Functional Voice Restoration After Laryngeal Transplantation: A Multidisciplinary Protocol and Longitudinal Outcomes

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.