Vocal Cord Paralysis

Vocal cord paralysis means that one or both vocal cords do not move, because the nerve supplying them is not working. Paresis is a partial weakness of the same kind. The vocal cords open for breathing and close for speaking, coughing and protecting the airway during swallowing.

When one cord is paralysed, the voice becomes weak and breathy and drinks may go down the wrong way. When both are paralysed, which is rare, the cords usually lie close together and the main problem is breathing. Some paralyses recover without intervention within 6 to 12 months. Permanent cases can be improved substantially, though a fully normal voice is not always restored.

Symptoms

• A weak, breathy or hoarse voice that tires quickly
• Running out of air in the middle of a sentence
• Inability to shout or to be heard in noisy surroundings
• Coughing or choking when drinking thin liquids
• A weak, ineffective cough
• Noisy breathing and breathlessness on exertion when both cords are affected
• Repeated chest infections from aspiration

Causes and risk factors

The recurrent laryngeal nerve takes a long course from the brainstem down into the chest and back up to the voice box, so it can be injured at many points. The common causes are surgery to the thyroid, parathyroid glands, neck spine, carotid artery, heart or lungs, and tumours of the lung, oesophagus, thyroid or mediastinum that press on the nerve. Breathing tubes, neck injuries, stroke and neurological disease are other causes. In about a fifth to a third of cases no cause is found, and a viral inflammation of the nerve is presumed. Because a hidden tumour is possible, an unexplained paralysis always needs imaging.

How it is diagnosed

• Flexible laryngoscopy with stroboscopy: A thin camera passed through the nose shows the movement, position and closure of the cords during speech.
• CT from the skull base to the upper chest: Follows the whole course of the nerve to look for a tumour when the cause is not obvious.
• Laryngeal electromyography: A needle test of the laryngeal muscles performed 1 to 6 months after onset. It helps to predict whether recovery is likely.
• Swallowing assessment: A bedside test, endoscopic evaluation or a videofluoroscopy study if there is coughing with drinks.
• Voice assessment: Recordings and questionnaires by a speech and language therapist, to measure the effect and track progress.

Treatment options

• Voice therapy: Exercises that improve closure and breath support and reduce strain. They are often enough for a mild paresis, and useful alongside every other treatment.
• Injection laryngoplasty: A filler such as hyaluronic acid or calcium hydroxylapatite is injected into the paralysed cord to bring it to the midline. It is done under local anaesthetic in the clinic, or under a brief general anaesthetic. The effect is temporary, lasting 3 to 12 months, which makes it suitable while waiting to see whether recovery occurs.
• Medialisation thyroplasty: A permanent implant placed through a small incision in the neck under local anaesthetic with sedation, so that the voice can be adjusted during the procedure. Sometimes combined with arytenoid adduction.
• Laryngeal reinnervation: A nearby nerve is connected to the damaged one to restore muscle tone. Results appear after 6 to 9 months. It suits younger patients best.
• Treatment of paralysis on both sides: Laser cordotomy or partial removal of the arytenoid widens the airway at some cost to the voice. A tracheostomy may be needed temporarily.
• Swallowing strategies: Thickened drinks, a chin-tuck posture and therapy to prevent aspiration.

When it is urgent

Noisy breathing, breathlessness at rest or a bluish colour means that the airway is at risk. Call emergency services. Choking episodes with fever and a cough suggest aspiration pneumonia, which needs prompt local treatment.

Travelling to Türkiye for treatment

A one-sided paralysis that has been present for more than 9 to 12 months, or one with a known permanent cause, can be treated with a planned thyroplasty in a visit of about 5 to 7 days. An injection needs only 2 to 3 days. Before any permanent procedure, make sure the cause has been investigated with imaging and that enough time has been allowed for recovery to occur. Voice therapy before and after the procedure matters and should be arranged at home in your own language. Narrowing of the airway from paralysis on both sides should be assessed locally and without delay, not after a flight.

Send your reports, scans and a short history and a Clinic-Y coordinator replies within 24 hours with suitable teams and written, all-inclusive proposals side by side. Reviewing your case is free.

Frequently Asked Questions