Endo Crinal Voice Disorders - PDF /KUNNAMPALLIL GEJO

ENDOCRINAL VOICE DISORDERS AND VOICE DISORDERS RELATED TO TRANSEXUALS
KUNNAMPALLIL GEJO JOHN
KUNNAMPALLIL GEJO ,MASLP
Introduction:
Endocrine gland (endo means within and krine means separate or glands of internal secretion). Endocrine glands are glands of internal secretions and posses no ducts. These ductless glands pour their secretions directly into the blood streams. Their secretions are known as hormones.
Hormones are carried in the blood stream to body organ or tissue and it excites for activity and growth and development. The endocrine system is an integrated system of organs which involve the release of extracellular signaling molecules known as hormones. The endocrine system is instrumental in regulating metabolism, growth and development, tissue function, and plays a part also in mood
The human voice is extremely sensitive to endocranial changes. Many of these are reflected in alterations of fluid contour of lamina propria just beneath the laryngeal mucosa. This causes alteration in the bulk and shape of the vocal folds resulting in voice change.
Major endocrine glands. (Male left, female on the right.) 1. Pineal gland 2. Pituitary gland 3. Thyroid gland 4. Thymus 5. Adrenal gland 6. Pancreas 7. Ovary 8. Testes
Sex hormones and its relation to voice:

Larynx is hormone dependant organ and human voice is influenced by 3 main sex hormones. Namely 1) Estrogen 2) Progesterone 3) Androgens.
The hormonal impact acts not only on the genital tract but also on these essential elements. Which are the mucosa, the muscles of the body tissues, the laryngeal instrument and the cerebral cortex. The hormonal climate determines the sex of voice, voice being a secondary sexual characteristic.
Puberty represents a hormonal earthquake for the individual. In a female, estrogens and progesterone will produce womans voice and in male, testosterone will produce mans voice. This means fundamental frequency a third lower than a childs voice for the woman and an octave lower for the man.
In men the thyroid cartilage develops as an Adams apple, a secondary male characteristic. The muscular and mucosal layers of the vocal folds thicken. The squamous mucosa differentiates in three quite distinct layers.
The vocal folds lengthen and widen. The cricothyroid membrane widens and corresponding muscle becomes more powerful. The absence of androgens at puberty leads to a feminine voice. The presence of this hormone at any stage in life will give masculine voice.
In women, there is little development of thyroid cartilage or of the cricothyroid membrane. The vocal muscle thickens slightly, but remains very supple and quite narrow. The squamous mucosa also differentiates in to 3 distinct layers on the free edge of the vocal folds. The subglottic mucosa becomes hormone dependent to estrogens and progesterones. Before puberty, there is no progesterone.
Sex hormones and the female voice, Abitbol J, Abitbol P, Abitbol B (1999)
In the following, the authors examine the relationship between hormonal climate and the female voice through discussion of hormonal biochemistry and physiology and informal reporting on a study of 197 women with either premenstrual or menopausal voice syndrome.
These facts are placed in a larger historical and cultural context, which is inextricably bound to the understanding of the female voice. The female voice evolves from childhood to menopause, under the varied influences of estrogens, progesterone, and testosterone. These hormones are the dominant factor in determining voice changes throughout life.
For example, a woman's voice always develops masculine characteristics after an injection of testosterone. Such a change is irreversible. Conversely, male castrati had feminine voices because they lacked the physiologic changes associated with testosterone. The vocal instrument is comprised of the vibratory body, the respiratory power source and the oropharyngeal resonating chambers.
Voice is characterized by its intensity, frequency, and harmonics. The harmonics are hormonally dependent. This is illustrated by the changes that occur during male and female puberty: In the female, the impact of estrogens at puberty, in concert with progesterone, produces the characteristics of the female voice, with a fundamental frequency one third lower than that of a child. In the male, androgens released at puberty are responsible for the male vocal frequency, an octave lower than that of a child.
Premenstrual vocal syndrome is characterized by vocal fatigue, decreased range, a loss of power and loss of certain harmonics. The syndrome usually starts some 4-5 days before menstruation in some 33% of women. Vocal professionals are particularly affected. Dynamic vocal exploration by televideoendoscopy shows congestion, microvarices, edema of the posterior third of the vocal folds and a loss of its vibratory amplitude.
The authors studied 97 premenstrual women who were prescribed a treatment of multivitamins, venous tone stimulants (phlebotonics), and anti-edematous drugs. We obtained symptomatic improvement in 84 patients. The menopausal vocal syndrome is characterized by lowered vocal intensity, vocal fatigue, a decreased range with loss of the high tones and a loss of vocal quality.
In a study of 100 menopausal women, 17 presented with a menopausal vocal syndrome. To rehabilitate their voices, and thus their professional lives, patients were prescribed hormone replacement therapy and multi-vitamins. All 97 women showed signs of vocal muscle atrophy, reduction in the thickness of the mucosa and reduced mobility in the cricoarytenoid joint. Multi-factorial therapy (hormone replacement therapy and multi-vitamins) has to be individually adjusted to each case depending on body type, vocal needs, and other factors.
I. VOCAL DISORDERS RESULTING FROM THYROID DISEASE Vocal disorders in hypothyroidism The thyroid gland regulates protein synthesis and tissues metabolism through the production of thyroid hormones, under the control of thyroid stimulating hormones; it is necessary for many other functions including growth. Perceptual features of hyperthyroidism include slight vocal instabilities including shaky voice, breathy voice quality and reduced loudness.
Deficiency of the thyroid hormone retards the growth of entire organism, keeping it in an infantile state. The degree of physical infantalism depends on when the thyroid gland started dysfunctioning. Hypothyroidism - vocal symptoms: It is more common in the elderly and often produces symptoms mistaken for aging changes. Hypothyroidism is a well recognized cause of voice disorders. Hoarseness, vocal fatigue, muffling of the voice, loss of range, and a feeling of lump in the throat may be present even with mild hypothyroidism.
Typically, the voice of the patient with hypothyroidism is hoarse and has gradually lowered pitch due to increased mass (edema) of the vocal fold. Ritter demonstrated an increased level of acid muco polysaccharides submucosally in the vocal folds. They probably act as an osmotic diuretic and increase fluid content in the lamina propria. This result in effectively increased vocal fold mass and decreased vibration.
In some cases, Rinkes edema may be apparent. In severe hypothyroidism with myxedema, these changes are more profound and may be associated with decreased muscle strength and vocal fold paralysis. According to Stempe and others (2000) hoarseness, low pitch, coarse and gravelly vocal symptom caused by thickened or edematous vocal folds and altered fluid content in the lamina propria are reported.
Cretinism:
It is a condition occurs due to hypothyroidism. Among the French authors, Terracol and Azemar (1935) drew attention to the state of laryngeal infantalism associated with all forms of cretinism. In 1926, Wegelin observed that laryngeal growth was markedly retarded in dwarfed cretins. Despite this retardation of laryngeal growth, male cretins usually reach the stage of vocal mutation into the adult male voice.
Ranging from the most severe hypoplasia of the larynx in total cretins, a graduated series of diminishing laryngeal insufficiency extends to the slight vocal disorders encountered in borderline cases of sub clinical cretinism. When cretinism was associated with hypo genitalism, the common sign of laryngeal hypoplasia was combined with a high speaking pitch and an infantile vocal timbre.
Many cretins are hard of hearing/deaf, and some are mentally retarded also. So poor auditory reception in conjunction with MR, represents a complex type of dysphonia. The voice in cretinism shows many similarities to vocal senility. All signs of aging, i.e., weakness of musculature, narrowing of blood vessels in the larynx, lowered thyroid activity etc. are correlated with decreased endocrine function.
According to Beidl (1922), muscular hypotonia in cretinism is mainly due to edematous congestion of the muscle fibers. Another cause is the deficient muscular sense resulting from poorly developed muscle spindles and other propriceptors of muscle action. Voices include small vocal range, husky voice, an infantile vocal timbre, weakness in phonation.
Voice in myxoedema:
Myxoedema is a constitutional disorder occurring chiefly in adults or older children. It is due to decrease or absence of thyroid, a disorder of metabolism hormones. Decreased production of thyroid hormone may result form atrophy or removal of the thyroid gland, lack of normal pituitary stimulation, inhibition of hormone formation, such as following the use of certain drugs.
Vocal signs: According to the description presented by Schenharl (1954) hoarseness is frequent in cases with myxedema. He interprets this dysphonia as a purely muscular disorder of vocal cord vibration. It appears that the substance of the vocalis muscle is reduced through muscular atrophy. Bowing of the vocal cords with incomplete glottal closure may be seen with ordinary laryngoscopy and with stroboscopic illumination.
This bowing of the glottis results from muscular atrophy and is in turn directly responsible for the weak, hoarse sound of voice. In contrast no irregularities of vocal cord vibration can be seen. In addition to the hoarse sound of the voice, the speech of myxedematous subjects is described as slow, thick, sluggish and somewhat dysarthric.
Thyroid function may fail in childhood causing juvenile myxedema but this is not as serious as in cretinism because normal development will have taken place in the fetus and early childhood. Signs: edematous vocal cords, hoarse voice. The gradual onset of disease at first may cause it to go unrecognized but early diagnosis and treatment are essential.
Juvenile myxedema
Myxedema in senescence:
It occurs at old age. An early sign is a slowly progressive deepening of the voice and a slight huskiness or blurred quality. The vocal fold movement remains intact but the cords increase in bulk due to deposition of muco polysaccharides in the sub mucosa. In the old people a diagnosis of myxedema may only be when it is well advanced.
HYPER THYROIDISM
When dealing with vocal symptoms arising from disorders of thyroid function, we should differentiate the following clinical entities: 1. Thyrotoxicosis 2. The thyro vocal syndrome 3. Neuroparetic types of laryngeal dysfunction resulting from thyroid disease.
Thyrotoxicosis: Dysphonia associated with hyper thyroidism is characterized chiefly by increased frequency of respiration and reduced vital capacity. (Rabinowitsch, 1923; McKinley, 1924) The vocal complaints vary a great deal in type and severity, as given below: Excessive vocal fatigability, often associated with spasmodic conditions Short phonation time Altered vocal timbre, sometimes assuming a broken pot quality Tremolus intonation Slight huskiness
The Thyro vocal syndrome: First described by Van der Hoeve in 1928, it is defined as a vocal disorder encountered in patients suffering from enlarged thyroid glands, but without signs of overt hyper thyroidism. Most outstanding among the complaints in such patients is the great fatigability of the voice. Moreover these patients have difficulty with refined phonation and in producing the high tones when they are singers. Tarneand (1944) noted a certain dullness of vocal timbre.
Neuroparetic disorders: These occur in cases of thyroid enlargement when the goiter is pressing on adjacent structures. The features of this disorder are Compression of trachea Laryngeal symptoms like huskiness or low speaking voice Difficulty in singing high tones
It should be noted that the thyroid gland is anatomically related to the recurrent and superior laryngeal nerves. Structural thyroid disorders including goiter, tumor may interfere with voice by causing vocal fold paralysis, impingement of the larynx or trachea, or impairment of vertical laryngeal motion. Similar problems may arise consequent to surgery of the thyroid gland.
II. VOCAL DISORDERS OF PARATHYROID GLANDS:

The parathyroid glands, usually four in number, are small endocrine glands which lie behind the capsule of the thyroid gland. The parathyroid hormone has a powerful effect on the rate of renal phosphorous excretion, as well as on the level of blood calcium. Little is known about the association of vocal disorders with states of hyperparathyroidism. Simpson (1954) reported 5 cases of which presented hearing disorders and one aphonia. Gutman Swenson (1934) described a case in which almost aphonic voice was associated with moderate increase of the serum calcium.
Two possibilities of problems may be expected in such cases Spasmodic conditions of phonation and spectrum due to reduced parathyroid function i.e. hypocalcemia Muscular weakness and delayed nervous excitability in hypercalcemia, resulting from excessive parathyroid function.
III. VOCAL DISORDERS WITH ADRENAL DISEASE:

Adrenal glands have great importance in intermediary metabolism. The adrenal consists of 2 chief portions, cortex and medulla. Cortex produces cortico steroids and medulla produces epinephrine (adraneline) which controls blood pressure. Adrenocortical hypo function leads to a progressive fatal condition called Addisons disease. Vocal signs: The generalized and continuous condition of muscular adynamia leads to weakness of the voice. In advanced cases of Addisons disease, vocal weakness is inevitably present. Segre (1933) noted a dulling of the vocal timbre as a first sign of vocal weakness.
Towards the expression of sex hormone receptors in the human vocal fold. Schneider B, Cohen E, Stani J, Kolbus A, Rudas M, Horvat R, van Trotsenburg M (2007) BACKGROUND: The human larynx is assumed to be a steroid receptor target organ. There are only very limited data on the evidence of steroid receptors in the vocal folds, although voice alterations due to hormonal influence and treatment have been found. GOAL OF THE STUDY: To investigate the expression of estrogen alpha, progesterone, and androgen receptors in human vocal folds (vocalis muscle, glands, lamina propria, epithelium). METHODS: Immunohistochemically, vocal fold cadaver specimens of 15 autopsied patients (6 women, 9 men), which were taken approximately 4 to 8 hours postmortem were investigated. Furthermore, one (male) vocal fold biopsy obtained intraoperatively during a laryngectomy was tested. RESULTS: No specific immunohistochemical staining for the different types of steroid hormones investigated could be observed in either the postmortem taken biopsies nor the intraoperatively one. However, several unspecific staining patterns could be observed. CONCLUSION: The results of this study contradict recently published data and question the expression of sex hormone receptors in the vocal folds. Main causes of false interpretations of unspecific staining are discussed.
IV. DISORDERS OF VOICE RESULTING FROM PITUITARY DISEASES:

Hyper pituitarism: A tumor in the region of the pituitary gland can cause over secretion of the pituitary growth hormone somatotrophin, producing an untimely enlargement of bone, cartilage, and soft tissue. The result is a condition known as Acromegaly. The dysphonia of Acromegaly is an excessively low pitch and hoarseness, the consequences of enlargement of the vocal folds and cartilages. The reduced fundamental frequency of the voice is augmented by enlarged pharyngeal and oral cavities.
Because the tongue becomes enlarged and the mandible prognathic; articulation defects are common. It includes following diagnostic features, it causes gigantism, metabolic disturbances such as changes in function of other endocrine glands. In advance cases, disorders of vision, with bitemporal hemignopia on the optic chaisma.
V. DISORDERS OF GONADS:
a) Voice of the castrate: Castration means the total removal of the gonads. A male castration through excision of the testicles has been known since the beginning of recorded history. Early history castration was associated with religious rites. Monks who hope to active holiness through renunciation of male physiology function of behavior. Castration becomes cultural phenomenon used in musical art. Effect of castration: It depends on the age of the castrated person, if it is done before puberty, it prevents vocal mutation thus castrated individual maintains the infantile voice throughout the life.
Vocal characteristics: Respiration: it is same as in normal adult males in regard to breath volume and respiratory movements. This is the chief reason why the male castrato voice is considerably more powerful than the female suprano. Since the male vocal mutation is prevented, the castratos vocal range corresponds to that of the adult female voice. As a result, Average speaking pitch is one octave too high, being identical with the female speaking pitch. Castrate lacks both the, male and female emotional feelings neutral timbre.
Effects of testosterone replacement on a male professional singer. King A, Ashby J, Nelson C (2001) Testosterone has been known to play an important role in the development of the postpubertal male voice for many centuries. In fact, the prevention of pubertal development of the voice by castrating young male singers was a well-known practice, especially in Italy beginning in the sixteenth century. The "castrati" were well known for their clear, highpitched voices. Because of the resulting small larynx and vocal folds, castrati apparently produced a distinctive resonance as well as the high pitch, which cannot be matched even by the counter tenors of today. Busy voice labs occasionally see males with sex hormone deficiencies secondary to chromosomal or gonadal problems. This is a presentation of an unusual patient who was a trained tenor singer and was found to have hypogonadism on a premarital health examination. Administration of replacement testosterone resulted in significant vocal register and voice KUNNAMPALLIL GEJO ,MASLP quality changes.
Female castration: Surgical irradiation of the ovaries in mature women usually does not cause any significant change in the adult female voice. When the ovariectomy must be performed in relatively young women, vocal changes may be similar to those that occur during normal menopause.
The Eunuch voice: Definition: term Eonuchoidism is introduced by Tandler and Gross (1913). It is defined as a body form and constitution similar to true eunuchism even though no castration has been performed. - Several types of eunuchoidism, some of these individuals are very tall, short and obese. All types are characterized by hypoplasia of genitals, deficient development of the secondary sex characteristics and disproportion of the skeleton 1) Gigantism 2) Obesity 3) Dwarfism
Etiology: Pluriglandular theory according to which eunuchoidism is caused by several diseases of several endocrine glands. Primary eunuchoidism results from absence or early atrophy of the testes which is caused by the pituitary deficiency. Vocal signs:
voice corresponds to the infantile voice in boys average speaking range is higher ( Altmans 1980, Seeman 1937)
A report on alterations to the speaking and singing voices of four women following hormonal therapy with virilizing agents. Baker J (1999) Four women aged between 27 and 58 years sought otolaryngological examination due to significant alterations to their voices, the primary concerns being hoarseness in vocal quality, lowering of habitual pitch, difficulty projecting their speaking voices, and loss of control over their singing voices. Otolaryngological examination with a mirror or flexible laryngoscope revealed no apparent abnormality of vocal fold structure or function, and the women were referred for speech pathology with diagnoses of functional dysphonia. Objective acoustic measures using the Kay Visipitch indicated significant lowering of the mean fundamental frequency for each woman, and perceptual analysis of the patients' voices during quiet speaking, projected voice use, and comprehensive singing activities revealed a constellation of features typically noted in KUNNAMPALLIL GEJO ,MASLP the pubescent male.
The original diagnoses of a functional dysphonia were queried, prompting further exploration of each woman's medical history, revealing in each case onset of vocal symptoms shortly after commencing treatment for conditions with medications containing virilizing agents (eg, Danocrine (danazol), Deca-Durabolin (nandrolene decanoate), and testosterone). Although some of the vocal symptoms decreased in severity with the influences from 6 months voice therapy and after withdrawal from the drugs, a number of symptoms remained permanent, suggesting each subject had suffered significant alterations in vocal physiology, including muscle tissue changes, muscle coordination dysfunction, and propioceptive dysfunction. This retrospective study is presented in order to illustrate that it was both the projected speaking voice and the singing voice that proved so highly sensitive to the virilization effects. The implications for future prospective research studies and responsible clinical practice are discussed.
Incomplete vocal mutation: Incomplete mutation of the voice appears in three clinical forms. Delayed mutation or mutatio Tarda Prolonged mutation or mutatio prolongata Incomplete mutation or mutatio incompleta Etiology: Incomplete mutation is associated with slight delays in physical maturation. Vocal symptoms: Prolonged mutation is characterized by persistence of the signs of vocal change over a several years instead of during few months. Faulty speaking habits vocal fatigue ( Zumsteeg, 1916)
Chronic hoarseness & weakness of the voice
Speaking pitch is too high Vocal range is very small
Laryngeal findings are highly characteristic. Vocal cords show various degrees of hyperemia, congestion, and irritation. The posterior portion of the glottis shows mutation triangle. The posterior portion of the glottis appears incompletely closed during phonation. The sign is interpreted as weakness of the inter-arytenoid muscles, reflecting faulty coordination of the phonic musculature.
Predicting mutational change in the speaking voice of boys. Fuchs M, Frehlich M, Hentschel B, Stuermer IW, Kruse E, Knauft D (2007) SUMMARY: The authors investigated whether acoustic speaking voice analyses can be used to predict the beginning of mutation in 21 male members of a professional boys' choir. Over a period of 3 years before mutation, children were examined every 3 months by ear, nose, and throat (ENT) and phoniatric specialists. At the same time, the voice was evaluated acoustically using analysis features of the Goettingen Hoarseness Diagram (GHD). Irregularity component and noise component, jitter, shimmer, mean waveform correlation coefficient, and fundamental frequency were determined from recordings of the speaking voice. Significant changes of acoustic features appeared 7 and 5 months before mutation onset, which indicates that vocal function is already restricted 6 months before mutation onset. This acoustic voice analysis is therefore suitable to support the care of the professional singing voice.
Mutational Falsetto voice: Definition: The mutational falsetto voice is characterized by the continued habitual use of the falsetto voice for speaking. It occurs only in males. Mutational falsetto voice represents a functional avoidance of vocal mutation despite the normal growth of the larynx and the potential presence of a normal adult male voice. Symptoms: monotonous high pitch, pitch is very high usually that of female, typical signs of constant use of the falsetto register for all oral expressions.
Androphonia: Virilization of the female voice. The term virilization is used to refer to an increase in mass and size of vocal folds that occur in women as the result of excessive secretion of androgenic hormone or due to injection of androgenic containing hormones.
Relationship Between Weight, Speaking Fundamental Frequency, and the Appearance of Phonational Gaps in the Adolescent Male Changing Voice. Willis E, Kenny DT (2007) SUMMARY: This prospectively longitudinal study used acoustic analysis over 12 months to identify phonational gaps in the vocal range of adolescent boys undergoing voice change, and to investigate any relationship between the appearance of phonational gaps, weight gain, and changes in speaking fundamental frequency (SF(0)). Eighteen pubescent boys were recorded producing three descending and three ascending glides over their physiological voice range using the vowel "ah." Recordings were digitized over the range 0-16kHz and then analyzed to determine both the frequency range, and appearance and frequency characteristics of the phonational gaps.
Data were plotted against changes in weight and SF(0) both as an indicator of pubertal development, and to test the hypothesis that changes in weight and SF(0) were related to the appearance of phonational gaps. Results indicated that minimum F(0) decreased significantly over the time period, and phonational gaps increased significantly, but there were no significant changes in maximum F(0) or range. Individual data indicated the initial appearance of a lower-frequency gap followed by a higher-frequency gap before the long-term establishment of a midrange gap. At time 5, all boys in the weight range 42.744.9kg had either low- or high-range gaps. The SF(0) for this group varied from 117 to 216Hz. All boys heavier than 54.8kg had highly variable phonational gaps. SF(0) range for this group was 99.5151Hz. Transitory low- then high-frequency phonational gaps appeared before the establishment of a midrange phonational gap. In this study, these phonational gaps were associated with certain weight ranges and rapid weight gain, with changes to boys' speaking voices, and with loss of ability to use the midand falsetto vocal range. KUNNAMPALLIL GEJO ,MASLP
Voice changes depending on ovarian function: In women the endocrine system is active through out the life controlling the reproductive system, initiating the puberty and the menstrual cycle and withdrawing at the climacteric. Endocrine changes during menstruation and pregnancy may produce edematous vocal folds as a result of fluid retention (Van Gelder, 1974).
Premenstrual vocal syndrome: The syndrome usually starts some 4-5 days before menstruation in some 33% of women. Vocal professionals are particularly affected. Premenstrual syndrome clinical signs as described by Abithol, 1989, are Vocal fatigue Decreased range, with loss of high tones and pianissimo in singers Loss of certain high harmonics with a more metallic and huskier voice. Dynamic vocal exploration by televideolaryngoscopy shows Congested vocal folds Edema of the posterior third of the vocal folds and of the crico arytenoid areas Less supple epithelium, with decreased amplitude and vibratory asymmetry visible on stroboscopy Posterior chink
Menstrual Dysodia : The most changes of the voice during menstruation include a slight decrease in quality of the higher tones. These vocal changes are explained by the physiological alteration of laryngeal appearantance during menstruation. Several authors have stressed the fact that the vocal folds are hyperemic and possibly slightly edematous during these days.
Vocal syndrome of menopause: The womans change of life is also reflected in the voice. The hormonal climate is greatly modified by menopause and results in changes in the voice. In this stage there is no more progesterone, there are few estrogens and androgens appear. The affects androgens are multiple. They act on the cerebral cortex, genital organs, on striated muscles, and hence on the vocal muscles. Other characteristics Smears of the vocal folds (striking parallelism between cervical smears) demonstrating a relative mucosal atrophy from androgen effects. There is also muscular atrophy Glandular cells in the sub and supra cordal mucosa become rarified. Hence there is reduced hydration of the free edges of the vocal folds There is dryness during phonation leading to rapid vocal fatigue and to dysphonia.
Voice characteristics include: Lowered pitch In professional singers the voice eventually losses its youthful brilliance, power and ability to reach higher tones. With the advancing age female voice becomes more brittle, wobbly, possibly tremulous and weaker, and the vocal range is reduced through loss of high tones.
Perceived Effects of the Menstrual Cycle on Young Female Singers in the Western Classical Tradition. (Ryan M, Kenny DT). SUMMARY: This study investigated the perceived effects of the female hormonal cycle on young female classical singers. All the singers, including male controls, were tertiary singing students from the Sydney Conservatorium of Music, Australia, who were selected for entry into vocal study programs by competitive audition. Female participants completed a questionnaire and daily diary in the first and third months of the study. Male controls completed the diary for the first month only. The questionnaire and diary focused on singers' physical symptoms, their mood states, and vocal production. Analysis of the diaries indicated that although 81% of female singers reported regular menstrual cycles and 43% reported using an oral contraceptive, neither of these factors was related to the voice quality variables as measured on the first day of the cycle. Singers who were not taking a contraceptive pill rated their voice quality lower and their mood higher than those on the pill. There was no relationship between temperature recording in the females and day of cycle. Perceived voice quality for female singers was lower on days 1-3 compared to the remainder of the cycle and there was a KUNNAMPALLIL GEJO ,MASLP trend for ratings to improve through days 1-7.
The voice parameters for male singers tended to be slightly flatter over the cycle days than for females. Although voice quality in females indicated a tendency to be lower on average during days 24-4 of the cycle, voice quality for males tended to be more alike during the two phases, days 24-4 and days 5-23. Overall, reduced voice quality was associated with more negative mood experiences. The six most severely affected females completed voice recordings of specific vocal tasks on the first day of the cycle and again in midcycle. These recordings were randomly presented to both the participants and expert vocal pedagogues to ascertain whether significant differences in vocal quality were perceptually identifiable. Singers, but not pedagogues, were able to accurately identify the timing of the recordings. Although the singer recognized that greater effort is required to produce the sound during menstruation, discernible differences were not detected by expert listeners.
Laryngopathia gravidarum: In modern laryngological terminology, Laryngopathia means localized laryngeal disease other than gross lesions caused by laryngitis, Paralysis or tumors growth. Nadoleczny (1923) was one of the first observe lowering of the voice in some pregnant women. As a rule the voice remains unchanged during the first few months of pregnancy, at least as long as abdominal respiration is not disturbed by uterine enlargement. From about six months on, professional singers notice a definite impairment of phonic respiration, of respiratory support in particular, it follows that singing should not be continued after the 5th or 6th month of pregnancy because the inevitable vocal strain may do permanent damage to the best trained singing voice.
Other causes of vocal changes are based on vasomotor disturbances with in the upper airways. As a result laryngeal mucosa appears hyperemic, congested and succulent and shows increased secretary activity of the mucosal glands. According to Schreiners (1942) analysis, about 1/5 of pregnant women are afflicted with this Laryngopathia. The severity of the subjective complaints and the resulting hoarseness, vary from severe pain with choking spells and aphonia to mild degrees of irritation and huskiness. All symptoms and signs disappear soon after delivery.
Voice in trans-sexuals
Introduction: The term transsexual was coined by Harry Benjamin (1966) an American psychiatrist Charlolle Wolf (1977) defines transsexuals as people who believe that their mind is tapped in the wrong sex body. She explains that some people are satisfied with hormone therapy alone, but when there is a violent clash between their sexual and gender identity, some will only be satisfied with surgical reassignment. It is the sense of belonging to the wrong or opposite sex that disturbs them, rather than the qualities of masculinity or feminity.
According to Brown and Rounsley (1966), transsexuals are individuals who very strongly feel they are or ought to be, the opposite sex. The body they were born with does not match their own inner conviction and mental image of who they are or want to be this dilemma causes them intense emotional distress and anxiety and often interferes with their day to day functioning.
Prevalence There are no reliable methods of gathering accurate statistics on the prevalence of Transsexualism because there is no national registry and many transgendered people do not seek sex reassignment surgery. There is disagreement about what the ratio is and why. Some gender clinics and therapist report the male to female (MTF) and the female to male (FTM) ratio to be 3:2.
The Trans-Sexual voice Since surgical sex change procedures have been more readily available, an increasing number of transsexuals have been referred to speech therapy. Female transsexuals can take androgens which have the effect of increasing the mass of vocal folds with a resulting drop in vocal pitch. For this reason the female transsexual is less likely to be referred for speech therapy than the males.
The importance of the voice in male-tofemale transsexualism. Neumann K, Welzel C (2004) Transsexuality is a complex, permanent transposition involving a paradoxical feeling of belonging to the opposite sex. Furthermore, in the case of male-to-female transsexuals, the unchanged male voice, which is at odds with the female outward appearance, poses a serious obstacle to full social integration of the woman. One way of permanently raising the fundamental frequency, requiring little effort, is modified cricothyroidopexy via miniplates, which has been used in our hospital since 1993 following a technique developed by Isshiki (thyroplasty type IV).
Until now, this operation has been performed on 67 female patients. To record the anatomicalmorphological and functional data, preoperatively, post-operatively, and a year after the operation, a detailed voice diagnosis was made, laryngoscopy was carried out, X-rays were taken, and computerassisted tomography was used to examine the larynx. Thus far, the functional results have been good. On average, the fundamental frequency has been raised by about one fourth. Whereas none of the female patients had a female-speaking voice before the operation, after the operation, about 30% of the patients' voices were in the female range, and 32% had at least a neutral-sounding voice.
STEPS ALONG THE WAY- THE PERSONAL PROCESSES

The transsexuals move through different steps along their way to the opposite gender as follows (Freidenberg, 2002). Psychotherapy Most transsexuals are working with a psychotherapist, who is specially trained in the area of gender dysphoria issues. (Gender dysphoria- term that connotes discomfort with ones socially and culturally assigned gender role. Some times used as a synonym for transsexualism) Cross dressing and cross living Living as a woman for the whole time. In the earlier stages the client may have dressed as female for some times or only on weekends etc.
Physical appearance and voice in male-to-female transsexuals.

Van Borsel J, De Cuypere G, Van den Berghe H.
It has been suggested that sex judgments of male-tofemale transsexuals based on the voice may be influenced by the physical appearance of the clients. To explore this hypothesis, a listener experiment was designed in which a panel of 22 laypersons and 22 students in speech-language pathology rated the "femaleness" of fourteen male-to-female transsexuals from video-recorded speech samples in three modes of presentation: auditory-only presentation, visual-only presentation, and audiovisual presentation. Results indicate that appearance and voice are indeed interacting factors.
Ratings from the auditory-only presentation were significantly lower than ratings from the audiovisual presentation and ratings from the visual-only presentation were significantly higher than those from the audiovisual presentation. It follows that the success of voice training in male-to-female transsexuals is not solely dependent on vocal characteristics and that speech pathologists should consider incorporating physical appearance as a treatment and outcome variable in the voice training of male-tofemale transsexuals.
Beginning electrolysis Removing body and facial hair permanently. Its a long, expensive and uncomfortable process, depending on the amount of facial & body hair to be removed. Beginning hormone therapy A transsexual client usually obtains hormones from an endocrinologist and monitors the dosages. Hormones estrogen and progesterone with MTF transsexuals results in some development of female body features. Plastic surgery for cosmetic changes Some clients have surgery to reduce the masculine thyroid cartilage prominence. Others have facial reconstruction to change the contours of the forehead, check bones and mandible to obtain more feminine facial structure.
Vocal fold surgery To change their voice to more feminine Sex reassignment surgery- For some client, the ultimate goals is to have sex reassignment surgery. For others, the step is never taken to obtain their personal goal.
Phono surgery Phono surgery is still relatively experimental& does not always produce satisfactory results. Various procedures are advocated to raise vocal pitch by changing the mass, length and tension of the vocal folds. Isshiki (1980), states that stiffness is the most important factor. Brally et al (1978) describe restriction of the anterior third of the vibrating segment of the folds. These authors also note the work of Donald (1982) who describes a procedure in laryngeal web is created in order to obtain raised vocal pitch. A procedure which involves removing the anterior third of the vocal folds and then stretching them and reattaching them to the thyroid cartilage is described by Oates & Dacakis (1983). This has the effect of increasing vocal fold mass so that higher fundamental frequency is produced.
Isshiki (1980) regards three types of intervention as possible in these cases.

Increasing vocal fold tension by crico thyroid approximation A longitudinal incision of the vocal fold Steroid injection in to the vocal folds in order to reduce mass. Surgical intervention in these cases is still experimental and maintaining an un obstructed air way & avoiding marked deterioration in voice quality are major considerations.
Feminine after cricothyroid approximation?

Van Borsel J, Van Eynde E, De Cuypere G, Bonte K (2007)
SUMMARY: A number of studies have evaluated the effectiveness of a cricothyroid approximation (CA) in creating a more female voice in male-to-female transsexuals (MFTs) from an acoustic perspective. An increase in pitch is of little value, however, unless it accurately indicates listeners' perceptions of gender. The purpose of this study was to further investigate the effectiveness of a CA in feminizing the voice from a perceptual perspective. Video recordings of nine MFTs, nine nontranssexual males (NTMs), and nine nontranssexual females (NTFs) were presented twice to the panel of judges in a randomized order: first auditory only (only hearing a subject's speech) and subsequently audiovisual (hearing and seeing a subject's speech).
The panel of judges, 42 students (21 female, 21 male) from different disciplines, rated the participants' voices on a 100-mm visual analog scale with "very male" and "very female" as left and right extremes, respectively. The group of MFT obtained scores that were situated in between those of the NTM and the NTF, both for the auditory only and the audiovisual mode of presentation. Perception of femaleness significantly correlated with average fundamental frequency for both modes of presentation. It can be concluded that a CA approximation is a viable option to raise the voice pitch in MFTs but that this surgery alone may not be sufficient to create a voice that is perceived as a totally female.
Pitch-raising surgery in male-to-female transsexuals (Gross M) Several surgical methods for pitch raising have been described such as cricothyroid approximation, anterior commissure advancement, scarification, and injection of triamcinolone into the vocal folds. These procedures have different disadvantages and risks. A new method for pitch raising via endolaryngeal shortening of the vocal folds is presented. Long-term results of the first 10 patients are presented. In 1 person, who smoked immediately after surgery, coughed, and did not observe voice rest, there was a dehiscent suture. In 9 transsexuals after surgery the voice range was reduced for the lower frequencies, and a permanent 9.2-semitone increase of the mean, spontaneous fundamental frequency was obtained. Changes in employment many clients attempt to make a totally new beginning, wishing to be known only as a female in a new work setting. Others make transition other job.
THE INTERVIEW
When arranging for an appointment, find out immediately how your clients want to be addressed. Scheduling by telephone also provides the clinician with the opportunity to establish any requests, such as asking the client to come in female attire. Once the client arrives, establish name and pronoun preference, including any confidentiality issues regarding telephone messages or e-mails. If the client has not revealed her transsexualism at work, it is imperative to honor that privacy and make careful notes to avoid an error. The clinician will want to obtain all relevant information, as in any initial interview process. An important consideration is, knowing where the client is in the gender reassignment process. It is helpful to ask the client how she might describe her understanding of where she is on the gender continuum. This information may have significant implications for treatment.
It is valuable to find out about the individuals relationship to family members and colleagues around the transition. Have they been told? Are they supportive or not? Does the client have an ally in the work place? This is important information, enabling the clinician to understand what support or what limitations might be imposed on the client during the therapy process. For example, many clients are still in a marriage, with a partner who resents or threatened by any vocal changes and other indications that point to transition. In order to practice vocal exercise, the client must practice in private. Some times client has no place to practice and are shared housing arrangements.
Expectations range widely and play a very important role with this population. One individual may want to sound like the clinician or like the actress. Others are deeply concerned with the telephone because it is often most difficult to pass on the telephone without visual markers providing additional cues to the listener.
Prior to beginning therapy, it is important to note what the client has done independently in an attempt to create voice changes. Some clients have tried nothing; others have tried suggestions and videotapes available on the internet or have tried informally alone or with a partner. Some clients in this practice have had a professional back ground in music. Because the clients initial attempts to modify the voice can provide salient information about the client vocal skills, it is important to obtain a sample of the modified speaking or singing prior to proceeding with therapy.
This can significantly improve the efficacy and shorten the duration of therapy. Some clients, once given some specific tools and exercises, can achieve successful results independently with monitoring and pertinent targeted interventions provided by the therapist. Finally, it is essential to obtain a complete health history as an important component of the interview. If, in this setting, any vocal quality concerns are other medical issues such as upper respiratory problems or hearing loss are noted. Medical referrals are made before initiating therapy.
At the end of the intake interview, the speech language pathologist should have a clear idea of the clients goals, expectations, motivation, support, health issues and likely commitment to therapy. These combined factors, following exploration of some trial therapeutic tasks, should allow the clinician to make at least a preliminary estimate about the extent of anticipated treatment needed to achieve acceptable results.
Aerodynamic analysis of male to female transgender voice (Mary Gorham and Richard Morris, 2006), the aim was to asses the glottal airflow differences between the female and the male voices of transgender participants speaking in their female and male voices. In addition the glottal airflow differences between the voices of the transgender participants and age matched biologic female and male participants were also determined. The third goal of the study was to determine if any aerodynamic measures were correlated to listeners perception of the feminity MFT voice. Procedure involves, each participants were asked to prolong the /a/ vowel three times at a comfortable pitch and loudness level for approximately 5 sec. the MFT participants were asked to produce the sustained vowels first in their biological male voices and then in their female voice. The results of the study revealed a significant increase in maximum flow declination rate during female voice production. Perceptual ratings of a feminine voice were associated with a fundamental frequency of 180Hz or greater, although Fo did not differ significantly between KUNNAMPALLIL GEJO ,MASLP male and female voice production.
In this study, the MFT persons produced significantly higher MFDR while phonating in their female voices which suggests a more abrupt shutoff of the glottal airflow, i.e. greater closing speed of the vocal folds during phonation. The high MFDR values may suggest increased laryngeal tension while phonating in an attempt to increase Fo. Excessive stiffness and tension of the laryngeal musculature and vocal tract may contribute to greater closing speed of vocal folds.
Thank you,
KUNNAMPALLIL GEJO

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ENDOCRINAL VOICE DISORDERS AND VOICE DISORDERS RELATED TO TRANSEXUALS

KUNNAMPALLIL GEJO JOHN

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

Sex hormones and its relation to voice:

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KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

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II. VOCAL DISORDERS OF PARATHYROID GLANDS:

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III. VOCAL DISORDERS WITH ADRENAL DISEASE:

IV. DISORDERS OF VOICE RESULTING FROM PITUITARY DISEASES:

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

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Chronic hoarseness & weakness of the voice

Speaking pitch is too high Vocal range is very small

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KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

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STEPS ALONG THE WAY- THE PERSONAL PROCESSES

Physical appearance and voice in male-to-female transsexuals.

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

Isshiki (1980) regards three types of intervention as possible in these cases.

Feminine after cricothyroid approximation?

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

KUNNAMPALLIL GEJO ,MASLP

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