Congenital bilateral vocal fold paralysis (BVFP) is the second most common cause of stridor in neonates. Etiologies of BVFP include neurologic, cardiopulmonary malformations, iatrogenic, traumatic, and idiopathic. One half of children with BVFP will require a tracheostomy for upper airway obstruction. Because more than 50% of BVFP will resolve spontaneously, many advocate surgical intervention to achieve decannulation after the age of one. The goal of surgery is to provide an adequate airway to allow decannulation with minimal impact on speech and swallowing. There is no one procedure accepted as the gold standard or first-line treatment to achieve decannulation in children with BVFP. The author's preference is to perform a vocal cordotomy as a first line for an endoscopic approach.