## Indications for Tracheostomy: Absolute vs Relative **Key Point:** Tracheostomy indications are classified into absolute (airway emergency) and relative (planned airway management) categories. ### Absolute Indications 1. Complete airway obstruction (foreign body, epiglottitis, angioedema) 2. Severe facial/laryngeal trauma 3. Bilateral vocal cord paralysis (in adduction) ### Relative Indications 1. **Bilateral vocal cord paralysis** (in abduction) — allows safe airway 2. **Laryngeal stenosis** — bypasses stenotic segment 3. **Laryngeal papillomatosis** — recurrent disease requiring repeated laser ablation 4. Laryngeal web 5. Laryngeal cleft 6. Vocal cord fixation ### Why Unilateral RLN Palsy is NOT an Indication | Feature | Unilateral RLN Palsy | Bilateral RLN Palsy | |---------|----------------------|---------------------| | **Airway** | Patent — no obstruction | Obstructed — emergency | | **Voice** | Hoarse, breathy | Breathy, weak | | **Tracheostomy need** | NO | YES | | **Management** | Voice therapy, medialization | Tracheostomy or posterior cordotomy | **Clinical Pearl:** Unilateral RLN palsy does NOT compromise the airway because the contralateral vocal cord remains mobile. The patient has voice changes but maintains adequate breathing. Tracheostomy is NOT indicated unless there is concurrent airway compromise from another cause. **High-Yield:** The key discriminator is whether the condition obstructs or threatens the airway. Unilateral cord pathology rarely does; bilateral cord pathology in adduction always does. 
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