How can Adam's apple be diminished

Operations on the larynx

The larynx is a system of cartilages that are connected to one another by muscles and ligaments and can move against one another. It is used to develop the voice, to control the airway to and from the lungs and to control the swallowing process. It also has a protective function by preventing food from entering the lungs and coughing to remove foreign objects from the lungs.

The most important parts of the cartilage skeleton are the large thyroid cartilage, the tip of which is visible from the outside as an Adam's apple, the deeper lying cricoid cartilage and the two inner, small, pyramidal adjusting cartilages.

The most important organ for the voice are the vocal cords (vocal folds, vocal folds). They are stretched between a common starting point at the front, on the inside of the thyroid cartilage and the two control cartilages at the back, and can take on different shapes due to the activity of the cartilages and muscles connected to them. Two muscles are primarily responsible for regulating the pitch of the voice: One connects the cricoid cartilage with the thyroid cartilage and causes a change in length and passive tension in the vocal cords. The active tension of the vocal cords is achieved by a muscle lying directly in them.

Operations on the larynx can on the one hand raise the pitch of the voice by tightening the vocal cords and on the other hand change the visual appearance by removing the Adam's apple. To tighten the vocal cords, the larynx usually has to be opened, which is associated with a greater risk. When the Adam's apple is removed, the voice itself is not changed. Since the larynx remains untouched, the risk is also lower.

Surgical interventions to change the pitch of the voice should in any case only be considered when all speech therapy options have been exhausted. After all, the changed pitch does not guarantee good passing if the voice guidance is not adjusted.

Shortening the vocal cords: glottoplasty

Surgical shortening of the vocal cords aims to tighten them more in order to achieve a higher voice. To do this, the vocal cords are pulled together and sutured at their anterior attachment point to the thyroid cartilage. These interventions require extremely precise work and represent a high risk: Even small mistakes can put different stresses on the vocal cords, which results in a croaking and hoarse voice. This makes further operations unavoidable. The success rate is also quite unsatisfactory. According to the Clinic for Audiology and Phoniatrics at the University of Berlin, it is only 80%. Like many doctors, we advise against such interventions.

Tensioning the vocal cords: cricothyroidopexy

By increasing the tension of the vocal cords, this method increases the pitch, similar to the tensioning of a guitar string. The vocal cords themselves are not touched, which drastically reduces the risk of hoarseness or loss of voice

Cricothyroidopexy uses the principle of passive tensioning of the vocal cords by a muscle that regulates the position of the cricoid cartilage and the thyroid cartilage in relation to one another. First, the smallest possible incision is made in a neck fold over the Adam's apple. Then the two cartilages are brought closer together, pressed together and rigidly connected in this position with wires, so that the vocal cords remain constantly tense. Due to the high load, there is a risk of later loosening due to the wire connections being torn out of the cartilage. To reduce this, there is an alternative surgical method in which the wire sutures are guided and fixed over titanium plates.

In order not to jeopardize the outcome of the operation, it is best not to speak at all in the first few days after the operation, but in any case as little as possible, and to eat rather mushy food. In any case, swallowing difficulties are to be expected. After about a week the sutures will have healed and you can eat as usual again.

The increased tension of the vocal cords results in an increase in the speaking voice. At the same time, the lower vocal ranges can no longer be used. With the singing voice you just can't get any deeper. Unfortunately, this does not result in an upward increase in the singing voice, so the vocal range is reduced. The modulation ability is not lost, but it is somewhat reduced. The controllability of the voice is also affected, you tend not to hit the notes so precisely. Those who like to sing should be aware that after such an operation corresponding restrictions can be expected.

In the first time after the operation, you may have an unnaturally high-pitched voice. But that normalizes after a few weeks. Talking over a long period of time is exhausting at first and needs to be practiced. For this reason alone, speech therapy is recommended after the operation. Especially if you have already tried to raise your voice with natural methods, it takes some time until you have forgotten this automatism that may already have been internalized. It is then no longer necessary to raise the voice - on the contrary, it strains the speaking apparatus unnecessarily, which can lead to a kind of "sore muscles in the larynx".

Usually, the speaking pitch reached after about three months then drops by one or two semitones. Reaching the final level of the vote can take up to a year.

The article "Operative voice elevation in male-to-female transsexuals" from the ENT clinic Halle-Wittenberg shows that the results can be viewed with skepticism. 59 patients were followed for one to seven years after the operation.

The increase in voice was 6 semitones or more in 42%, 3-5 semitones in 32%, 1-2 semitones in 19%, no increase in 3.5% and even deepening in 3.5% the voice.

Ten patients had to be reoperated after an average of 13 months due to a later drop in their voice, which only led to an increase of 1-2 semitones in three patients.

Reduction of the Adam's apple: Larynx reduction plastic

The reduction of the Adam's apple - precisely: the uppermost tip of the shield leaf that protrudes in men - aims exclusively at a visual change. After opening the skin immediately above the Adam's apple, the shield leaf is sawed off, the cartilage smoothed and sewn up again. The vocal cords and larynx should not be touched.

The procedure takes about an hour and can be performed under or under local anesthesia. The incision in the neck is made exactly as in cricothyroidopexy and can be included in such an operation without any technical effort.

In order to keep the scarring as low as possible, one should not speak during the first four days after the operation, eat pulpy food and move the larynx as little as possible. Swallowing and speaking are especially painful in the first week after the operation and it takes three to four weeks for the pain to completely subside.

As a long-term consequence, there is a scar that is usually barely visible in a fold of skin on the neck. In around 10% of patients, however, adhesions between the outer skin and the underlying layers form, which results in scarred, cosmetically unfavorable distortions on the skin of the throat, especially during the act of swallowing. To avoid this as much as possible, the layers under the cut should be shifted from one another from about a week after the operation by placing the finger lightly on the scar and gently moving the skin up and down.

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Operative voice elevation in male-to-female transsexuals
K.Neumann, C.Welzel, A. Berghaus, ENT Clinic Halle-Wittenberg