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Larynx graft gives patient a natural voice again

CLEVELAND-It wasn’t quite “Dr. Strome, I presume,” but the whispered, raspy “hello” was good enough for anyone.

Forty-year-old Timothy Heidler had waited half his life to say hello, and Cleveland Clinic otolaryngologist Marshall Strome was the man who let him. Heidler’s gravelly salutation was the first word uttered with the world’s first successful total laryngeal transplant, performed by Dr. Strome just 72 hours earlier.

A motorcycle accident in 1979 destroyed Heidler’s larynx, leaving him dependent on an electrolarynx for speech. He had never liked it and yearned to speak naturally.

Meanwhile, Dr. Strome had been dreaming about transplanting a larynx. In an attempt in Belgium in 1969, the larynx was never fully perfused and the still-speechless patient died.

During 20 years of research, Dr. Strome delineated three objectives of laryngeal transplantation-creating a stable, patent airway; establishing effective glottic closure; and crafting a functional voice. Unlike previous investigators who used a dog model, Dr. Strome chose a rat in the early 1990s. “The rat model was sentinel,” he says. “With it I was able to define the time interval for the larynx to be maintained without blood-20 hours.” He used 3-D simulations to construct models of swallowing.

In 1996 Dr. Strome was ready to try the procedure on a human. His ideal patient would be young and healthy, with the proper psychological profile. Dr. Strome put the word out on the ENT grapevine that he was planning a total laryngeal transplant and was looking for candidates who hadn’t had cancer. Heidler fit the perfect-patient profile.

Once patient and surgeon were matched up in late 1996, the search for a donor began. Dr. Strome wanted not only a blood and tissue match, but also bulk, a donor organ large enough so that when it was transplanted “the vocal cords would be close enough together that you don’t need motor function.” With closely packed vocal cords, the patient can be taught to cause them to vibrate-causing sound-by force of air.

Another problem was revascularization and perfusion. To assist this, Dr. Strome decided to transplant the donor’s thyroid as well as larynx.

On Jan. 3, Dr. Strome was notified that a hospital in Cincinnati had what was believed to be the perfect donor. With his full surgical team, Dr. Strome flew there to harvest the organs. Because of the historic nature of the operation, all six head-and-neck surgeons at the clinic, plus two residents, got a chance to participate in the harvest and then the 12-hour transplant here. Revascularization worked, with full perfusion of the grafted larynx in 10 hours.

In the future, the plan is to have two surgeons on the harvest team and two on the transplant team.

Recovery was so quick and uneventful that Heidler, who had been told he wouldn’t speak for at least a week after surgery, pushed for an earlier vocal debut. When Dr. Strome acceded, Heidler rasped out the long-awaited hello three days postop.

The postop drug regimen includes cyclosporin, bactrim, prednisone, and an antifungal agent. The surgeons breathed a sigh of relief when they determined that the donor, like the recipient, was free of cytomegalovirus. CMV is the primary infection risk with lung transplants, and Dr. Strome presumed it would pose a similar threat for the laryngeal procedure.

Steadily ahead of schedule, Heidler was swallowing liquids two weeks postop. That was a “very optimistic sign because it’s harder to swallow liquids than it is to swallow solids,” says Dr. Strome. The patient was discharged in less than a month instead of the anticipated six weeks.

Each week he returns here for biopsies, which serve not only to monitor infection but also to determine when the larynx becomes sensate. “Right now we can do the biopsy with impunity. But when that touch is associated with motion or gagging, we’ll know the larynx is sensate.” Then for a while Heidler will be followed monthly.

At his discharge he was speaking in a gravelly whisper and still had a tracheotomy. When the larynx is sensate, the tracheotomy will be closed and Heidler’s voice, now a work in progress, will be established. Dr. Strome expects it will be fully audible by mid-summer.

Though the surgery is remarkable, it is unknown how widespread the procedure will be. It’s so expensive Dr. Strome couldn’t even estimate the cost. In Heidler’s case, the Clinic underwrote the total cost.

And it’s not for everyone, says Dr. Strome. “It’s for the select patient who post-laryngectomy feels he or she is really missing something.” On the other hand, he adds, “it should not just be a rich person’s procedure. After all, laryngectomy patients are disfigured and disabled. They can’t swim or shower, and they are blowing air all the time.”

Dr. Michael Spafford, a Johns Hopkins head-and-neck surgeon, says the jury is still out on both the feasibility of the procedure and the efficacy, noting that a larynx does more than speak. “When the tracheotomy is closed, will this larynx provide an airway? Will it protect the lungs”?

Also unclear is what role, if any, transplantation could play in laryngeal cancer. Dr. Strome says that if a patient is more than five years out and cancer-free, a graft could be tried, the risks of immunosuppression notwithstanding. Dr. Spafford agrees.

But for now, Dr. Strome is satisfied. “If I hear that hello from him 1,000 times, each and every one will be remarkable.” -Peggy Peck

Taken from Physician's Weekly May 11, 1998 Vol. XV, No. 18













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