Surgical management of puberphonia recent concepts

By

Dr. T. Balasubramanian M.S. D.L.O.

Introduction:

Mutational falsetto is also commonly known as Puberphonia. This condition is caused due to the failure of the voice to drop in its pitch from the higher levels after puberty. These patients hence suffer from lack of resonance in voice, breathiness of voice and lack of pitch variations. These patients have easy fatigability of voice and are unable to raise their voice in noisy environments.

This condition is caused due psychological problems in the patient which prevents lowering of the pitch of the voice of an adolesecent to that of a adult range. Puberphonia is more common in adolescent males and may also occur rarely in females.

The following are the probable psychological factors that could lead to the developement of puberphonia:

1. Over identification of the affected boy with his mother

2. Failure of the boy to accept his adult male role

3. Social immaturity

4. Anxiety to maintain a Soprano voice

5. Incordination of muscles of vocalization

The pitch of the voice in puberphonia is caused by increased tension of laryngeal musculature. This condition is responsive to voice therapy. If voice therapy fails then botulinum toxin injection into the cricothyroid muscle could be of help. Ideally 15 units of Botulinum toxin can be injected to each side.

Surgical management of Puberphonia:

When all the above conservative methods fail then surgery will have to be resorted to. Isshiki type III relaxation thyroplasty has shown promise in managing these patients. This surgical procedure lowered the pitch of voice in these patients by shortening the length of the vocal folds. In the classic Isshiki type III thyroplasty 2 – 3 mm of vertical strips of cartilage were excised on each side of midline of thyroid cartilage. This procedure caused retrusion of the middle portion of the thyroid cartilage causing a reduction in the length of the vocal folds.

Diagram showing the two vertical incisions on either side of midline of thyroid cartilage (Ishikki type III thyroplasty)

Figure showing the depressed anterior segment of the thyroid cartilage

Figure showing the anterior segment of thyroid cartilage which has been pushed behind and the free edges of thyroid cartilage reapproximated

Various modifications of Type III Ishikki thyroplasty have been proposed. These include:

Retrusion thyroplasty:

In this modified procedure the lamina of thyroid cartilage is incised bilaterally and its anterior segment is depressed anteriorly.

Relaxation thyroplasty:

In this procedure a small window is created close to the anterior commissure tendon and the cartilage window created is pushed behind.

Tucker's procedure:

This is a less invasive procedure in which a superiorly based cartilage window is created at the level of anterior commissure and is pushed behind causing relaxation of the vocal folds.

This surgical procedure is very useful in treating patients in whom psychologic counselling and voice therapy has failed.