glottic insufficiency, more than we'd expect."

Of 15 glottoplasty patients, four (26.7%) experienced short-term complications of granulation (n = 3) or a suture pulled out (n = 1), all of which resolved. The eight (53.3%) long-term complications consisted of a web greater than 50% in four, glottic insufficiency in seven, incomplete web in two, and two with scar.

Commenting on the finding of a relatively high prevalence of glottic insufficiency, Naunheim said that he thinks it has previously been underreported. "It is often hard to get patients to have a perfect alignment of the vocal folds after suturing the anterior aspect of them together," he noted. He showed laryngoscopy photos of one of his patients with a significant keyhole anteriorly where there was not complete closure of the interior of the vocal fold.

Naunheim noted some limitations of his study. "We are looking retrospectively, of course, and many of these patients did present specifically for the complications that they're experiencing," he said, "So we cannot claim any prevalence rates or anything like that. And we've had significant changes in the past year due not only to COVID but the changing healthcare environment for people undergoing gender affirming laryngeal surgery."

Session moderator Daniel Fink, MD, of the University of Colorado Anschutz Medical Campus in Aurora, commented to Medscape Medical News that with any newly popularized procedure, it is good to know what to expect in terms of complications. "I think initially, people get very excited to report the positive outcomes, and as we get more advanced and more mature, we see what the potential complications are," he said. "So learning what those potential complications are and learning how to address and avoid those is really the next evolution of the surgery to maximize its efficacy."

During a short question and answer period after Naunheim's talk, Natasha Mirza, MD, of the University of Pennsylvania, offered an alternative glottoplasty procedure. She said that instead of suturing the vocal folds together, injecting filler into them can effectively push them together. The filler lasts about 6-8 weeks, during which time the vocal folds heal together without a suture present.

"The idea there is that the suture is what's causing the granulation tissue to form. And so if you avoid the suture, you avoid the granulation tissue," Fink said. But he pointed out, "As we're talking about the evolution of this surgery, we don't have any comparative data" on the various techniques to avoid granulation tissue.

Fink said that the prevalence of laryngoplasty as one aspect of gender-affirming surgery is "increasing dramatically" as health insurers cover it more often. This technically demanding surgery is performed mostly by laryngologists who specialized in the procedure. He said that word gets around in transgender communities about the most proficient surgeons as well as ones who will treat patients with respect.

Managing expectations is an important part of voice treatment and involves patient counseling with the surgeon and with a psychologist as well as working with a speech-language pathologist before and after surgery.

Though surgery alters voice pitch, Fink said that speech training to alter cadence and some other aspects of speech often obviates the need for surgery.

"I was always taught the best surgery is no surgery," Fink said. "And so if we can get these patients better [by] working with a speech pathologist and...have a voice that works for them, having a communication modality that works for them, then we're doing them a service that way," he said. "Surgery is great when it's needed…but it's not always needed.

Naunheim reported that he is a paid consultant and scientific advisory board member for Kyttaro Ltd subsidiary of Cambridge Science and has received research funding from the National Institutes of Health and from the American Academy of Otolaryngology–Head and Neck Surgery. Fink had no disclosures.

American Academy of Otolaryngology–Head and Neck Surgery 2022 [No abstract numbers]. Presented September 12, 2022.