Cricothyroid Approximation
CTA, or Isshiki type IV thyroplasty in the textbooks, has been used to raise pitch for longer than any other operation still in common use. It works from the outside. Through a small cut in the front of the neck, the surgeon stitches the thyroid cartilage and the ring of cartilage below it closer together. That tilts the voice box and stretches the vocal folds inside, and a tighter fold vibrates faster.
The folds themselves are left alone. Nothing is cut or joined inside the airway, which is the main thing that sets CTA apart from a glottoplasty.
The catch is durability. CTA can lift pitch a long way at first, but part of that rise tends to relax over months or years as the stitches and cartilage settle. That is why most surgeons now use it second, or alongside a glottoplasty, rather than on its own. I have watched people leave hospital thrilled with a voice that had drifted noticeably lower by their one-year check, and I would rather you knew that going in.
At a glance
- Also known as
- CTA, Isshiki type IV thyroplasty, type IV thyroplasty
- Surgery time
- About 1–2 hours
- Anaesthesia
- General, or local with sedation so you can speak during it
- Hospital stay
- Day case or one night
- Back to work
- About 2 weeks for desk work that doesn't need your voice
- Full recovery
- 3–6 months to use the voice freely; pitch is judged at around a year
- Scar
- A few centimetres, in a skin crease below the Adam's apple
- Typical cost
- Roughly $8,000–$16,000 (United States, self-pay)
Figures reviewed .
On this page
Who it’s for
The usual candidate has done the training and hit a wall. Months with a speech-language pathologist, resonance and intonation in decent shape, and a speaking pitch that still drops the moment they tire or stop concentrating. For some of them the gap is wide enough that a surgeon wants more lift than a glottoplasty alone tends to give.
The other common route here is a glottoplasty that helped but not enough. CTA works on the cartilage frame rather than the folds, so it can be added later without undoing the first operation. Some surgeons do the two together from the start.
Some surgeons preview the effect before anyone operates. With a camera in place, they press the two cartilages together gently from the outside while you speak, which gives a rough sense of how far your voice might rise. It is a guide rather than a guarantee, and if yours is offered, it is worth hearing.
Hold off if you have not trained, or if what gives you away is resonance rather than pitch. If the gap is modest, a glottoplasty is the more common first step, and if you cannot live with some of the gain fading, this is the wrong operation to lead with. Singers should raise their range at the first appointment, because CTA narrows it.
You do not need to have been on hormones, since oestrogen does nothing to the larynx. Surgeons will want you off nicotine for several weeks either side, and any reflux treated beforehand.
At the assessment
Ask whether the surgeon can press the cartilages together while you speak, to preview the rise. Listen closely to how that voice feels to make, not only how high it goes, because that tension is what you would be living with.
How it’s done
The operation copies, permanently, something your body already does. When you slide up to a high note, the cricothyroid muscle pulls the front of the two cartilages towards each other and stretches the folds. CTA holds them in that position with stitches.
Some surgeons keep you lightly sedated under local anaesthetic for the key part, because it lets them hear the result. You will be asked to say a few words or hold a note while they adjust the tension. Others use a general anaesthetic and set the tension by measurement and experience.
The incision is short and horizontal, low on the front of the neck, usually in a natural crease. The thin muscles over the voice box are eased apart down the middle to get at the cartilage. Stitches go through the lower edge of the thyroid cartilage and the top of the cricoid cartilage below it, sometimes over small buttons or plates to spread the load.
Drawing those stitches together tips the front of the thyroid cartilage down, and the folds behind it lengthen and tighten. The tension is checked, by your voice if you are awake, then tied off. Some surgeons also remove tissue between the cartilages so they scar together, which is meant to hold the position better over time. The muscles and skin are closed, occasionally over a small drain. Nothing enters the airway, so there is no stitching inside the throat.
Before the operation
Ask whether you will be awake enough to speak while the tension is set. If you will, practise a short phrase at your target pitch beforehand, so you have something easy and familiar to say on the table.
Cricothyroid approximation recovery
The neck is the part you feel. It is sore, swollen and stiff at the front for the first week or so, and swallowing feels odd. Ordinary painkillers usually cover it.
Voice rest is the part you have to work at. Most surgeons ask for complete or near-complete silence for about a week, then a slow, rationed return. The stitches are holding cartilage that has not healed into place, and loud or strained voice pulls against them. The early voice is often breathy and higher than it will end up, and it tires quickly.
After that, recovery is retraining. The new pitch needs resonance and habits to match it, and most of the people I have seen get a good long-term result carried on with a voice therapist for months afterwards. Your surgeon's protocol wins wherever it differs from the timeline below.
| Day 0 | Home the same evening or next morning. Dressing on the neck, throat feels full. Silence starts now. |
|---|---|
| Days 1–7 | Voice rest, no whispering or throat clearing. Neck swelling at its worst, then easing. Soft foods help. |
| Weeks 2–3 | Short, quiet speech allowed on your surgeon's schedule. Desk work realistic if it doesn't need calls. |
| Weeks 4–8 | Talking time builds. Voice thin and tires fast. Therapy restarts and focuses on easy, unstrained use. |
| Months 3–6 | Most everyday limits lifted. Scar softening. Some drop from the first post-op pitch is common in this window. |
| Months 9–12 | Pitch has mostly settled. This is the fair point to judge the result and discuss any revision. |
In the first three months
Don't judge the result by the voice you have in the first weeks. It is usually higher than the one you will keep, and expecting the drop makes it far easier to live through when it comes.
Read more: Voice Training After Surgery
Cricothyroid approximation scars
One horizontal line, usually a few centimetres, low on the front of the neck. Surgeons try to hide it in an existing skin crease. It is pink and firm for a few months, then fades to a pale line over a year or so for most people. On some necks it stays raised or widens, and darker skin can heal darker along the line.
Risks and complications
In the first week the risks are the ordinary ones for a short cut in the neck. A bleed or infection in the wound, fluid gathering under the scar, or swallowing that feels tight for a few days. Swelling around the airway can occasionally make breathing feel tight in the first day or two, which is one reason some surgeons keep you overnight.
Voice problems come next. The voice can be hoarse or breathy for weeks, and some people are left with a voice that tires faster or has less power at full volume. Overcorrection, a voice that sounds strained or too high, is less common than the opposite but does happen.
The risk specific to CTA is relapse. The stitches can loosen or cut through the cartilage, and the tissues can stretch back towards where they started. Published reports vary widely on how often and how much. Some loss of the early rise is common, and a near-complete return is possible. A revision is technically harder than the first operation, and its result is less predictable.
Cricothyroid approximation results
A good result, judged at around a year, is a speaking pitch that sits higher without effort, holds up through a long day, and still sounds like your voice.
What tends to disappoint is range. CTA holds the folds taut, so the lower notes go, and many people find it harder to drop into a deeper voice on purpose. Some lose a little at the top as well. Singers feel this most. The other disappointment is expecting pitch to finish the job, since a higher voice with untrained resonance can still be heard as male.
Judge the number with the timing in mind. A pitch measured in the first weeks, when swelling and fresh stitches hold the folds tight, will almost always be higher than the one you keep. If a surgeon quotes results, ask when they were measured.
Alternatives to cricothyroid approximation
Training comes first for everyone, and plenty of people find it is enough. Voice feminization training changes resonance, intonation and weight, and surgery changes none of those.
If surgery is on the table, Wendler glottoplasty is now the more common first choice in many hands. It shortens the vibrating part of the folds through the mouth, with no neck scar, and its rise tends to hold better. CTA earns its place when the gap is large, when a glottoplasty has fallen short, or combined with one. Feminization laryngoplasty is the bigger neck operation some surgeons offer instead. Laser voice adjustment is the smallest option, with the most modest and least predictable effect.
If two surgeons recommend different operations for the same voice, I would take that as normal rather than alarming. This is an area where experienced people disagree.
Wendler Glottoplasty
A Wendler glottoplasty joins the front of the two vocal folds into a small web, leaving a shorter length to vibrate and a higher voice. It is done through the mouth, leaves no visible scar, and costs some of the lower range and volume for good.
Best for: someone whose trained voice still falls back to a low pitch under strain
Feminization Laryngoplasty
A feminization laryngoplasty opens the voice box through the front of the neck, narrows the thyroid cartilage and shortens the vocal folds inside it, often with a shave of the Adam's apple. It aims at a larger pitch change than glottoplasty, with a neck scar, a heavier recovery and thinner long-term evidence.
Best for: someone who has trained, wants a bigger pitch change than glottoplasty offers, and can reach a surgeon who does many of these
Laser-Assisted Voice Adjustment
Laser-assisted voice adjustment treats the vocal folds with a laser through the mouth, reducing their bulk and stiffening them so they vibrate faster. It is the lightest of the pitch operations, with the smallest and least predictable rise and the thinnest evidence.
Best for: someone with a small remaining pitch gap who wants the lightest possible procedure
Combining cricothyroid approximation with other surgery
CTA is often paired with a glottoplasty, either in one sitting or as a second step, so the tension from one adds to the shortening from the other.
It also pairs naturally with a tracheal shave, since both go through the front of the neck. Some surgeons do the two through a single incision. The CTA stitches pass through the thyroid cartilage, so anyone shaving it later needs to know exactly where they sit. If both are on your list, tell every surgeon involved before either date is set.
Cricothyroid approximation cost
Ask for the all-in figure. The pre-operative scope, surgeon, anaesthetist, theatre and any overnight stay should all be in it, and some practices quote the surgeon alone. Then ask what happens if the pitch drops back. Relapse is a known part of this operation, so a practice's policy on revision matters more here than for most procedures.
Therapy afterwards is rarely included, and it is not optional. Budget for months of sessions alongside the operation itself.
| Country | Self-pay | Public / insurance |
|---|---|---|
| United States Offered by fewer surgeons, so the spread of quotes is wide | Roughly $8,000–$16,000 | Often refused as cosmetic; appeals sometimes succeed with a therapist's letter |
| Thailand Stay about two weeks; line up a therapist at home before you fly | Roughly $3,500–$7,500 | Self-pay only for international patients |
| United Kingdom Offered by a small number of private laryngologists | Roughly £6,000–£12,000 | Therapy is funded through gender services; surgery almost never |
Choosing a cricothyroid approximation surgeon
CTA is done by laryngologists, usually as part of a wider voice surgery practice. Two numbers are worth asking for. How many they do a year, and how many of those patients lost a meaningful part of the rise by the one-year mark. A surgeon who follows people for a year or more can answer the second one. A surgeon who can't may not be seeing them long enough to know.
Ask why they'd choose CTA for you rather than a glottoplasty, or both. A clear reason tied to your gap and your earlier treatment is a good sign. Ask to hear recordings from a year out, not just the week after. Ask, too, whether they'll work with your voice therapist, because the result depends on the months after the operation.
At the consultation
Ask what they do when a patient's pitch drops in the first year, and what that costs. A surgeon who has a practised answer has followed their patients long enough to see it.
Frequently asked questions
Is CTA the same as a glottoplasty?
No. A glottoplasty shortens the folds from inside the throat. CTA tightens them from outside by moving the cartilage, through a small neck cut. See alternatives.
Will the higher pitch last?
Some of it usually does, but part of the early rise commonly relaxes over the first year or so. See risks.
Can I sing afterwards?
Many people can, but with a narrower range, and the lowest notes usually go. Raise it before you book. See results.
Do I still need voice training after CTA?
Yes. The operation moves pitch only. Resonance, intonation and speech habits still need practice, and they decide how your voice is heard.