Vocal Cord Paralysis (VCP)

Preop airway picture - Awake flexible fiberoptic laryngoscopy is the study that makes the diagnosis; pull the ENT report and note which cord is immobile and where it rests. Median cords mean stridor and a narrow glottis with a near-normal voice. Lateral cords mean a widely patent airway but no glottic seal, so breathiness, choking, and aspiration dominate.

Unilateral VCP - The plan is to protect the one cord that still moves and to prevent laryngeal edema. The mobile cord is doing all the closing; anything that swells or traumatizes it costs the patient both voice and airway protection.

Bilateral VCP - Glottic size is fixed, so edema is the enemy. Avoid intubation when the case allows it, use a smaller ETT when it doesn't, intubate atraumatically, give perioperative corticosteroids, plan a smooth emergence, and extend postoperative monitoring.

Aspiration - Glottic closure is incomplete, so these patients aspirate. Ask about choking or coughing with liquids and about dysphonia; VCP raises perioperative aspiration and respiratory distress risk whether it is temporary or permanent.

Intubation-related laryngeal injury - Most of it comes from sustained pressure on airway tissue, in short and long intubations alike. The modifiable factors are ETT lumen size, cuff location, and cuff inflation pressure. Intubation-related VCP may resolve within six months or be permanent.

Acute postoperative obstruction - New bilateral VCP after thyroid or other neck surgery ranges from mild exertional stridor to acute life-threatening airway obstruction and can need urgent intubation or tracheostomy. Stridor in a fresh post-thyroidectomy patient is bilateral VCP until proven otherwise — get ENT and difficult-airway equipment to the bedside before the airway closes.

Local anesthetic near the laryngeal nerves - Hoarseness, stridor, and respiratory distress have followed local infiltration during carotid procedures, thyroid surgery, and right-sided vascular line placement. It resolves as the block wears off, but in PACU it looks exactly like a surgical nerve injury.

Right-sided cervical lines - Direct nerve injury during right-sided cervical vascular line placement or catheter tunneling can cause permanent paralysis. Weigh that before siting a right IJ in a patient who already has one paralyzed cord.

After medialization - Injecting or implanting filler into the immobile cord moves it toward midline, improving contact with the mobile cord, glottic closure, voice, and aspiration. Check the record for it — it changes what you see on laryngoscopy.

Symptom timing - Changes in voice, breathing, and swallowing from acute unilateral VCP are usually evident within 24 hours of injury, though diagnosis often lags two weeks because it gets written off as postintubation hoarseness. A new hoarse, weak voice after your case deserves a laryngoscopy referral, not reassurance.

Vocal cord paralysis (VCP) is the absence of movement of one or both vocal cords. It is neurogenic — damage to the vagus, the recurrent laryngeal nerve (RLN), or the superior laryngeal nerve, or central disease such as stroke, multiple sclerosis (MS), or amyotrophic lateral sclerosis (ALS) — or mechanical, from injury to the arytenoids or posterior glottic tissue. Iatrogenic surgical injury leads both lists; nearly 90% of bilateral cases follow nerve transection at thyroidectomy. Malignancy, intubation, and trauma follow.

The cords do two jobs: abduct to open the glottis for breathing, adduct to phonate and to seal the airway against aspiration. Lose one and the patient has a breathy voice and an incompetent glottis. Lose both and glottic size is fixed, so any added laryngeal edema can push a marginal airway into obstruction.