Paradoxical vocal cord movement (PVCM) causes inspiratory stridor and extra-thoracic airway obstruction through inappropriate adduction of the vocal cords during the respiratory cycle. We report on a patient with severe PVCM necessitating tracheostomy insertion. Using the technique of endoscopic suture lateralization of a vocal cord, we succeeded in decannulation 22 years after tracheostomy. PVCM of this severity is rare and its management remains unclear. Successful treatment in this manner has not been documented previously. A brief review of current management options for this condition is included.