Vocal cord immobility in Guillain-Barré syndrome: a diagnostic challenge

We present the case of a man in his 40s with Miller Fisher/Guillain-Barré overlap syndrome complicated by bilateral vocal cord (BVC) paralysis and respiratory failure. MRI, nerve conduction studies confirming motor-predominant axonal loss, and positive anti-GD1b and GM1 antibodies supported the diagnosis. Emergency intubation and tracheostomy for ventilatory weaning was required. Persistent BVC immobility despite peripheral neurological recovery prevented decannulation and prompted further evaluation. Laryngeal electromyography (LEMG) revealed BVC denervation and reinnervation suggesting neurological recovery and mechanical fixation as the likely cause of persistent BVC immobility. Intraoperative findings confirmed a type 1 Bogdasarian posterior glottic stenosis. Voice-preserving microlaryngoscopic surgery with CO₂ laser scar excision, balloon dilation and steroid injection improved airway patency and led to successful tracheostomy decannulation. This case highlights the importance of recognising both neuropathic and mechanical causes of persistent BVC immobility following neurological injury and intubation, the value of multidisciplinary management and LEMG in guiding diagnosis and treatment.