What is the next step in managing a post-thyroidectomy patient who develops stridor after extubation (removal of endotracheal tube) with vocal cords found midway between open and closed on laryngoscopy?

Post-Thyroidectomy Stridor with Vocal Cords in Paramedian Position: Immediate Reintubation Required

The next step is C. Reintubation - this patient requires immediate emergency reintubation to secure the airway, as vocal cords positioned midway between open and closed indicate bilateral recurrent laryngeal nerve injury causing critical airway obstruction. 1, 2, 3

Clinical Recognition and Pathophysiology

The laryngoscopic finding of vocal cords "midway between open and closed" is the classic presentation of bilateral recurrent laryngeal nerve (RLN) paresis, which occurs in approximately 0.2% of benign thyroid surgeries but represents a life-threatening emergency. 3

• Bilateral RLN injury causes the vocal cords to assume a paramedian position, creating a critically narrowed glottic aperture that produces stridor and rapidly progressing respiratory distress. 3
• This differs from unilateral RLN injury (which causes hoarseness but maintains adequate airway) and from laryngeal edema (which would show swollen but mobile cords). 3
• Stridor is a late sign of airway compromise - by the time it develops, the patient is already in critical danger and intervention must not be delayed. 1, 2, 4

Immediate Management Algorithm

Step 1: Recognize the Emergency

• The combination of post-thyroidectomy stridor with vocal cords in paramedian position on laryngoscopy confirms bilateral RLN injury requiring immediate airway intervention. 3
• This is a "cannot wait" scenario - the patient will rapidly progress to complete airway obstruction and respiratory arrest without intervention. 1, 3

Step 2: Prepare for Emergency Reintubation

• Call for senior anesthesia help immediately without attempting conservative management. 1, 2
• Administer high-flow supplemental oxygen and position the patient head-up while preparing for intubation. 1, 2
• Have emergency front-of-neck airway equipment immediately available at bedside (cricothyroidotomy kit). 1, 4

Step 3: Perform Emergency Reintubation

• Use videolaryngoscopy at first attempt to maximize success and minimize trauma. 1, 4
• The narrowed glottic opening from bilateral RLN injury makes intubation technically challenging but still feasible with appropriate equipment. 3, 5
• Avoid multiple intubation attempts - if first attempt with videolaryngoscopy fails, proceed directly to surgical airway (cricothyroidotomy). 1, 4

Why NOT Tracheostomy or Cricothyroidotomy as First-Line

Tracheostomy (Option A) is incorrect because:

• Tracheostomy is a controlled surgical procedure requiring operating room setup, surgical team, and 20-45 minutes to perform safely. 1
• This patient needs immediate airway control within minutes, not the time required for formal tracheostomy. 1, 3
• Tracheostomy may be needed later for definitive management if RLN injury is permanent, but reintubation must come first. 3

Cricothyroidotomy (Option B) is incorrect as first-line because:

• Cricothyroidotomy is reserved for "cannot intubate, cannot oxygenate" scenarios when reintubation has failed. 1, 4
• The laryngoscopy has already visualized the vocal cords, confirming that the glottis is accessible (though narrowed). 3
• Emergency reintubation should be attempted first with videolaryngoscopy, reserving cricothyroidotomy for rescue if intubation fails. 1, 4

Post-Reintubation Management

After securing the airway with reintubation:

• Transfer to ICU for ongoing mechanical ventilation and monitoring. 1, 2
• Consult otolaryngology for definitive assessment of RLN function and prognosis. 6
• Most bilateral RLN injuries are temporary due to surgical manipulation, edema, or neuropraxia rather than transection. 3
• Serial laryngoscopy should be performed to assess for return of vocal cord function before considering extubation. 6
• If bilateral RLN injury proves permanent, tracheostomy will be required for long-term airway management, but this is a controlled decision made after stabilization. 3

Critical Pitfalls to Avoid

• Never delay intervention hoping for spontaneous improvement - bilateral RLN injury does not resolve acutely and the patient will deteriorate. 1, 3
• Do not attempt conservative management with nebulized epinephrine or steroids - these treat laryngeal edema, not mechanical obstruction from paralyzed vocal cords. 1, 7
• Avoid multiple intubation attempts - each failed attempt worsens laryngeal trauma and edema, making subsequent attempts harder and increasing mortality. 1, 4
• Do not rely on pulse oximetry alone - it lags behind clinical deterioration and can provide false reassurance until sudden decompensation occurs. 1