When the larynx has lost its volitional motion because of mechanical fixation, such as in intubation-related posterior glottic stenosis, or because of neurological damage, such as in bilateral vocal fold paralysis following thyroidectomy, all decisions regarding airway enhancement involve an essentially arithmetic trade-off between improved airway and impaired voice/swallowing.

Familiarity with the suture lateralization device is essential and should be performed on a practice basis numerous times prior to the actual case.

In the case of the reversible lateralization, the patient is evaluated in clinic and if both vocal folds are recently paralyzed, the vocal fold with less volitional motion is chosen. In cases where it is not clear, palpation of cricoarytenoid joint motion is performed under anesthesia; it is better to lateralize the side with the stiffer joint, since preservation of potential motion on the other side is advantageous if it recovers motion.

Beware of subclinical swallowing dysfunction in glottic stenosis patients; it is important to pursue a swallow evaluation (e.g., modified barium swallow) prior to most cases of glottic stenosis surgery. Decannulating a patient while crippling swallowing function is not acceptable in most patients.

Care must be taken to evaluate the airway at all four levels (supraglottis, glottis, subglottis and trachea) with careful endoscopy to avoid the circumstance of a successfully widened glottis and persistent airway obstruction.

This procedure may be less successful in cases where the arytenoids are mechanically fixed, since the posterior glottis, where most airflow takes place, will not be meaningfully altered by suture lateralization.

Inadequate endoscopic laryngeal exposure represents a major barrier to successful completion of this procedure and alternate open approaches should be considered (e.g., arytenoid abduction).

Again, familiarity with the device is essential for ease of use.

Prolene suture can be easily weakened by small tears, so careful handling of the suture will prevent undesired breakage.

The primary technical error that must be avoided is putting the needle directly through the vocal fold. If this occurs, simply withdraw the needle and retry. The zero degree and even the seventy degree telescope can be useful in assessing vertical position prior to deploying the needle.

It is sometimes difficult to place the needle below the vocal fold without encountering the thyroid cartilage. Careful trial and error can allow smooth passage of the needle under the vocal fold outside of the larynx without having to pierce through the inferior edge of the thyroid cartilage.