Bilateral vocal fold paralysis (BVFP) in adduction is characterised by inspiratory dyspnea, due to the paramedian position of the vocal folds with narrowing of the airway at the glottic level. The condition is often life threatening and therefore requires surgical intervention to prevent acute asphyxiation or pulmonary consequences of chronic airway obstruction. Aside from corticosteroid administration and intubation, which are only temporary measures, the standard approach for improving respiration is to perform a tracheotomy. Over the past century, a vast majority of surgical interventions have been developed and applied to restore the patency of the airway and achieve decannulation. Surgeons can generally choose for every individual patient from various well-established treatment options, which have a predictable outcome. An overview of the surgical techniques for laryngeal airway enlargement in BVFP is presented. Included are operative techniques, which have found application in clinical practice, and only to a small extent in purely anatomic or animal studies. The focus is on two major groups of interventions--for temporary and for definitive glottic enlargement. The major types of interventions include the following: (1) resection of anatomical structures; (2) retailoring and displacing the existing structures, with minimal tissue removal; (3) displacing existing structures, without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal musculature. The single interventions of these four major types have always followed the development of the medical equipment and anaesthesia. At the beginning of the twentieth century, when medicine was unable to counteract surgical infection, endoscopic or extramucosal surgical techniques were dominant. In the 1950s, the microscopic endoscopic laryngeal surgery boomed. At the end of the twentieth century many of the classical endoscopic operations were performed either with the help of surgical lasers alone, or in combination with other interventions.

Background: Definitive enlargement of the glottis with preservation of adequate voicing in patients with bilateral recurrent nerve paralysis remains a surgical challenge especially in patients with previous unsuccessful surgery. Study design: Report of a novel surgical technique for glottis enlargement and presentation of midterm results. Methods: Four adult patients with bilateral recurrent nerve paralysis were subjected to submucosal arytenoidcordectomy through a thyreofissure approach with ventricular folds transposition and long-term translaryngeal stenting. Two of them had had previous surgeries at the glottic level. Preoperative data as well as postoperative functional results are reviewed. Follow-up ranged from 8 to 28 months. Results: In all patients tracheostomy closure was achieved. Midterm follow-up revealed stable airway, adequate for the patients' routine physical activities. Postoperatively patients phonated with the ventricular folds and the resulting voice quality was good. Conclusions: We describe a novel approach for management of impaired airway because of bilateral recurrent nerve paralysis and/or stenosis. It comprises intralaryngeal soft tissue resection, enlargement of the cartilaginous framework of the larynx and long-term translaryngeal stenting. The surgical approach described here proved to be successful both in patients with simple bilateral vocal fold motion impairment and in those, who have been already unsuccessfully treated with other surgery. Nevertheless the technique should be regarded as an option only in complicated revision cases, rather than a primary intervention in bilateral vocal fold paralysis.