Adam’s apple reduction in transgender patients who are transitioning from male to female produced significant benefit for the patients, according to findings presented at the 2022 Triological Society Combined Sections Meeting in January. The presentation was titled, “Evaluating Patient Benefit from Laryngochondroplasty,” and was the 2020 Triological Society Thesis with Distinction Award winner.
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March 2022Also known as laryngochondroplasty, or tracheal shave, the procedure to reduce the prominence of the thyroid cartilage was described at least as early as 1975, and new approaches have been developed over time, said Christopher Tang, MD, a head and neck surgeon at Kaiser Permanente in San Francisco. In the procedure (Arch Otolaryngol Head Neck Surg. 2008;134:704- 708) used in this study (Laryngoscope. 2020;1305:S1-S14), surgeons used a flexible fiberoptic laryngoscope and a laryngeal mask airway. The technique involves making an incision at the cervicomental angle, elevating the subplatysmal flaps, and dividing the strap muscles to expose the thyroid cartilage.
“There are a lot of very important structures that attach to the thyroid cartilage—the epiglottis, the false vocal cords, the true vocal cords—so it’s very important to remove only the cartilage superior to all the attachments,” he said. To help with this, Dr. Tang said, he placed an 18-gauge needle through the thyroid cartilage into the airway, visualizing the needle through the laryngeal mask airway with the flexible endoscope. He could see the needle emerging at the level of the vocal fold, and then knew that removing cartilage above that point was safe.
There are a lot of very important structures that attach to the thyroid cartilage— the epiglottis, the false vocal cords, the true vocal cords—so it’s very important to remove only the cartilage superior to all the attachments. —Christopher Tang, MD
From April 2016 to April 2020, a total of 209 patients received an Adam’s apple reduction procedure in the Kaiser Permanente system, and Dr. Tang performed the procedure in 91 of those cases. After the surgery, he gave the patients the Glasgow Benefit Inventory (GBI) questionnaire to fill out, and 73 of the patients did so.
The patients were an average of 31 years old at the time of the surgery, and waited 96 days, on average, for the surgery to be performed. They traveled an average of 45 miles for the surgery; more than 10 of the patients drove more than 100 miles for the procedure. The group was also racially diverse, with 16.5% Asian, 23.1% Hispanic, 57.1% White, and 3.3% Black.
The GBI, developed to assess benefits after otorhinolaryngology procedures, poses questions about physical and psychosocial outcomes. These questions include the following:
- Have the results of the laryngochondroplasty affected your daily activities?
- Have the results of the laryngochondroplasty made your overall life better or worse?
- Since you have had the laryngochondroplasty, have you felt more or less embarrassed when with a group of people?
- Since you have had the laryngochondroplasty, do you feel more or less support from your friends?
- Since you have had the laryngochondroplasty, do you catch colds more or less often?
- Since you have had the laryngochondroplasty, do you feel better or worse about yourself?
Patients give one of five responses to these questions, such as “much more,” “more,” “no change,” “less,” or “much less.”
The overall score on the GBI was 41.95 (95% CI: 39.34-44.56), “suggesting that there is a statistically significant improvement in the quality of life after laryngochondroplasty,” Dr. Tang said. “There was a greater benefit for the general subscore, but less benefit for the social and physical health subscores. Nonetheless, all the subscores had a 95% confidence interval showing a positive benefit.”
The subscore for general benefit was 60.75 (95% CI: 57.75-63.75), the social subscore was 16.89 (95% CI: 11.77- 22.01), and the physical health subscore 4.33 (95% CI: 0.97-7.69).
Dr. Tang noted some limitations. The questionnaire is given after the procedures, so there could have been a retrospective bias, he said. Only the transcervical technique was evaluated, and there are several other approaches that can be used, which would change the location of the scar. In addition, the results “might not be generalizable to the submental or intraoral approach.”
There was also a big range on the time to follow-up—from 26 to 1,544 days—so the responses could have varied depending on how soon a given patient completed the questionnaire. “If you see someone a month after surgery versus four years postsurgery, it’s quite different,” he said.
“Although the GBI is widely accepted in otolaryngology, it’s inherently limited since it utilizes a five-point, Likert-type scale instead of a continuous scale, like [the one used in a] visual-analog scale,” Dr. Tang said.
Still, the results should be encouraging for use of the procedure, he said. “Laryngochondroplasty has been performed for over 40 years,” said Dr. Tang. “It’s a safe procedure with excellent outcomes that greatly increase patients’ quality of life and is of great benefit to them, according to the Glasgow-Benefit index.”
An audience member noted that one of the benefits to the GBI is that patients report at their current time point, offering an assessment once the procedure is done. However, with the one disadvantage of the GBI being recall bias, it might be worthwhile to try to overcome that in future studies, he added.
Dr. Tang acknowledged that “there definitely is recall bias, since we didn’t administer the test beforehand.” But he agreed that a validated outcomes study would be a good approach, if possible, with questionnaires given before and after “so that you could compare quality-of-life differences.”
Thomas R. Collins is a freelance medical writer based in Florida.