What is the best management approach for an older adult patient with vocal cord paralysis and stridor, considering potential comorbidities and risk of respiratory failure?

Management of Vocal Cord Paralysis with Stridor

In an older adult with vocal cord paralysis and stridor, immediate escalated care with expedited laryngeal examination is mandatory, followed by urgent airway stabilization—typically requiring tracheostomy in bilateral cases or close ICU monitoring with airway preparation in unilateral cases with respiratory compromise. 1

Immediate Assessment and Stabilization

Recognize This as a Respiratory Emergency

• Stridor with vocal cord paralysis represents impending respiratory failure requiring immediate intervention. 1
• Position the patient upright immediately to reduce work of breathing and facilitate respiratory effort 2
• Administer high-flow humidified oxygen (FiO2 1.0) to maintain oxygenation while assessing the airway 2
• Call for senior anesthesia/critical care support immediately—this is a potentially difficult airway requiring expert management 1, 2

Perform Urgent Direct Laryngeal Visualization

• Flexible fiberoptic laryngoscopy must be performed urgently to determine whether paralysis is unilateral or bilateral and to assess vocal cord position. 1, 3
• Bilateral abductor (adducted) vocal cord paralysis causes severe airway obstruction and typically requires immediate tracheostomy 4, 5, 3
• Monitor continuously for signs of respiratory compromise: accessory muscle use, declining oxygen saturation, altered mental status, or respiratory alkalosis 2

Determine Underlying Etiology

Investigate Recent Surgical History and Malignancy Risk

• Recent head, neck, or chest surgery (especially thyroid, carotid, or thoracic procedures) is the most common cause of iatrogenic vocal cord paralysis. 1
• Recent endotracheal intubation can cause vocal cord injury, edema, or arytenoid dislocation 1
• In smokers or patients with concomitant neck mass, esophageal or laryngeal malignancy must be excluded urgently, as these can cause direct airway invasion or tracheoesophageal fistula 1, 2, 3

Consider Neurologic Causes

• Vocal cord paralysis combined with dysarthria, dysphagia, or other upper motor neuron signs may indicate amyotrophic lateral sclerosis, Shy-Drager syndrome, or other progressive neurologic conditions 1, 6
• These patients require early laryngeal examination and expedited neurology referral 1

Airway Management Strategy

For Bilateral Vocal Cord Paralysis with Respiratory Distress

• Tracheostomy is the gold standard for bilateral vocal cord paralysis in adducted position causing airway obstruction. 4, 5, 3
• If intubation is required before tracheostomy, prepare for modified rapid sequence intubation with double setup for front-of-neck access (FONA), as the airway may be difficult 2
• Pre-oxygenate thoroughly with head-up positioning and high-flow nasal oxygen 1, 2
• Identify the cricothyroid membrane by palpation or ultrasound before induction, as emergency cricothyrotomy may be necessary 2
• Limit intubation attempts to maximum three, as repeated attempts increase trauma and risk of "can't intubate, can't ventilate" scenario 2

For Unilateral Paralysis or Less Severe Cases

• Close monitoring in ICU for 6-24 hours post-intervention is essential, as upper airway injury can cause delayed airway compromise 1
• Keep patient NPO initially, as laryngeal protective reflexes may be impaired even when conscious 1, 2
• Monitor for signs of aspiration, as reduced laryngotracheal reflexes increase aspiration risk 1

Post-Stabilization Management

ICU Transfer and Monitoring

• Transfer to ICU for continuous monitoring after airway stabilization 2
• Monitor for complications including aspiration pneumonia, mediastinitis (if esophageal pathology present), or progressive airway edema 1, 2
• Assess swallowing function before reintroducing oral nutrition, progressing through stages to demonstrate adequate airway protective reflexes 1

Common Pitfalls to Avoid

• Do not delay airway intervention waiting for diagnostic workup—stridor with vocal cord paralysis can progress rapidly to complete airway obstruction. 1, 4, 3
• Do not assume unilateral paralysis is benign in older adults with comorbidities—respiratory reserve may be limited 4
• Do not overlook malignancy as the underlying cause, especially in smokers or those with neck masses—delayed diagnosis worsens outcomes 1, 2, 3
• Avoid excessive sedation or opioids, which can worsen upper airway obstruction and reduce protective reflexes 1

Definitive Treatment Planning

• For bilateral paralysis, endoscopic procedures (such as endoscopic anterior and posterior cricoid split or suture lateralization) may allow eventual decannulation in select cases, though tracheostomy remains standard 5, 7
• For unilateral paralysis, voice therapy and medialization procedures can be considered once the airway is secure and etiology determined 1