55 year old who worked as a medical secretary before becoming a full time carer.

Voice scores: VHI-10: 20, GRBAS: 11001, RSI: 16, Narrative speech frequency: 148 Hz

Background: Total thyroidectomy in December 2020 for a very large predominantly left side retrosternal goitre causing tracheal shift and narrowing. Immediately after the surgery, she woke up with hoarseness and an endoscopy examination 8 weeks post operatively confirmed mobile cords bilaterally. She was managed with SLT vocal therapy which had only improved her voice slightly.

Because of the persistently low pitched voice, she was unhappy with it and was referred to our centre in September 2021 for a second opinion.

Assessment: Videostrobolaryngoscopy confirmed bilateral mobile cords however there was a lack of stretch on both cords with falsetto pitch. Given the suspicion of SLNs injury, an LEMG performed in February this year had confirmed only one motor unit fibre present in each cricothyroid muscle bilaterally. Both left thyroarytenoid muscles had normal signals.

Outcome: After a total of 11 months of SLT input at our center, despite her best effort, she continues to feel her voice is hoarse and she is often mistaken as male over the telephone. She is very keen for surgical intervention to improve her pitch and following a discussion on the options of endoscopic glottoplasty versus laryngeal framework, she decided to proceed with type IV thyroplasty due to the instant feedback and benefits from LA.