Signs and Symptoms of Vocal Cord Paralysis
Vocal cord paralysis presents with a constellation of symptoms primarily affecting voice quality, airway function, and swallowing ability, with hoarseness, breathy voice, and aspiration being the most common manifestations. 1
Primary Symptoms
Voice Changes (Most Common Presentation)
- Hoarseness (97.8% of cases) 2
- Breathy voice quality
- Low-pitched cry or voice (particularly in infants) 3
- Voice fatigue
- Decreased vocal volume/projection
- Inability to raise voice volume
- Diplophonia (two-toned voice)
Respiratory Symptoms
- Shortness of breath, especially during speech
- Noisy breathing or stridor
- High-pitched inspiratory stridor (particularly in bilateral paralysis) 3
- Exertional dyspnea
- Respiratory distress (more severe in bilateral cases)
- Ineffective cough
Swallowing Difficulties
- Aspiration (37.8% of cases) 2
- Choking or coughing while eating/drinking
- Sensation of food "sticking" in throat
- Recurrent pneumonia due to aspiration 1
Distinguishing Features by Type
Unilateral Vocal Cord Paralysis
- Mild to moderate hoarseness
- Voice fatigue with prolonged use
- Breathy voice quality
- Mild dysphagia
- Possible aspiration of thin liquids
- Symptoms typically evident within 24 hours after injury 4
Bilateral Vocal Cord Paralysis
- Relatively normal voice (may be surprisingly good)
- Severe airway compromise
- Significant stridor
- Respiratory distress ranging from mild stridor with exertion to acute airway obstruction 4
- Often requires more urgent intervention
Physical Examination Findings
- Vocal cord position on laryngoscopy:
- Midline position (52.8% of cases)
- Paramedian position (44.4% of cases)
- Lateral position (2.8% of cases) 2
- Asymmetric vocal cord movement
- Incomplete glottic closure during phonation
- Pooling of secretions in pyriform sinuses
Associated Findings
- Impaired laryngeal sensation (significantly associated with aspiration) 1
- Poor performance status (associated with increased pneumonia risk) 1
- History of previous aspiration pneumonia (increases risk of recurrent pneumonia) 1
Important Clinical Considerations
Risk Factors That Should Prompt Evaluation
- Recent surgical procedures involving the head, neck, or chest
- Recent endotracheal intubation
- Presence of concomitant neck mass
- History of tobacco abuse
- Professional voice user status 1
Diagnostic Pitfalls
- Mistaking partial movement impairment (paresis) for complete paralysis
- Failing to distinguish between neurogenic causes and mechanical fixation
- Missing bilateral involvement when only examining for unilateral symptoms
- Attributing symptoms to other conditions without laryngeal examination
Etiological Distribution
The most common causes of vocal cord paralysis include:
- Idiopathic (31.11%)
- Tumors (31.11%)
- Surgical injury (28.89%)
- Other causes including trauma, neurological disorders, and systemic diseases (9%) 2
Early recognition of these signs and symptoms is critical for proper diagnosis and management, as delayed diagnosis can lead to increased morbidity from aspiration pneumonia, respiratory compromise, and voice-related quality of life impairment.