Functional Voice Restoration After Laryngeal Transplantation: A Multidisciplinary Protocol and Longitudinal Outcomes.
Laryngeal transplantation offers the potential for patients to regain vocal function, yet standardised voice rehabilitation protocols are lacking. We share the experience of our team in the regular follow-up of voice function evaluation and address this gap by establishing a multidisciplinary pathway for functional recovery.
Four male transplant recipients (3 laryngeal cancers, 1 hypopharyngeal cancer) underwent protocolized assessments at 1/3/6/8 months post-op: subjective assessment (GRBAS scale) and objective evaluation (multiparametric acoustic analysis and electronic laryngoscopy). Personalized rehabilitation was delivered weekly by a licensed speech therapist. Protocol evolution occurred: Patients 1-2 received conventional training; Patients 3-4 received intensive neuromuscular reinnervation strategies.
The voice of the four patients showed a gradual decrease in the degree of hoarseness, a gradual alleviation of breathiness, and a gradual decrease in asthenia score, with the overall condition improving. The MPT was about 1.8 s at 1 month after surgery which kept increasing in all patients. The 3rd patient, who performed the best among the 4 patients, had an MPT of more than 10 s at 8 months after surgery. Laryngeal mucosa sensory function was gradually established in patients starting 3 months after operation, and compensatory vibration of ventricular band appeared at 8 months after operation with the assistance of voice training.
This study anchored to neuromuscular reinnervation milestones demonstrates that standardised evaluations coupled with individualized training progressively restore vocal function. Our protocolized framework guides evidence-based rehabilitation for institutions pursuing laryngeal transplantation WHAT THIS PAPER ADDS: What is already known on this subject Laryngeal transplantation surgically restores laryngeal anatomy but faces functional recovery challenges due to delayed neuromuscular reinnervation. Existing literature focuses predominantly on immunosuppression and graft viability, with sparse evidence guiding postoperative voice rehabilitation. Standardised protocols for phonatory recovery-routine in other neurogenic voice disorders (e.g., vocal fold paralysis)-are absent. Fewer than 20 human cases have been reported globally, and only two publications detail voice outcomes. Consequently, rehabilitation strategies remain ad hoc, lacking consensus on intervention timing, exercise biomarkers, or psychological support frameworks. What this study adds to existing knowledge This study establishes the first protocolized voice rehabilitation framework for laryngeal transplantation, anchored to neuromuscular milestones: Pharyngeal reflex recovery (3 months) signalling sensory reinnervation; Ventricular band compensation (8 months) indicating motor adaptation. We demonstrate that early, structured rehabilitation (initiated at 1 month) enables significant voice restoration (MPT: 1.8 s → >10 s). Critically, we identify modular design principles accommodating clinical interruptions (e.g., ICU admissions) without compromising core outcomes. We anticipate these findings will guide evidence-based rehabilitation for institutions pursuing laryngeal transplantation and inform standardised pathways for complex laryngologic rehabilitation. What are the potential or actual clinical implications of this work? Rehabilitation Standardization: Provides evidence-based timelines (1/3/6/8-month assessments) and neuromuscular biomarkers to guide intervention intensity. Broad Applicability: The protocol shows cross-utility for bilateral vocal fold paralysis and post-traumatic neurogenic dysphonia, leveraging shared reinnervation mechanisms. Contingency Management: Modular training design maintains efficacy despite clinical interruptions (e.g., 40% cohort ICU/oncology transfers). Technology Integration: Validates objective metrics (MPT, mucosal wave symmetry) as targets for future AI-assisted biofeedback tools. Clinicians should prioritise early sensorimotor retraining (<3 months) while monitoring compensatory strategies (ventricular vibration) as functional proxies.
Four male transplant recipients (3 laryngeal cancers, 1 hypopharyngeal cancer) underwent protocolized assessments at 1/3/6/8 months post-op: subjective assessment (GRBAS scale) and objective evaluation (multiparametric acoustic analysis and electronic laryngoscopy). Personalized rehabilitation was delivered weekly by a licensed speech therapist. Protocol evolution occurred: Patients 1-2 received conventional training; Patients 3-4 received intensive neuromuscular reinnervation strategies.
The voice of the four patients showed a gradual decrease in the degree of hoarseness, a gradual alleviation of breathiness, and a gradual decrease in asthenia score, with the overall condition improving. The MPT was about 1.8 s at 1 month after surgery which kept increasing in all patients. The 3rd patient, who performed the best among the 4 patients, had an MPT of more than 10 s at 8 months after surgery. Laryngeal mucosa sensory function was gradually established in patients starting 3 months after operation, and compensatory vibration of ventricular band appeared at 8 months after operation with the assistance of voice training.
This study anchored to neuromuscular reinnervation milestones demonstrates that standardised evaluations coupled with individualized training progressively restore vocal function. Our protocolized framework guides evidence-based rehabilitation for institutions pursuing laryngeal transplantation WHAT THIS PAPER ADDS: What is already known on this subject Laryngeal transplantation surgically restores laryngeal anatomy but faces functional recovery challenges due to delayed neuromuscular reinnervation. Existing literature focuses predominantly on immunosuppression and graft viability, with sparse evidence guiding postoperative voice rehabilitation. Standardised protocols for phonatory recovery-routine in other neurogenic voice disorders (e.g., vocal fold paralysis)-are absent. Fewer than 20 human cases have been reported globally, and only two publications detail voice outcomes. Consequently, rehabilitation strategies remain ad hoc, lacking consensus on intervention timing, exercise biomarkers, or psychological support frameworks. What this study adds to existing knowledge This study establishes the first protocolized voice rehabilitation framework for laryngeal transplantation, anchored to neuromuscular milestones: Pharyngeal reflex recovery (3 months) signalling sensory reinnervation; Ventricular band compensation (8 months) indicating motor adaptation. We demonstrate that early, structured rehabilitation (initiated at 1 month) enables significant voice restoration (MPT: 1.8 s → >10 s). Critically, we identify modular design principles accommodating clinical interruptions (e.g., ICU admissions) without compromising core outcomes. We anticipate these findings will guide evidence-based rehabilitation for institutions pursuing laryngeal transplantation and inform standardised pathways for complex laryngologic rehabilitation. What are the potential or actual clinical implications of this work? Rehabilitation Standardization: Provides evidence-based timelines (1/3/6/8-month assessments) and neuromuscular biomarkers to guide intervention intensity. Broad Applicability: The protocol shows cross-utility for bilateral vocal fold paralysis and post-traumatic neurogenic dysphonia, leveraging shared reinnervation mechanisms. Contingency Management: Modular training design maintains efficacy despite clinical interruptions (e.g., 40% cohort ICU/oncology transfers). Technology Integration: Validates objective metrics (MPT, mucosal wave symmetry) as targets for future AI-assisted biofeedback tools. Clinicians should prioritise early sensorimotor retraining (<3 months) while monitoring compensatory strategies (ventricular vibration) as functional proxies.
Authors
Zeng Zeng, Gu Gu, Jiang Jiang, Ainiwaer Ainiwaer, Zheng Zheng, Yang Yang, Ren Ren, Chen Chen
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