Vocal fold paralysis (VFP) is a neurological condition that is characterized by reduced or absent movement of one or both vocal folds. When bilateral VFP (BVFP) occurs, both vocal folds assume a paramedian position, thus causing narrowing of the airway at the glottic level and therefore inspiratory dyspnea. VFP is mostly caused by laryngeal or extra-laryngeal cancers, iatrogenic injury during neck, thyroid gland, or chest surgery, and various neurogenic conditions. Patients with BVFP usually are recognized by noisy inspiratory breathing, with normal or nearly normal voice [1].

Treatment for BVFP is mainly surgical, and several procedures can be used. The most common one is tracheostomy, which is very effective but results in an open wound that requires continual postoperative management, and thus patients experience decreased quality of life [2].

Cordotomy is another common treatment for BVFP. It is an irreversible surgical procedure that results in airway enlargement at the glottic level. This is achieved with the excision of laryngeal soft tissues, such as parts of the vocal fold, the vocal ligament, or the thyroarytenoid muscle. Some authors describe this technique including the excision of the overlapping segment of the false vocal fold too [3]. Dennis and Kashima introduced the endoscopic laser cordotomy technique in 1989 [4]. This procedure has different advantages, such as rapidity, simplicity in concept, immediate assessment of the airway, reliability, short hospitalization, and low risk of complications. Cordotomy is susceptible to granulation and scar formation. It was reported that bilateral or revision cordotomies were needed in about 30% of patients due to a decreased glottal opening from the formation of scar tissue or granulation. Another most commonly seen side effect associated with cordotomy is the deterioration of voice quality. Patients often complained of a rough and breathy voice because of damage to the vibratory part of the operated vocal fold [5]. For these reasons, multi-stage surgery may be preferable. The basic goal of the procedure is to avoid tracheostomy with acceptable vocal impairment.

Depending on the case, the operation can be modulated from the simple section of the vocal ligament (cordotomy) to the more or less extensive removal of the posterior portion of the vocal muscle (cordectomy) to the lateral extension favored by the partial removal of the ventricular fold (ventricular cordectomy) [6].

In our experience, it is preferable to preserve at least the anterior two-third of the glottic plane to maintain acceptable vocal quality and to avoid sacrificing the arytenoid so as not to cause swallowing dysfunction. In selected cases, bilateral treatment may be considered at a later stage.

Several other procedures were studied to treat BVFP such as arytenoidectomy and laterofixation of the arytenoid and/or the attached vocal fold using a combination of endoscopic and external means. Even newer approaches are being developed, such as reinnervation, laryngeal pacing, gene therapy, and stem cell therapy in order to preserve the voice. However, there is very little clinical data about these new treatment options [2].

The technique described is a posterior cordectomy with supraglottic extension to the false homolateral chord. We chose this procedure in order to manage a BVFP affecting an 84-year-old female patient, who presented herself at our emergency ward for sudden dyspnea. She had recently undergone a left pulmonary apical lobectomy due to an adenocarcinoma. Fibrolaringoscopy evaluation showed a left paramedian vocal fold paralysis and an idiopathic hypomobility of the contralateral vocal fold, thus causing an important narrowing of the respiratory space. Furthermore, a relevant supraglottic laryngospasm with false vocal fold dystonia contributed to exacerbating her clinical status.