Adult Bilateral Vocal Fold Paralysis

Purpose of Review: Patients with bilateral vocal fold paralysis (BVFP) typically present with signs and symptoms of airway compromise due to glottic obstruction. While the most common etiology of BVFP in the adult population is iatrogenic surgical injury to the injury to the recurrent laryngeal nerves (RLNs), the differential diagnosis is broad and includes malignancy, neurologic, and idiopathic etiologies. Management is dictated by the degree of airway compromise and prognosis for recovery of neural function. We describe etiologies and treatment options for BVFP in the adult population. Recent Findings: Multiple management strategies for BVFP have been described and are evolving. Tracheotomy is often employed initially while return of vocal fold mobility is awaited. Other short-term temporizing treatments, such as suture lateralization and laryngeal botulinum toxin injection, have been developed and can potentially allow patients to avoid tracheotomy. When mobility does not return after an appropriate observation period, permanent treatment options such as cordotomy and medial arytenoidectomy may be considered. These procedures improve ventilation by expanding the glottic airway and typically result in some loss of voice quality. Promising experimental treatments include laryngeal reinnervation and laryngeal pacing. Summary: Etiologies of BVFP are numerous and management is often dictated by prognosis for recovery of vocal fold mobility. Both temporizing and permanent treatment options for improving ventilation have been developed. Experimental treatments such as reinnervation and laryngeal pacing are promising and may offer the best combined voice and airway outcomes.