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Key Features

  • Hoarseness or stridor

  • May present with difficulty swallowing

  • Unilateral or bilateral vocal cord paralysis

    • May be congenital

    • May result from injury to the recurrent laryngeal nerves (more common)

  • Risk factors for acquired paralysis include

    • Difficult delivery (especially face presentation)

    • Neck and thoracic surgery (eg, ductal ligation or repair of tracheoesophageal fistula)

    • Trauma

    • Mediastinal masses

    • Central nervous system disease (eg, Arnold-Chiari malformation)

Clinical Findings

  • Varying degrees of hoarseness, aspiration, or high-pitched stridor

  • Unilateral cord paralysis

    • More likely to occur on the left because of the longer course of the left recurrent laryngeal nerve and its proximity to major thoracic structures

    • Patients are usually hoarse but rarely have stridor

  • With bilateral cord paralysis,

    • The closer to midline the cords are positioned, the greater the airway obstruction

    • The more lateral the cords are positioned, the greater the tendency to aspirate and experience hoarseness or aphonia

  • If partial function is preserved (paresis), the adductor muscles tend to operate better than the abductors, with a resultant high-pitched inspiratory stridor and normal voice


  • Paralysis can be assessed by

    • Direct visualization of vocal cord function with laryngoscopy

    • Recording the electrical activity of the muscles (electromyography), which can differentiate vocal fold paralysis from arytenoid dislocation


  • Airway intervention (tracheostomy) is rarely indicated in unilateral paralysis but is often necessary for bilateral paralysis

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