Endoscopic Posterior Cricoid Split with Rib Grafting for Bilateral Vocal Fold Paralysis

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Author: Vikash Modi
Specialties: Laryngology, Otolaryngology, Pediatric Otolaryngology
Schools: Weill Cornell Medical College
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Basic Info

Endoscopic posterior cricoid split with rib grafting can be used in children with bilateral vocal fold immobility due to bilateral vocal fold paralysis or cricoarytenoid joint fixation with posterior glottic stenosis. It is preferred to vocal cordotomy/arytenoidectomy because it is a non-destructive procedure with no impact on voice and swallowing.  It is also preferred to open laryngotracheal reconstruction because it does not disrupt the anterior cricoid ring thereby preserving the "spring" of the cricoid.

DOI: http://dx.doi.org/10.17797/gcnyoduseo



1. Size airway
2. Insert metal tracheostomy tube
3. Spontaneous Ventilation
4. Insert Lindholm laryngoscope and suspend to the Mayo stand. Spray vocal folds with 2% lidocaine. Attach suction to side port of laryngoscope
5. Insert Lindholm laryngeal spreader in an inverted fashion to distract false vocal folds. Suspend with rubber bands to suspension apparatus
6. Use straight alligator, curved alligator, and/or straight suction to move interarytenoid muscles posteriorly. Palpate the superior margin of the cricoid and push it inferiorly so it tilts anteriorly.
7. Use carbon dioxide laser to divide cricoid (smallest spot size on 5 watts in pulsed mode) to divide posterior cricoid.
8. May use sickle knife to get tactile feedback when dividing the most posterior aspect of the cricoid to ensure the posterior cricoid perichondrium is not divided. (Do not undermine posterior cricoid perichondrium)
9. Measure length of cricoid split with the suction
10. Harvest rib graft
11. Carve rib graft in an inverted "T-shape" with perichondrium on the luminal surface. Place rescue stitch on the cephalad end of the graft (5.0 prolene suture)
12. Use stout laryngeal forcep to place graft in posterior glottic region
13. User right angle probe to move graft and ensure flanges are tucked in under posterior edges of the cricoid.
14. Cut and remove the rescue suture
15. Remove laryngeal spreader, replace metal tracheostomy tube with age appropriate tracheostomy tube, and remove laryngoscope.


Bilateral Vocal Fold Immobility
Bilateral Vocal Fold Paralysis
Cricoarytenoid Joint Fixation with posterior glottic stenosis
Subglottic Stenosis Grade 3 or less
Age older than 12 months


Poor endoscopic exposure of the larynx (i.e. micrognathia, retrognathia)
Grade 4 subglottic stenosis
Severe transglottic stenosis
Tracheal Stenosis
Under 12 months of age



See above under Procedures Steps 1-5

Preoperative Workup

1. Awake flexible fiberoptic laryngoscopy
2. Direct laryngoscopy and bronchoscopy
3. Palpate for cricoarytenoid fixation
4. Laryngeal EMG

Anatomy and Landmarks

1. True and false vocal folds
2. Interarytenoid muscles
3. Cricoid cartilage


- Less destabilization of the cricoid resulting in faster recovery, less morbidity, and no need for stenting when compared to the open approach
- Non-destructive procedure which preserves the laryngeal anatomy resulting in less affect on voice and swallowing when compared to vocal cordotomy/arytenoidectomy


- Graft extrusion

Disclosure of Conflicts

- Graft extrusion




1. Modi VK. Endoscopic posterior cricoid split with rib grafting. Adv Otorhinolaryngol. 2012; 73:116-22
2. Gerber ME, Modi VK, Ward RF, Gower VM, Thomsen J. Endoscopic posterior cricoid split and costal cartilage graft placement in children. Otol Head Neck 2013 Mar; 148:494-502
3. Inglis AF, Perkins JA, Manning SC, Mouzakis J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope. 2003; 113:2004-2009

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