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Bilateral Vocal Cord Paralysis

Life-threatening airway condition with both vocal folds immobile in median or paramedian position, often after thyroid surgery or post-intubation, requiring urgent airway management and tailored reconstruction.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

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What is Bilateral Vocal Cord Paralysis?

BVCP arises when both recurrent laryngeal nerves (RLN) are dysfunctional. Etiology: thyroidectomy (most common, 1-3% rate including transient), prolonged intubation (post-intubation laryngeal trauma), cervical/anterior mediastinal surgery (cardiothoracic, esophageal), neck trauma, malignancy (esophageal, thyroid, lung apex), neurologic (Parkinson's, MSA, ALS, brainstem stroke), idiopathic (15-20%).

Position of vocal folds depends on injury type: bilateral RLN injury → adducted (median) position with severe airway obstruction; bilateral vagal injury → cadaveric (paramedian) position with airway obstruction and aspiration risk. Voice is often preserved (because folds approximate) but airway is compromised — opposite of unilateral paralysis.

Diagnosis: laryngoscopy showing bilateral immobility, electromyography (EMG) at 6 months to differentiate denervation from synkinesis or mechanical fixation. Workup: imaging from skull base to mediastinum (CT or MRI) to identify surgical scar, mass, or compression.

Symptoms

Biphasic stridor (inspiratory and expiratory)
Dyspnea on exertion progressing to dyspnea at rest
Obstructive sleep apnea symptoms
Voice often relatively preserved (or weak/breathy if cadaveric position)
Aspiration if cadaveric position with sensory deficit
Cyanosis with effort, exercise intolerance
Acute respiratory failure if presented late

Risk Factors

Recent thyroidectomy or parathyroidectomy
Prolonged endotracheal intubation (>72 hours)
Cardiothoracic surgery (especially patent ductus, aortic arch)
Cervical spine surgery (anterior approach)
Esophageal cancer or surgery
Neurologic disease (Parkinson's, MSA, ALS, MS)
Brainstem stroke
Penetrating neck trauma

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Acute biphasic stridor — emergency room
  • Progressive dyspnea on exertion or rest after recent surgery
  • Sleep-disordered breathing with snoring and apnea
  • Stridor in newborn (congenital BVCP — emergency)
  • ENT urgent evaluation for any post-thyroidectomy stridor

Treatment Methods

01
Acute airway management: assessment of severity, oxygen, head elevation, heliox; emergent tracheostomy if respiratory failure or progressive distress; urgent ENT evaluation
02
Initial conservative management: tracheostomy as bridge to recovery (50% of post-thyroidectomy BVCP recovers within 6-12 months), voice rest, monitoring with serial laryngoscopy
03
Diagnostic workup: laryngoscopy (immobility position, sensation), laryngeal EMG at 4-6 months (denervation pattern, recovery prediction), imaging (CT/MRI from skull base to mediastinum), neurology evaluation
04
Cordotomy/Posterior cordotomy (Dennis-Kashima procedure): CO2 laser unilateral excision of vocal process and posterior third of true cord, creating glottic gap for breathing; preserves voice acceptable but breathy; success 80-90% decannulation
05
Arytenoidectomy: total or partial removal of arytenoid cartilage, larger airway than cordotomy but worse voice; transoral CO2 laser approach
06
Reinnervation: ansa cervicalis to RLN reinnervation may restore tone and possibly some movement; better for unilateral but emerging for bilateral
07
Laryngeal pacing: implantable electrical stimulation of posterior cricoarytenoid muscle synchronized with inspiration — emerging technology, selected centers
08
Suture lateralization (Lichtenberger, Ejnell): suture-mediated abduction of one vocal fold under local anesthesia, reversible procedure
09
Cricotracheal resection or laryngotracheoplasty: for combined glottic-subglottic stenosis from prolonged intubation
10
Post-procedure: voice therapy, swallow evaluation if cadaveric position with aspiration risk, dyspnea reassessment, decannulation trial
11
Pediatric BVCP: 50% spontaneous recovery in first 1-2 years; tracheostomy bridge, then tailored airway procedure (cordotomy, posterior cordotomy)
12
Long-term: 60-80% successful decannulation with appropriate procedure; voice quality often acceptable but reduced; multidisciplinary follow-up (ENT, voice therapy, sleep medicine)

Which Department to Visit?

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.