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Innovative Larynx Restoration Surgery

Patient Speaks for first time in years

Amy Hancock had three weeks to figure out what her first words would be. Hancock, who lost her voice to laryngeal cancer over five years ago, had time to think about it after undergoing an innovative larynx restoration surgery at Barnes-Jewish Hospital on May 23.

On June 16, her surgeon, Washington University otolaryngologist Randal Paniello, M.D., removed a tube from her throat, allowing her to speak for the first time post-op.

Her first words: "Thank you, Dr. Paniello."

Prior to surgery, Hancock, 26, was only able to speak with the help of an electrolarynx. Hancock would hold the small microphone-like device against her throat to create sound. Now, she can verbally communicate without the help of the device.

Her voice is weak at this point, but Dr. Paniello doesn't think it will be for long. "We expect with more practice that she'll sound like a woman with a hoarse voice," said Dr. Paniello. As for the electrolarynx, "she'll be dropping that in the trash very soon," he says.

Using skin tissue, an artery and a vein from Hancock's forearm and some cartilage from her nose, Dr. Paniello and his team crafted a makeshift speaking tube and placed it between her trachea and esophagus. To Dr. Paniello's knowledge, he is the only surgeon to attempt this procedure in the United States.

"It's worth everything," says Hancock, "It's worth all the stitches all the bandages, everything."

While there was a chance the surgery wouldn't work, Hancock never lost hope according to her mother, Mary Anne Pittman. "She said it was going to work," says Pittman, "She knew all along."

Hancock was diagnosed with laryngeal cancer when she was only 20 years old.

After failing to respond to traditional radiation treatment, she underwent surgery to have her larynx removed. Doctors tried three times to perform conventional surgical techniques to restore her voice, but all failed.

The staff at BJH clearly touched Hancock's heart and vice versa. Several nurses and staff members from Dr. Paniello's team came to support her at a press conference for local media following up on her surgery. "I want to thank the doctors and nurses," says Hancock, "I was very well cared for here."

Second write up on this:

Rare voice surgery
Here is first for US

When Amy Hancock lost her larynx to cancer, she thought she had lost her voice forever.
But today, Dr. Randal C. Paniello, a head and neck surgeon at the Washington University School of Medicine, will remove tissue from Hancock's left arm and fashion it into a tube that may enable her to talk. The surgery will be at Barnes-Jewish Hospital.

The surgery has never been done in the United States, but has helped at least 10 people in Germany talk after losing their larynxes.

Hancock, 26, remembers the moment she lost her voice - five years, five months and 13 days ago. It was the defining event of her life - "but not in a bad way," she said.

Many good things have happened to her since she lost her larynx, Hancock says, including getting the five-pound toy poodle she dotes on. She carries a small photo album in her purse. Most of the snapshots show the black dog, named Macie, in various outfits, including a tiny white wedding dress.

But Hancock got her poodle for more than companionship. The diminutive dog is also an alarm system. Hancock lives alone and can't scream if something bad were to happen, she said.

Hancock's doctors tried surgery after surgery, injections of botox - lots of botox, Hancock says - to give her more normal speech. Botox is used to increase vibrations, which are needed for speech, by stopping muscle spasms in the throat. None of those attempts worked, and Hancock uses an electrolarynx to speak. Hancock holds the device, which looks like a small microphone, against her throat. The electronic larynx creates vibrations, allowing Hancock and other users to speak. But the sound is robotic.

And there are other annoyances. At the grocery store, Hancock has to dig through "about five pounds of lipstick" in her purse to find the electronic device just to answer the question, "Cash or credit?"

She had to alter her career plans. Most likely, Hancock will not work as a country radio DJ again as she did before starting college. She works in the membership office at the Missouri Botanical Garden.

Hancock says her doctor understands the daily frustrations of living without a larynx and has been aggressive in helping her pursue a better quality of life. So when Paniello approached her with the chance to try the new technique, she jumped at it, she said.

A larynx transplant would give Hancock the most benefit, Paniello said, but only a few larynxes have ever been transplanted in humans - only one successfully. Transplants pose particular dangers for cancer patients. The drugs used to suppress rejection of the transplanted organ may also keep the body's immune system from fighting off a recurrence of cancer, Paniello said. Hancock's insurance company would not approve the experimental transplant procedure.

So Paniello looked through medical and scientific literature and found a report from a doctor detailing a new way to help people speak.

Paniello will remove a patch of skin from Hancock's left arm. He also will take an artery and vein to feed the flap of skin. As a result, Hancock will have no pulse in her left arm. Paniello will repair the wound in Hancock's arm with a skin graft from her leg. She will have to wear a cast on her arm to allow the graft to heal properly.

Hancock said the scavenging of "spare parts" from her body doesn't bother her. "I'm already like a road map. I don't worry about more scars," Hancock said.

Paniello will fashion the 2-inch-by-2-inch patch of skin into a breathing tube that he will insert into Hancock's trachea. The German doctors simply extend the windpipe with the tube of skin when the larynx is removed, but Hancock's trachea has been turned to allow her to breathe through a permanent hole in her throat. Consequently, Paniello must make an incision in the trachea and insert the skin tube to reconnect Hancock's trachea and esophagus.

The doctor will also use a small piece of cartilage from Hancock's nose to make the flap at the end of the tube stiff - like a trash can lid, Paniello said. The flap is crucial for the tube to function properly, he said.

Normally the larynx closes to keep food or liquid out of the lungs. The flap should perform the same function. The tube will be positioned so that food or drinks traveling down the esophagus to the stomach push the flap down to cover the tube.

Because Hancock breathes through the hole in her throat, she must block the open trachea to talk. When she covers the hole with either her thumb or a removable valve, air is forced through the tube, causing the flap at the end to open and let the air into Hancock's oral cavity.

Hancock says she looks forward to the chance to express herself without the use of electrolarynx.

"I think my life will be better with a more normal-sounding voice," Hancock said.

But Hancock's voice will not be normal, Paniello said. "She won't end up with a high-frequency feminine sound," he said. Physics won't allow it.

In people with intact larynxes, the vocal cords open and close rapidly, producing vibrating jets of air coming from the lungs. The tongue, lips, and mouth shape the vibrating air into the distinctive sound of a person's voice.

Most men's voices have frequencies that range from about 100 hertz to 160 hertz. The lower the frequency, the lower the voice. Women's voices usually range from about 150 hertz to 250 hertz. But the tissues in the neck, including the transplanted tissue from Hancock's arm, vibrate at much lower frequencies - well below 100 hertz - giving patients who talk without larynxes a rumbling, gravely voice, Paniello said.

Many say it's still an improvement over the robotic monotone of the electrolarynx.

"It's better to sound hoarse than to sound like a machine, they think," Paniello said.

Hancock said she's realistic about the expectations she has for her new voice.

"I think I'm probably never going to sing a duet with Garth (Brooks), but I probably never would have anyway." She says she will work hard to have a better voice.

Her doctor doubts that speech therapy will make her sound like a woman, but doesn't doubt his patient's dedication.

"I know that, though, if anybody can make it work, it's her. She's very motivated," Paniello said.

She doesn't feel that she is brave to try the surgery, Hancock said. Anyone in her position would do the same, she said.

"It's not like I said 'God, my life is boring. Why don't you challenge me?'"

By Tina Hesman of the Post-Dispatch
May 23, 2003













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