Royal College of Surgeons says UK should trial voice-box
4 July 2011
A Royal College of Surgeons working group says the UK should
proceed with trials for laryngeal (voice-box) transplantation. The
procedure would be used to restore power of speech, allow swallowing and
improve breathing for the 1,000 people every year in the UK whose larynx
is destroyed by trauma or benign or low-grade malignant tumours.
This is the finding of a Royal College of Surgeons working group
reviewing the ethics, technical evidence and patient services needed
for the introduction of the procedure.
As the procedure is designed to improve quality of life rather
than save it, there is an ethical balance to be struck — especially
as the lifelong anti-rejection medication that the patient would
need to take carries its own risks.
The taskforce, which included a range of medical and lay
- The procedure should not be carried out on patients with
locally advanced or recurrent cancer, such patients are at
present considered unsuitable for laryngeal transplantation
because of the high risk of further tumour.
- Further research is needed on nerve regeneration which is
essential if the transplanted larynx can become a functional
(allowing breathing, speaking and swallowing) and universal
- Care needs to be taken in choosing suitable patients for
this procedure by a multi-disciplinary team of doctors — a
psychologist and/or a psychiatrist must be a core-member of the
- The transplant team must provide and monitor detailed
functional and psychological outcomes at pre and post-operation
At present patients with destroyed larynx undergo laryngectomy —
a procedure which means they have a permanent breathing hole (or
stoma) in their neck. As a result, these patients experience a range
of problems which include difficulties speaking, swallowing,
lifting, straining, coughing, smelling, tasting and even kissing.
Many also experience additional challenges coming to terms with
visible changes to their appearance.
The larynx creates and controls sound through muscle and
cartilage interaction of the vocal cords and this is controlled by
sensory nerves. The difficulty of restoring the complicated nerve
and muscle functions has, to date, been beyond surgery in the United
Kingdom. A team of US surgeons attempted the procedure ten years ago
and this was the only transplant until recently when technical
challenges were overcome and a second successful pilot procedure was
conducted in the United States by an international team.
Working Group Chair Professor Tony Narula (RCS Council Member and
Consultant Ear Nose and Throat Surgeon) said: “New surgical
techniques and a greater understanding of organ rejection are making
an ever wider range of transplants possible. This presents exciting
opportunities for treating conditions and improving quality of life
in ways that simply were not possible in the past. But just because
something is possible doesn’t necessarily mean it is in the best
interests of patients. When trialling this procedure the medical
team must meet the highest ethical standards and submit their plans
to independent open scrutiny.”
Dr Daniel Sokol, working group member and Honorary Lecturer in
Medical Ethics at Imperial College London said: "This report
confirms the surgical profession's commitment to ethical,
patient-focused practice, looking to the future whilst learning from
the lessons of the past. The committee's conclusion is that
laryngeal transplantation is, in some circumstances, technically
feasible and morally permissible, but due caution is needed to
ensure that the risks of harm are minimised. We hope the report will
assist the pioneers of this most promising procedure."