Authors: Bhutta R et al.
Cureus, 17(9): e93264, September 2025 DOI: 10.7759/cureus.93264
Summary
This narrative review synthesizes practical airway management considerations for patients with vocal cord paralysis (VCP), focusing on how unilateral versus bilateral immobility changes intubation mechanics, intraoperative risk, extubation safety, and postoperative outcomes. The authors highlight that VCP is frequently under-recognized in routine preop airway evaluation, yet it can convert an otherwise straightforward induction/emergence into a rapidly deteriorating airway scenario—especially in bilateral VCP where the cords may be fixed near the midline and even mild edema can critically narrow the glottic aperture.
A core theme is that “better view” is not the same as “safe tube passage.” Video laryngoscopy often improves visualization of the glottis, but VCP can create distorted geometry, midline fixation, and subglottic resistance that make tube advancement difficult and can produce false reassurance. The review emphasizes atraumatic technique: careful passage, readiness with smaller endotracheal tubes, soft-tip stylets, and bougie/introducer strategies when the gap is narrow. In high-risk scenarios—particularly suspected or known bilateral VCP or prior laryngeal surgery/implants—the authors support awake fiberoptic intubation as a high-control approach that preserves protective reflexes and allows real-time navigation around an abnormal glottis.
Extubation is presented as the highest-risk phase for many VCP patients. Impaired glottic closure and reduced laryngeal sensation raise aspiration risk, while bilateral VCP patients may decompensate quickly after tube removal. The review argues for deliberate, criteria-driven extubation planning rather than routine practice: ensuring full neuromuscular recovery, considering pre-extubation airway assessment when feasible, using edema-mitigation strategies in selected high-risk cases, and planning an appropriate postoperative monitoring environment (often ICU-level observation for bilateral or borderline cases). The authors also emphasize team-based planning with clear roles and rescue pathways (including ENT/surgical airway readiness) when VCP severity or airway reserve is uncertain.
Overall, the article’s main value is not a new algorithm, but a consolidated set of practical “failure modes” (false reassurance with VL, tight glottic aperture, edema vulnerability, aspiration risk) and preventative behaviors (anticipation, gentle technique, device selection, extubation planning, and escalation readiness). It repeatedly notes the evidence gap: VCP-specific comparative data on DL vs VL, standardized extubation protocols, and outcome-focused studies are limited, leaving many decisions dependent on expert practice patterns and institutional resources.
Key Points
• VCP increases risk at both intubation and extubation; bilateral VCP is particularly vulnerable to rapid obstruction with minor edema
• Video laryngoscopy can improve glottic view but may still fail at tube passage and can create false reassurance in VCP
• Awake fiberoptic intubation is a strong option for bilateral VCP, fixed midline cords, and prior laryngeal surgery/implants
• Atraumatic strategy matters: smaller ETT options, bougie readiness, gentle advancement, and careful cuff management
• Extubation should be treated as a planned high-risk event with readiness for immediate rescue and appropriate post-extubation monitoring
What You Should Know
If you suspect VCP (history of thyroid/neck/cardiothoracic surgery, hoarseness, stridor, prior prolonged intubation, vocal fold implant), the biggest safety win is anticipating the problem early and shifting from “routine airway” to “structured airway plan.” In practice: minimize trauma (tube size/technique), avoid complacency from a good VL view, and treat extubation like a high-stakes step—fully reversed, fully awake, with backup plans and the right location to monitor afterward.
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