Larynx transplant restores woman's ability to speak after 11 years
21 January 2011
Brenda Charett Jensen, a 52-year-old woman from Modesto, California, had lost the use of her larynx (voicebox) during surgery in 1999. The breathing tube used during the operation at the time had injured her throat, causing scar tissue to form and prevent breathing. She was given a tracheotomy - a surgical hole in the trachea (windpipe) beneath the larynx - to enable her to breathe.
In October 2010, an international team of surgeons performed an operation to replace her larynx, thyroid gland and trachea. The 18-hour procedure, which took place at the UC Davis Medical Center in Sacramento, California, was followed by two months of rehabilitation, during which the nerves have been regenerating and she has learnt to speak again.
The only other documented larynx transplant took place at the Cleveland Clinic in Cleveland, Ohio, in 1998. This new operation involved much more tissue, however - it is the first time that the larynx, trachea and thyroid were transplanted together. In addition, the nerves have been repaired, which should, in time, allow the muscles to move and enable the surgeons to remove the tracheotomy from the patient.
"This operation has restored my life," said Ms Jensen. "I feel so blessed to have been given this opportunity. It is a miracle. I'm talking, talking, talking, which just amazes my family and friends.
"Every day is a new beginning for me. I'm working so hard to use my vocal cords and train my muscles to swallow. I'll probably never sing in a choir or anything, but it's exciting to talk normally, and I can't wait to eat and drink and swim again."
The techniques used were developed by Professor Martin Birchall, a visiting professor of otolaryngology at UC Davis and then at UCL. Professor Birchall's work was funded principally by the Wellcome Trust.
"Despite decades of effort, patients with advanced laryngeal disease or injury have faced reconstructive procedures that are literally 150 years old," said Professor Birchall, who specialises in the repair of paralyzed laryngeal nerves and throat disorders.
"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."
The transplant involved several steps. First, the larynx had to be removed from the donor and the larynx removed and replaced from the patient. The team retrieved the donor's entire larynx, thyroid and a six-centimetre segment of the trachea; the thyroid gland is intricately intertwined with the larynx and provides critical blood supply for the new larynx and trachea.
After removing the organ, the team immediately tested it using a saline solution to ensure that the larynx would be healthy and have a good supply of blood. The larynx and trachea were then placed in an ice saline solution until transplantation.
Correctly reattaching blood vessels and nerves was crucial to the success of the operation. The acts of swallowing, moving the vocal cords and breathing entail extremely 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. The surgical team reconnected five nerves, three arteries and two veins 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," said Paolo Macchiarini, professor of regenerative surgery at the Karolinska Institutet, Sweden, who led the world's first in-human transplantation of a tissue-engineered windpipe in 2008 and was part of the surgical team that performed on Ms Jenson. "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."
Dr John Williams, Head of Clinical Activities at the Wellcome Trust, says: "This is a truly extraordinary achievement and a genuine breakthrough. Professor Birchall and colleagues have clearly transformed the life of their patient and their work offers much hope both for patients in need of similar procedures and indeed for research into transplantation and regenerative medicine in general."
Image: Nasal cavities and larynx. Credit: Wellcome Images.