Voice box surgery a doctor's new challenge

Sherry Wittenberg wasn't ready to give up her voice when told that she had a rare form of cancer in her larynx. The she met up with Douglas Chepeha, a surgeon who gave her a chance to continue talking - once he used part of her shoulder blade in the medical procedure. (Brian Kaufman / Detroit Free Press / MCT)
Sherry Wittenberg wasn't ready to give up her voice when told that she had a rare form of cancer in her larynx. The she met up with Douglas Chepeha, a surgeon who gave her a chance to continue talking - once he used part of her shoulder blade in the medical procedure. (Brian Kaufman / Detroit Free Press / MCT)
Posted: February 17, 2012

DETROIT - The little boy who would grow up to become a surgeon at the University of Michigan learned right away - parts is parts.

Douglas Chepeha started out as a carpenter, making boats and decks and furniture out of scraps of wood; and then, he took that same mental approach into surgery.

That's how he saved Sherry Wittenberg's voice: He removed part of her shoulder blade and inserted it into her voice box, like a strange home renovation project inside a human body.

Chepeha views the human body as a Home Depot for body parts. Although other surgeons have used part of the sternum for transplants, Chepeha harvested the tip of Wittenberg's shoulder blade because it had a natural curve and was wrapped with a chunk of muscle with a good blood supply.

Wittenberg's voice isn't perfect. Once a singer in a choir, she can't really hold a tune anymore. But she can talk. And she can still work in telephone sales.

To fully appreciate this groundbreaking surgery, you have to start at the beginning. The day Chepeha received his first tool set.

Chepeha was about 31/2 when his grandfather gave him a saw and hammer. He became infatuated with building small, simple boats out of wood scraps.

"I built about 200 boats by the time I was 6 or 7," said Chepeha, who grew up in Edmonton, Alberta, in a working-class, hockey-loving, blue-collar neighborhood.

As a college student, he ran a small construction company. "I built decks and fences and did landscaping and gutted basements," he said. "When I first got married, I built most of the furniture for my house because I couldn't afford to buy new."

All of that training as a carpenter - how to use tools and plan a job and do everything with precision, while using scraps of material for different projects - proved to be an ideal training for a surgeon.

"Really, a surgeon is a glorified tradesman," Chepeha said. "All those amazing sheet metal guys make those amazing copper roofs and those amazing carpenters make unbelievable furniture. I think surgeons do the same thing. But I'm working on a human, so the stakes are a little higher. But in terms of technical skills, I don't think there is any difference."

Chepeha once took skin off a woman's arm and used it to reconstruct a tongue.

"It's weird for the patient to come in and see me," Chepeha said. "I talk to them about the cancer, and then I have to kind of look around their body (for parts). I tell them it's like going to Home Depot. I have to see what I can get. But everybody has a different shaped body."

Then he met Wittenberg, who presented him with a new challenge.

Wittenberg, 59, was devastated when she found out that she had a rare, slow-growing cancer in the cricoid cartilage, a ring that supported her voice box. There are about 50,000 people diagnosed with larynx cancer every year in the U.S., although less than 1 percent have this particular cancer.

A doctor in Jackson, Mich., told her that she needed a complete laryngectomy - the removal of the larynx - which would have caused her to lose her voice, forcing her to communicate using an electronic device or voice prosthesis.

"He looked me in the eye, and said, 'If you don't do anything, it could block off your airway, and you are not going to be able to breathe,'" Wittenberg said.

She sought a second opinion and found Chepeha.

"I told Dr. Chepeha that I'm an inside sales rep," said Wittenberg, who works for a steel company in Jackson. "I'm on the phone all day long. All my customers are out of state. My voice is really important to me, because I have to use it every day. It's my job."

Chepeha came up with an experimental reconstructive surgery, hoping to save her voice. He proposed removing the tumor and surrounding cartilage, then using part of her shoulder blade to reconstruct the cartilage in her voice box.

Chepeha wasn't sure it would work.

"I don't promise them the moon," he said. "I'm very clear on what I'm doing. I told her that it is very likely that we would have to do a larengectomy if this doesn't work."

Chepeha performed the surgery in March 2010, and it lasted 16 hours.

After he removed the cartilage from Wittenberg's shoulder blade, he had to shape it to fit the small space in her neck. "The problem is you can't really see it really well because you have to leave it covered in muscle, because that's how the blood gets to it," Chepeha said "We just didn't cut out a piece of bone and stick it in there."

After the cartilage was shaped, it looked "like the crescent shape of the moon," he said.

"We got all the structures exactly where we wanted them," said Chepeha, who spends 1,000 hours in an operating room per year, doing about 300 surgeries.

Wittenberg returned to work almost three months after the surgery.

"I'm just thankful I can talk," she said.

Wittenberg, who sang alto in a high school choir, said her voice now sounds lower and flatter.

"I don't think my voice is normal now, but I'm used to it," she said. "I hear me now and I think it's more squeaky. I used to be able to sing and hold a note. ... There is no way you would want to hear me now."

She feels lucky, like she hit the lottery. "Stop and think. It's what, one in a million?"

Chepeha said the reconstructed cricoid involved the joint that controls the vocal cords, changing the sound of Wittenberg's voice.

Wittenberg is scanned every six months to make sure the cancer hasn't spread to another part of her body. "I could probably glow in the dark - I've had so many CAT scans," she said. "They have never found any tumors anywhere else."

Chepeha said the technique could help many other patients, including those with different types of mouth cancers, as well as children who are born prematurely and have been on a ventilator a long time.

Chepeha's technique is featured in this month's issue of Laryngoscope, an international peer-reviewed journal for throat doctors. "That signals that it's a pretty big advance and your colleagues give you a slap on the back," Chepeha said.

He is a perfectionist, almost never satisfied. But he admits to feeling pride with Wittenberg's results.

"This is why you come to work," he said. "This is what I'm about. I really believe that people should have an opportunity to continue in what they did before, just maintain their lives as much as possible."

How Sherry Wittenberg got her voice back

 This month, Sherry Wittenberg became a cover girl for a nationwide publication - but it's not the most glamorous picture. And it's not even that flattering - you would have a hard time recognizing her. But her story could help people around the world.

A photo taken inside Wittenberg's voice box graces the cover of this month's issue of Laryngoscope, an international peer-reviewed journal for throat doctors. Wittenberg became a cover story after Douglas Chepeha used part of her shoulder blade to reconstruct her voice box in a surgery at University Hospital in Ann Arbor, Mich.

It is the first time this type of surgery has been done successfully.

Chepeha, director of microvascular surgery in the Department of Otolaryngology at the University of Michigan Medical School, said the advance could help many other patients, including cancer patients who lose their voices and premature babies who end up with ruined voice boxes after being on a tracheotomy tube too long.

"It's literally like figuring out that you can take a foundation out from under a house and the house won't fall apart," he said. "It's a big step forward."

Chepeha speaks in construction similes often because he used to own a small contracting company, building decks and tearing out basements. And those skills came into play, as he saved Wittenberg's voice.


(c) 2012 the Detroit Free Press

Distributed by MCT Information Services

 

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