OTAL laryngectomy and total occlusion of the larynx with tracheostomy are associated with an impaired sense of taste and smell, an increased incidence of tracheobronchial infections, stomal encrustations, loss of nasal respiration, and loss of a human-sounding voice. A fundamental consideration in treating a patient whose larynx has been irreparably damaged is whether the goals of surgery should include replacement of the larynx to improve the patient's quality of life. An early attempt to treat laryngeal cancer with a partial laryngeal transplant 1 was accompanied by rapid recurrence of the tumor, an outcome that quashed interest in the procedure for nearly two decades. Similarly, tracheal transplantation has had only limited success. 2,3 In 1987, we initiated a program to explore the potential of laryngeal transplantation. The program addressed four issues critical to successful transplantation: revascularization, reinnervation, rejection, and the ethics of transplanting an organ considered by some to be nonvital. In rats, the rate of success of laryngeal transplantation was nearly 100 percent. 4,5 In these studies in animals, we classified the histologic features of laryngeal rejection 6 ; determined the maximal tolerable period of ischemia; evaluated preservative solutions 5 ; determined doses of cyclosporine, 7 prednisone, and adjunct in vitro radiation 8 ; and studied the use of sirolimus and tacrolimus. 9 In 1998, we performed a total laryngeal transplantation in a man who had sustained a severe traumatic injury to the larynx and pharynx. 10 We describe the procedure and report the results in detail here. CASE REPORT The Patient and the DonorThe patient was a 40-year-old man who had been in a motorcycle accident 20 years earlier. His larynx and pharynx had been T crushed, leaving him aphonic. He lost his sense of smell and taste a year after the injury. He used an external device (Cooper-Rand Electrolarynx) to speak. Despite attempts at another institution to reconstruct his larynx, it was totally stenotic and shortened, with immobile arytenoid cartilages and a fragmented cricoid cartilage. A barium swallow revealed narrowing of the pharynx and upper esophagus and a pharyngolaryngeal fistula. The supraglottis was bathed in oropharyngeal secretions.Other than mild essential hypertension that was treated with valsartan and hydrochlorothiazide, the patient was healthy. Although he had mild dysphagia, his nutritional status was normal. He did not smoke. Serologic tests for cytomegalovirus and Epstein-Barr virus were negative, and his serum creatinine concentration was normal. With the exception of the tracheal stoma and the aforementioned laryngeal, tracheal, and pharyngeal abnormalities, the results of a physical examination were normal.After surgery was proposed, the patient was interviewed once by a psychiatrist and four times by members of the surgical team and a speech pathologist. All those involved agreed that the patient understood the risks and agreed that his motivation was appropriate. The procedure...

On the basis of this case and several detailed in the literature, we therefore hypothesize that radiation therapy is not only an ineffective treatment for MAC, but evidence exists that this modality may induce conversion to a histologically and clinically less favorable neoplasm.

This research investigated the histopathologic and migratory properties of injectable alternatives for vocal fold medialization. Thirteen dogs underwent sectioning of the recurrent laryngeal nerve followed by vocal fold injection with 1 of 4 substances: Teflon, autologous fat, silicone suspension, or hydroxyapatite cement. Six months later, the animals were painlessly sacrificed and histopathologic analysis of the larynx and regional lymph nodes was performed. Although regional lymph node migration was noted, Teflon injection resulted in minimal vocal fold inflammatory reaction. Vocal folds injected with autologous fat exhibited persistence of fat at the injection site without significant inflammation or migration. Silicone suspension caused a localized giant cell reaction without regional lymph node migration, and 1 study subject died secondary to acute inflammation with critical respiratory compromise. Hydroxyapatite cement was well tolerated without inflammation or migration. This pilot study indicates that a wide range of possible substances for vocal fold medialization exist. Many of these may produce results superior to those obtained with Teflon and are thus far untested.

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