Description

In this BoardsCast episode, we finish Tobias Chapter 101 — Larynx with the harsh reality of laryngeal paralysis:

You can’t fix the nerve; you can only fix the airway.

Arytenoid lateralization (“tieback”) is not “restoring function.” It’s a permanent mechanical redesign of the airway gate — forcing the larynx open so the patient can breathe, even though the biologic motor is permanently offline. 

You’ll learn:

• The dominant model: tieback = mechanical redesign (not nerve recovery) 
• Why these dogs crash: inspiration creates a vacuum that pulls flaccid arytenoids inward (the paper-straw effect) 
• What the surgery actually does: a permanent non-absorbable suture from the cricoid → muscular process of the arytenoid to hold one side abducted 
• Why unilateral works: small radius gain = massive resistance drop (Poiseuille’s law) 
• The unavoidable tradeoff: you improve airflow by permanently weakening the seal → aspiration pneumonia is the big complication
• The board answer: unilateral tieback is preferred because bilateral massively increases aspiration risk (near-guaranteed failure rates reported) 

Key takeaway: when the gate won’t open, you prop it open — and then you manage the aspiration risk forever.

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