Laser surgical management of bilateral vocal fold immobility

Bilateral immobility of the vocal folds can have a dramatic impact on both airway and voice. The diagnosis is based on history and physical examination and is supported by some objective tests such as computed tomography or magnetic resonance imaging evaluations. Although airway management is often the first consideration, a critical determination that is important both to an assessment of prognosis and to surgical planning is the differentiation between fixation and paralysis. The focus of surgical therapy has predominantly been directed at vocal fold lateralization, although there is growing interest in reinnervation and laryngeal pacing. There are a number of reliable lateralization and traditional techniques that are best performed with a tracheostomy in place. A lateralization procedure that removes the vocal process with a CO2 laser and a portion of the body of the arytenoids with preservation of the medial mucosa and with/without an external stitch lateralization is described. It can usually be performed without a tracheostomy. A unilateral lateralization procedure is highly successful in the management of bilateral vocal fold paralysis, since the wound healing will pull the vocal fold in a lateral position. In bilateral fixation, however, bilateral lateralization procedures are usually required since the defect will partially fill back in, narrowing the surgically created defect.