In a patient with bilateral recurrent laryngeal nerve palsy following thyroid surgery, the vocal cords are found to lie in the paramedian position. What is the expected clinical presentation?

• A Aphonia with adequate airway
• B Breathy dysphonia with aspiration but adequate airway
• C Adequate voice but severe inspiratory stridor with respiratory distress ✓
• D Normal voice and airway initially, deteriorating over 6 months

Explanation

With bilateral RLN palsy, both cords are denervated and assume a paramedian (near-midline) position due to the balance of laryngeal muscle tone without abductor activity. This near-midline position is adequate for vibration and voice (glottic closure is reasonable), so voice may be near normal. However, the near-closed glottis causes severe airway narrowing especially on inspiration, producing inspiratory stridor and respiratory distress. This is the paradox of bilateral RLN palsy: voice is preserved but airway is critically compromised, necessitating tracheostomy.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.