Bilateral Vocal Fold Paralysis

Bilateral vocal cord paralysis occurs when both vocal folds are unable to move.  Bilateral vocal fold paralysis most commonly occurs because of a problem with the recurrent laryngeal nerve, which is the nerve which controls motion of the vocal folds . The recurrent laryngeal nerve travels upwards towards the larynx next to the trachea and esophagus and is responsible for these motions. When the nerves are normal and vocal folds are unable to move, there may be problem with the cricoarytenoid joint.

Bilateral vocal fold paralysis with vocal folds in the open position.  This person's airway is compromised by approximately 75%, causing shortness of breath.

Patients with bilateral vocal fold immobility may complain of:

  • Shortness of breath
  • Noisy breathing
  • Normal voice and sometimes altered voice

Bilateral vocal fold immobility may be a result of many causes.  Some of these include:

  • Trauma
  • Stroke
  • Surgery, including spine, esophagus, or thyroid surgery

Evaluation includes:

  • Stroboscopic examination of the larynx
  • Possible bronchoscopy
  • Laryngeal EMG

Treatment for bilateral fold paralysis is primarily aimed at enlarging the size of the airway to improve breathing. Most commonly the vocal folds remain fixed in a 'near closed' position, preventing the breathing in and out large amounts of air. Patients complain of shortness of breath with exertion, such as walking up stairs.

The challenge in treating patients with bilateral vocal fold immobility is the following. As the size of the airway is increased, a patient’s voice and ability to swallow worsen.

  • Bilateral vocal fold immobility can be a result of
  • Trauma
  • Unknown etiology
  • Stroke
  • Surgery, including spine, esophagus, or thyroid surgery

Treatments for bilateral vocal fold immobility include:

Tracheotomy - the narrowed area is bypassed with a tracheotomy tube. Patients are able to speak and swallow normally.

    Cordotomy - Vocal fold cordotomy literally means to cut the vocal fold. Cutting the vocal fold increases the size of the airway, but also affects a patient’s voice. Occasionally only cutting the vocal fold provides an adequately sized airway. This surgery is done in the operating room through the mouth during direct laryngoscopy. A microscope is used to enlarge the view of the vocal folds and a laser is used to cut the vocal fold.

      Arytenoidectomy - the arytenoid is the cartilage that is connected to the back half of the vocal fold. Removing a portion of this cartilage enlarges the airway. This is done in conjunction with a cordotomy, and is performed through the mouth using a laser.

        Vocal fold lateralization - In this procedure the vocal fold is positioned to the side, or laterally, to enlarge the size of the airway. This is done with a stitch passed from the skin to the inside of the larynx and back out. This procedure is temporary.