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BackTable / ENT / Article
Modern Approaches to Bilateral Vocal Fold Paralysis Treatment: Beyond the Trach
Ashton Steed • Updated Aug 1, 2025 • 32 hits
Bilateral vocal fold paralysis presents a rare but complex challenge for otolaryngologists, requiring careful navigation between optimizing airway patency and preserving voice. Dr. James Daniero explains the spectrum of management options for these patients, from established surgical techniques to emerging innovations like laryngeal pacing. Drawing on his clinical experience, he outlines how patient selection, surgical timing, and thoughtful sequencing of interventions can maximize safety, functional outcomes and quality of life.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Interventions for bilateral vocal fold paralysis requires balancing airway patency with preservation of vocal quality.
• Commonly used surgical interventions include tracheotomy with speaking valve, suture lateralization, and posterior cordotomy or arytenoidectomy.
• Patient selection for advanced airway surgery must consider prior airway interventions, swallowing function, time since injury, and patient age.
• Optimal candidates for advanced airway surgery are typically under 60 years old and within 18 months of onset of injury.
• Bilateral laryngeal pacing, now in clinical trials, offers a potential future solution that preserves anatomy and restores motion.
Table of Contents
(1) Surgical Options to Restore the Airway
(2) Patient Selection for Advanced Airway Surgery
(3) Pacing the Larynx
Surgical Options to Restore the Airway
Patients with bilateral vocal fold paralysis present a complex challenge for long-term optimization of both airway and voice. Once a patient is beyond the acute phase of their injury, otolaryngologists can evaluate options to improve breathing, preserve or enhance vocalization, and work toward potential decannulation. Dr. Daniero explains the “ladder” of interventions, beginning with a tracheotomy and speaking valve to maintain vocal fold anatomy for future procedures. Each subsequent step requires balancing airway patency against phonatory quality. Suture lateralization can improve airflow but carries a risk of scarring that may limit future interventions. Posterior cordotomy, with or without arytenoidectomy, is a common approach that widens the airway while preserving the membranous vocal fold when possible; however, patients should be counseled about the likelihood of permanent voice changes. These techniques achieve decannulation in over 80% of cases but may require revision and can further impact voice quality when performed bilaterally.
[Dr. James Daniero]
Part of the excitement of this conversation is really where we're going next, which is what we think about in terms of, okay, so we have a patient. Let's say that we don't have an acute airway concern. We've moved past that phase. They have a tracheotomy, what have you. We're thinking about what options they may have surgically to be decannulated if they have a tracheostomy in or otherwise, alternatives to tracheostomy from some of the more tried and true, longstanding methods out there to some of our newer options that you've been able to offer out on the forefront.
[Dr. James Daniero]
It's really exciting field. Fortunately, it's a pretty rare diagnosis, but it has no really good solution currently. Typically, I'd talk to patients about the whole ladder of interventions. The first option is tracheotomy speaking valve. That requires us not to touch your vocal folds and leaves the door open for future interventions that may be coming mainstream to avoid a destructive surgery.
The next level up from that is actually to perform a surgery. There's suture lateralization to try and decrease the amount of injury to the vocal fold. At least in my hands, when I've done that, there's always been some level of scarring that remains behind even after that lateralization. I haven't seen it dramatically change the amount of invasiveness of that procedure.
Then I think what most people would say is the standard option is the posterior cordotomy or posterior cordotomy plus or minus an arytenoidectomy, and that endoscopic removal of the posterior more airway portion of the larynx, leaving the membranous portion as untouched as possible, but still leaving an airway. Allow some phonation, some vibration, but certainly, I counsel them, it's a significant decrease in the voice.
One of the things is, since their vocal folds are normal anatomically, their voice is very strong and good. Even though their vocal folds are not working, once we create the airway, they're going to have a significant sacrifice in their vocal quality, and that's permanent. Sometimes we can do some little things to titrate and improve vocal quality afterwards, but it's very limited success in restoring normal voice after those procedures.
They're very effective, they achieve decannulation 80% of the time or more. You can get some good results. Sometimes they require revision, sometimes bilateral surgery is necessary, which obviously affects the voice even more. It can be the tried and true way of proceeding with trying to achieve decannulation in the patients that have more severe obstruction up front.
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Patient Selection for Advanced Airway Surgery
Airway surgery for bilateral vocal fold paralysis requires meticulous planning, as patient selection is key to achieving optimal outcomes. The best candidates have minimal prior airway interventions as each surgery can limit future options. Confirming the diagnosis by ensuring true paralysis rather than vocal cord fixation or another condition with potential for spontaneous recovery is essential. Other key considerations include swallowing function, time since injury, and patient age. Ideally surgery is performed within 18 months of the inciting event and in patients under 60 to maximize success rates. A thorough, individualized evaluation guides selection of the safest and most effective approach for each patient.
[Dr. Stephen Schoeff]
Can we back up just a little bit and talk about how you're selecting a patient for that? Obviously, at really high risk, really highly involved surgery, very complex, difficult to explain, difficult to describe, how are you selecting and counseling patients, what are the criteria, and how do you prepare a patient for what is truly a very advanced operation with probably some degree of uncertainty?
[Dr. Gopi Shah]
I'm sorry. A question on top of your question, Steve. If you've already done the chordotomy, have we burned bridges to do the reinnervation?
[Dr. James Daniero]
Good question. Patient selection is critical in this. Ideally, no intervention on the larynx. If you're going to go through this procedure, you want to make sure that, number one, they have a shot at recovery. The rates of bilateral motion are somewhere around 30% or less. You want to get the best result possible. Those are patients that are generally younger and have a shorter term paralysis.
You want to make sure they're definitely paralyzed as well. Going to the OR for diagnostic EMG in the OR is often helpful. I know they do a lot of this in pediatrics. I don't know, Dr. Shah, your experience with it, but putting an EMG that we use typically for monitoring the face, we put those EMG electrodes right down into the vocal fold, and then have a spontaneously breathing semi-awake patient.
It's a little tricky to get our anesthesiologists on board with that because they're not used to doing DLs that way, but certainly in peds, we do them all the time. We say, this is protocol we do. It's a little harder in adults for sure, but making sure we can go into the PCA and into the TA muscle and get really high quality EMG rather than the office-based where we have a lot more difficulty getting a good PCA, posterior cricoarytenoid signal from office placement from a diagnostic standpoint.
For Botox, it's a different story, but from a diagnostic standpoint, it's a lot easier to do in the OR, and we can really get the placement appropriate and be sure we know what we're treating. Certainly, if it's a fixation standpoint, reinnervating a fixed cricoarytenoid joint is not going to help. Often, we have both.
We have, a lot of times, people that are intubated and they're managed for a while before they get their tracheotomy waiting for maybe nerve recovery to happen and they're not sure what the issue is. They extubate and intubate several times before they set aside, "Oh, they need a tracheotomy." Now you might have some injury on top of the nerve damage in the first place.
Just assuming, oh, yes, it was that thyroid surgery, it was the ACDF, without knowing the actual status of the joint is really important. I think that's critical and it should actually be evaluated and mentioned.
Then from an aspiration status, I think that is also important. Like I said, they suffer a hit from a swallowing standpoint with this pretty invasive surgery and we're re-injuring and reinitiating a lot of reinnervation by cutting the nerves again. You may have some setback from a dysphagia standpoint, it's going to get worse, and we want to make sure that they're a good candidate if they are not experiencing dysphagia preoperatively. Sometimes a swallow study would be very helpful.
[Dr. Stephen Schoeff]
Great. Say somebody is listening to this and thinking about, "Okay, I have a patient and I wonder if I could refer them for this procedure and beyond even necessarily ideal," but are there some situations where you'd say, "Ah, this is just--" You mentioned dysphagia, you mentioned significant laryngeal injury, are there firm cutoffs where you'd say, "Gosh, yes, that's just not the right patient." Firm age cutoffs when we think about nerve regeneration, where do you think about that?
[Dr. James Daniero]
Time from injury, I think 18 months is a pretty good guide. Anything past 18 months out from injury, in the best scenarios, we're getting marginal results. They're life changing for the individual, but sometimes we're not getting a motion back in a good portion of these patients. We want to make sure that they're within a window that we think that we can help them.
From an age standpoint, we know from the unilateral reinnervation literature and Randy Peniel's study, classically, the cutoff was age of 52. Hopefully, there's a cutoff that's a little bit higher than that. What I use is about 60. Over that, again, we're trying to optimize the chances of reinnervation. It's a bit of a long shot to get that perfect bilateral innervation with function. The older the nerves are, the less likely they are to reinnervate in that way.
Oh, I was going to say one more thing about evaluation of the diaphragm. We have to make sure the phrenic is actually working before we go ahead and take one of the nerves. Certainly, you don't want to take a branch of the phrenic that weakens the diaphragm on their only working side. We have an inspiratory fluoroscopy for chest X-rays that are helpful and, from my standpoint, mandatory assessment beforehand.
Pacing the Larynx
One of the most promising recent advances in airway surgery is bilateral laryngeal pacing. Dr. Daniero highlights ongoing clinical trials at Vanderbilt University using technology adapted from deep brain stimulators to restore vocal fold motion in patients with bilateral paralysis. This “pacemaker for the larynx” delivers electrical stimulation to the posterior cricoarytenoid muscles, enabling abduction of the vocal folds. While still in a trial phase, future iterations aim to synchronize vocal fold movement with inspiratory drive, potentially allowing patients to achieve near-normal airway function that adapts to their individual breathing patterns.
[Dr. Stephen Schoeff]
Then I think we're getting toward wrapping up, but I'd like to bring up a little bit just the one other thing that's floating out there that I know you're not directly involved with but are quite familiar with, which is the idea of the bilateral pacing, which I think is also an exciting thing that we could see in the future that could be another additional option beyond the destructive options. My understanding is that it's in trials right now.
[Dr. James Daniero]
Yes, that's correct. It's a fascinating additional approach. This is, again, for paralysis, not just for immobility, but pacing the larynx with the latest version and the trial that they're running. This is at Vanderbilt University. Dr. Zealer, Gelbard, Garrett, and Netterville have all been involved in this really groundbreaking research.
They are doing a clinical trial using a deep brain stimulator, a certain type of deep brain stimulator that allows for the best stimulation, the best electrical signal to get the most mobility. That comes out of David Zealear’s work that he's been doing for the last 50 years, pretty much going back into the '70s, coming out of his dog studies, now progressing into humans, really fascinating work.
The ideal situation is that that is triggered by inspiratory function. The really fascinating finding from a lot of the research is, people do pretty well with it just having a metronome pace to it. They set it like a pacemaker and it opens and closes the vocal fold at a certain interval. What they found when they were doing the beagle studies is that they would put them on treadmills and they would accommodate, they would change the breathing pattern to the metronome in order to get the best airflow. They would habituate to it.
What they've seen in their human trials is the same thing. Now ideally, it would be seamless and triggered by inspiratory function tacked down to the phrenic, but it's still a significantly complex surgery in of itself, and I think future iterations may have the inspiratory trigger. Even just with a pacemaker setting where the leads are placed into the posterior cricoarytenoid muscle and tunneled into the muscle itself, direct stimulation of the muscle produces a significant opening of the airway.
[Dr. Stephen Schoeff]
That's exciting. It sounds like potentially, the evolution could be that it's not even pacing the muscle directly, but it's purely a neurological surgery. It's purely just a DBS, or would it still have a laryngeal component?
[Dr. James Daniero]
Oh, no. This is a DBS stimulator that is placed with electrodes directly into the muscle, the PCA, for abduction. Not a brain-- they're using that implant, but not in the brain itself.
[Dr. Stephen Schoeff]
That technology, but the pacing leads are placed in the neck, in the larynx to stimulate that posterior cricoarytenoid.
[Dr. James Daniero]
Correct.
[Dr. Stephen Schoeff]
Very cool.
[Dr. James Daniero]
Pretty neat. There's been several patients that have been implanted. I think they're refining the technique, making it more generalizable before it's prime time, but it's on the verge. I tell patients about it. Once I do a destructive option for them, they may not get the best outcome with a pacer when it becomes available. For some of the younger patients that have to live with permanent bilateral paralysis for the rest of their lives, this does enter the conversation, even though it's still experimental and in trials.
[Dr. Stephen Schoeff]
I think that's one of the things I picked up as well and that I've been thinking about is how we approach the long-term planning where if we have a patient with potentially 30, 40 years ahead of them, it makes a lot of sense to consider waiting, or either if we can, up front, look at the bilateral reinnervation or waiting to see how this technology evolves and have more options in the future.
[Dr. James Daniero]
It's been neat to follow Dr. Zealear's research. He's shown that directly stimulating the muscle, even after it's completely deinnervated, can still have significant motor function afterwards with the right stimulus. That's why the specific device is important because they've gone through several reinnervation of how the signal should be delivered, and it seems like this DBS is the latest. There may be additional pulse generators in the future, but it's getting there.
[Dr. Gopi Shah]
You're saying the rate at which somebody breathes is set to the metronome pace. There's no external control. Usually, we accommodate--what they've seen at least in the beagle study is that the accommodation is made to keep up or continue with that pace to breathe.
[Dr. James Daniero]
I understand the first several patients that have been implanted as well have done the same where they accommodate, they learn to speak in certain phrases like that so that they can adjust for it. It becomes second nature as far as breathing and switching over breathing and talking.
Podcast Contributors
Dr. James Daniero
Dr. James Daniero a laryngologist at the University of Virginia.
Dr. Stephen Schoeff
Dr. Stephen Schoeff is a laryngologist at Kaiser Permanente in Tacoma, Washington.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2025, May 20). Ep. 223 – Evaluation & Management of Bilateral Vocal Fold Paralysis [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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