Management of Vocal Cord Paralysis with Stridor
For an older adult with vocal cord paralysis and stridor, immediately secure the airway with tracheostomy as the definitive intervention, as this represents impending respiratory failure requiring urgent action rather than diagnostic delay. 1
Immediate Stabilization (First 15 Minutes)
- Position the patient upright immediately to reduce work of breathing and optimize respiratory mechanics 1
- Administer high-flow humidified oxygen at FiO2 1.0 to maintain oxygenation while preparing for definitive airway management 1
- Call for senior anesthesia and critical care support immediately, as vocal cord paralysis with stridor represents a potentially difficult airway requiring expert management 1
- Avoid sedation or opioids entirely, as these worsen upper airway obstruction and suppress protective reflexes 1
Airway Management Decision Algorithm
For bilateral vocal cord paralysis with respiratory distress (stridor), proceed directly to tracheostomy as the gold standard intervention. 1 This is the definitive recommendation from the American Academy of Otolaryngology-Head and Neck Surgery, particularly critical in older adults with comorbidities who cannot tolerate prolonged respiratory compromise.
If Intubation is Attempted Before Tracheostomy:
- Use awake fiberoptic nasotracheal intubation only if performed by an experienced operator 2
- Pre-oxygenate with head-up positioning and high-flow nasal oxygen 1, 2
- Apply meticulous topical anesthesia to nasal passages, oropharynx, and larynx 2
- Limit intubation attempts to maximum 3 attempts to prevent "can't intubate, can't ventilate" scenario 1
- Have emergency front-of-neck access (cricothyrotomy) equipment immediately available 2
Critical pitfall to avoid: Do not delay definitive airway intervention while pursuing diagnostic workup, as stridor with vocal cord paralysis can progress rapidly to complete airway obstruction. 1
Post-Stabilization Management (First 24 Hours)
- Monitor in ICU for 6-24 hours post-intervention, as upper airway injury can cause delayed airway compromise 1
- Keep patient NPO initially to prevent aspiration, since laryngeal protective reflexes are impaired even when conscious 1
- Assess swallowing function with formal evaluation before reintroducing oral nutrition 1
Etiology Investigation (After Airway Secured)
Look specifically for these causes in older adults:
- Recent head, neck, or chest surgery (most common iatrogenic cause) 1
- Recent endotracheal intubation causing vocal cord injury, edema, or arytenoid dislocation 1
- Malignancy (esophageal or mediastinal tumors causing recurrent laryngeal nerve compression) 3
- Neurological conditions presenting with vocal cord paralysis (though rare as initial presentation) 4
Long-Term Considerations
In pediatric populations, endoscopic procedures like anterior and posterior cricoid split have emerged as alternatives to tracheostomy 5, but in older adults with comorbidities and acute respiratory distress, tracheostomy remains the safest and most reliable intervention to avoid the mortality risk of respiratory failure. 1, 6