Case Study of Laryngotracheal Transplant

Introduction

•   Loss of laryngeal function impacts communication, swallowing, and respiration and affects overall quality of life (QOL).
•  Laryngeal transplantation has been proposed as an option for patients not amenable to alternative treatment options.
• Challenges in microvascular reconstruction and re-innervations, as well as ethical considerations for the transplantation of a non vital organ, have limited the acceptance of this procedure.

Subject (Case History)

• 51 year old female with a prolonged history of traumatic, tracheotomy tube- dependent, benign, and complete laryngotracheal stenosis (stenosis extended to the second tracheal ring).
•  Failed endoscopic restoration of laryngeal quality. Patient was determined by a multidisciplinary team to be not amenable for nontransplant alternatives for restoration of laryngeal function.
• Patient underwent psychological assessment, counseling, and informed consent. Clearance to perform the transplant surgery was obtained. In addition a research protocol, and informed consent were approved by the University of California Review Board.

Preoperative Evaluation and Preparation

• Patient underwent preoperative laryngeal electromyography (EMG) and comprehensive videofluoroscopic swallow study from lips to stomach.
• Patient was extensively counseled and prepared for a laryngectomy and tracheoesophageal puncture as a fallback procedure if the transplant failed.

Results of Transplant

• No signs of clinical or pathologic rejection of transplant to this date. Multiple biopsies were taken (6 hours, 1, 14, 30, and 137 days) post- transplant. All of which showed a normal appearing larynx with no detection of rejection.

• Airway: The larynx and trachea were inspected on a frequent basis post-transplant (everyday day for 8 days, 10, 14, 20 days).
• Voice: The patient was able to speak 14 days after she received the transplant. Three months after surgery, sensory testing of the larynx revealed a typical laryngeal adductor response bilaterally but limited, primarily paradoxical vocal fold movement noted. Botox injections were given to the patient which induced extreme lateralization of the vocal folds. Two months later her voice and tone was back to normal and her vocal folds remained minimally mobile in a median position.
• Acoustic measures: acoustical recordings from standardized speech tasks were measure. The patient’s fundamental frequency range measured was considered within normal limits.
• Swallowing: Recovery of swallowing function was prolonged.

1. Evidence of pharyngeal motor integrity and epiglottic inversion was present after 4 months.
2. Botox injections were performed 2 months postoperatively due to management of pooled secretions.
3. A mild stenosis at the pharyngeal site was identified at 5 months postoperatively. Stenosis dilated in clinic.
4. Patient underwent daily dysphagia therapy after surgery and was transitioned to three days a week at home. She was cleared to eat a pureed diet at 7 months, a general diet at 11 months, and her gastrointestinal tube was removed at 13 months. At 18 months she denied any difficulties with dysphagia and no signs or symptoms of aspiration pneumonia.

• A multidisciplinary approach resulted in a successful transplant without evidence of rejection to this date.
•  This case study demonstrates successful transplantation of a larynx with a long segment of trachea. Many refinements and advances are described in this report: successful revascularization and transplant of larynx and trachea, and first attempt at selective innervations of the left vocal fold. Challenges to this patients swallowing may have been due to her extensive history of diabetes and associated neuropathy, however, this must be a part of pre-operative counseling for future patients receiving laryngeal transplant surgery.

Resource:

Farwell, G.D., Birchall, M.A., Macchiarini, P., Luu, Q.C., de Mattos, A.M.,  Gallay, B.J.,

Richard, V.P., Grow, M.P., Ramsamooj, R., Salgado, M.D., Brodie, H.A., Belafsky, P.C. (2013). Laryngotracheal Transplantation: Technical Modifications and Functional Outcomes, The Laryngoscope, 123, 2502-2508.