Rare larynx transplant restores voice

UC DAVIS (US) — In only the second transplant surgery of its kind, surgeons have replaced the larynx, thyroid gland, and trachea of a woman who has been unable to speak for more than a decade.

“We are absolutely delighted with the results of this extraordinary case,” says Gregory Farwell, associate professor of otolaryngology at University of California, Davis and lead surgeon for the transplant.

“The larynx is an incredibly complex organ, with intricate nerves and muscles functioning to provide voice and allow breathing. Our success required that we assemble an exceptional, multi-disciplinary team, use the most recent advances in surgical and rehabilitation techniques, and find a patient who would relish the daunting challenges of undergoing the transplant and the work necessary to use her new voicebox.”

The only other documented larynx transplant took place at the Cleveland Clinic in 1998.

Prior to the transplant, the patient was unable to speak or breathe normally because of complications stemming from a previous surgery several years ago that closed off her airway and made her completely dependent on a tracheotomy tube.

For more than a decade, she has been limited to vocalizing words using a handheld electronic device that produces an artificial, robot-like sound. In order to breathe, she has relied on the tracheotomy, which is still in place and visible at the base of her neck.

“This operation required extensive planning and a range of specialties,” says Peter Belafsky, associate professor of otolaryngology who brought Jensen’s case to the attention of his colleagues and was the transplant project’s principal investigator.

Because the patient’s condition was not life-threatening, the transplant was an elective procedure.  Transplantation is not an option for everyone who suffers from a missing or nonfunctioning larynx because it requires a lifelong regimen of immunosuppressant medications to guard against organ rejection.

“Despite decades of effort, patients with advanced laryngeal disease or injury have faced reconstructive procedures that are literally 150 years old,” notes Martin Birchall, professor of laryngology at University College London and a visiting professor of otolaryngology at UC Davis.

“This transplant provides us with a much greater understanding about the viability of laryngotracheal transplantation and patient response, and it may prove to be a good option to help other people.”

Correctly reattaching blood vessels and nerves was critical to the success of the operation. The acts of swallowing, moving the vocal chords and breathing entail complex and coordinated movements, requiring good blood perfusion and well-functioning nerves.

Much of the delicate implant work was conducted using a double-sided, surgical microscope, with surgeons working simultaneously on each side of the patient to suture the organ into place. Five nerves, three arteries and two veins were reconnected during the operation.

“Being able to restore nerves and reconnect blood vessels in and around the larynx and trachea, and have it all work, was a real test,” says Paolo Macchiarini, professor of regenerative surgery a Karolinska Institutet in Sweden, who led the world’s first in-human transplantation of a tissue-engineered windpipe in 2008.

“Not only is it highly relevant for future transplants, it offers us insights that may one day lead to using stem cells to repair the voicebox and surrounding areas in the throat.”

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