My Voice Sounds Too High (or Too Low)!
by Dr. Christopher Chang, last modified on
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Rarely, there are some adult individuals who are quite unhappy with their voice, not due to clarity or volume problems, but due to an abnormally low or high pitch. For men, this means that their voice sounds too high to the point that they are often mistaken for being female on the phone. Even for some women, this may be an issue as they come off sounding like a little girl.
Too low a vocal pitch is also a problem. For women, this means that their voice sounds so low that their voice is often mistaken for a man's.
And then there is the trans-sexual population where their voice does not match their new gender selection.
Before reading further, it may behoove you to learn how a voice is produced in the first place so that you can better understand the evaluation and treatment. Click here for an overall voice tutorial.
Voice is Too High and Needs to be Lower
For the man (or woman!) with the high-pitched voice, a workup is required before any type of intervention:
- Stroboscopic evaluation of the voicebox needs to be performed to characterize the anatomy of the vocal cords. Usually, the vocal cords will be found to be shorter and thinner than normal. Why does this matter? Keep in mind that vocal cords are just like a violin string; a thin string has a higher fundamental pitch than a thick string. Watch this video demonstrating this difference. Besides vocal cords, overall muscle tension in the voicebox and throat may also elevate the pitch. The analogy here would be akin to organ pipes where the shorter the length and smaller the diameter, the higher the pitch. Watch this video demonstrating this change. If you are not sure what you are looking at, click here for a tutorial on how a voice is produced.
- Endocrine evaluation which would include finding out the sexual hormone levels in the body, esp testosterone levels. Some men are found to have primary or secondary hypogonadism in which there is an abnormally low level of testosterone in the blood. Why is this important? Well, testosterone is the main hormone responsible for male secondary characteristics obtained during puberty which includes a deep voice.
- Voice therapy evaluation. The main point of this evaluation is to determine whether thoracic, cervical, pharyngeal, and laryngeal muscles are playing a role in the abnormally elevated vocal pitch and if so, whether these muscles can be "adjusted" to decrease vocal pitch through exercises.
- Rarely, a psychological evaluation may be needed.
With this information, the proper course of treatment can be determined to lower the vocal pitch to a more appropriate level. Such an intervention may include:
- Voice Therapy (almost always a first-line treatment prior to pursuing other treatments). Variable response and may take several months.
- Hormone therapy under endocrinologist supervision (usually testosterone administration). Improvement occurs slowly over 3-12 months.
- Surgical (see below). Depending on the surgical approach, response may be variable, but long-lasting with minimal patient effort.
For the woman with an abnormally high-pitched voice, a stroboscopic evaluation is all the workup required. In terms of treatment, voice therapy almost always is the one and only treatment needed. Endocrine evaluation is not necessary.
Voice is Too Low and Needs to be Higher
For the woman with the low-pitched voice, a similar workup is required except for the endocrine and psychological evaluation which only rarely are needed.
- Stroboscopic evaluation of the voicebox needs to be performed to characterize the anatomy of the vocal cords. Usually, the vocal cords will be found to be much thicker than normal. This thickness may be due to a vocal cord mass or polypoid degeneration (often associated with smokers and "talkers").
- Voice therapy evaluation. The main point of this evaluation is to determine whether thoracic, cervical, pharyngeal, and laryngeal muscles are playing a role in the abnormally decreased vocal pitch (ie, the "glottal fry") and if so, whether these muscles can be "adjusted" to increase vocal pitch through exercises.
Personally, I have yet to encounter a man who complains his voice is too low, but the evaluation would still be the same as that for the woman.
Surgery to Adjust Vocal Pitch
If an abnormally low vocal pitch is due to a vocal cord mass, that's by far the easiest to correct and the outcome almost always very favorable by removing the vocal cord mass. In all other cases, adjusting the pitch of the human voice is not easy and the results never guaranteed, esp if the vocal cords are anatomically normal. In general, increasing the vocal pitch is easier than decreasing it.
Please note that our office no longer offers elective vocal pitch surgery.
Decreasing the pitch of the human voice surgically is mainly acquired by one of 2 strategies.
- Decreasing the length of the vocal cords
- Laryngoplasty (Isshiki Thyroplasty Type 3) whereby thin strips of the paramedian thyroid cartilage are removed in order to decrease the front-to-back length of the voicebox (thereby shortening the vocal cords making them thicker).
- Laryngoplasty (Modification of the Isshiki Thyroplasty Type 3) whereby a central cartilage window of the thyroid cartilage is mobilized and recessed posteriorly with an implant in order to decrease the length of the vocal cords (thereby shortening the vocal cords making them thicker). Publication
- Botox injection to the cricothyroid muscles (results in the inability of the vocal cords to lengthen). Downside if the results are good is that the botox does wear off and reinjection needs to occur every ~3-4 months. If this works reliably, there is a surgical equivalent.
- Making the vocal cords thicker
- Injecting collagen into the vocal cords (thereby making it thicker)
Increasing the pitch of the human voice surgically (assuming normal vocal cords) is accomplished by:
- Stretching the vocal cords thin
- Cricothyroid approximation
- Anterior commissure advancement
- Decreasing the length of the vocal cords
- Anterior glottic web
- Laryngofissure approach (excising half the vocal cord lengths and reattaching)
Obviously there are risks involved with each of these procedures and voice therapy is mandatory both before and after the procedure for best outcomes.
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