What are the typical symptoms and management options for vocal cord paralysis, particularly in older adults or individuals with a history of stroke or trauma?

Presentation of Vocal Cord Paralysis

Vocal cord paralysis typically presents with hoarseness, breathy voice quality, and difficulty adjusting volume or pitch, with unilateral paralysis causing voice changes and bilateral paralysis presenting as a medical emergency with stridor and acute airway obstruction. 1, 2

Clinical Presentation by Type

Unilateral Vocal Cord Paralysis

Voice symptoms:

• Hoarseness is the most common presenting symptom, occurring in 1.2%-5.0% of cases following procedures like thyroid surgery 2
• Breathy or weak voice quality 1
• Difficulty adjusting volume or pitch 1
• Voice fatigue and reduced vocal endurance 1
• Inability to project voice or speak loudly 1

Respiratory and swallowing symptoms:

• Aspiration of food and liquids into the trachea due to impaired airway protection 2
• Persistent cough or choking when swallowing 1
• Shortness of breath or tiring easily from speaking 1
• Noisy breathing in some cases 1

Laterality patterns:

• Left vocal cord involvement occurs in 73% of cases 3
• Right vocal cord involvement in 27% of cases 3
• The left recurrent laryngeal nerve is damaged more commonly during cardiac surgery as it extends into the chest and loops under the aortic arch 2

Bilateral Vocal Cord Paralysis

This is a medical emergency requiring immediate intervention: 2

• Stridor (high-pitched breathing sound) 2, 4
• Acute airway obstruction 2
• Symptoms range from mild stridor with exertion to complete airway obstruction 4
• Increased snoring or episodes of sleep apnea may precede other symptoms 5
• Respiratory distress that may require intubation or tracheostomy 4

Common Etiologies to Consider

Surgical causes (most common identifiable cause):

• Thyroid surgery: occurs in up to 2.1% of thyroidectomy patients 2
• Anterior cervical spine surgery: hoarseness in up to 50% immediately post-surgery 2
• Cardiac surgery: hoarseness in 17-31% of patients, with RLN injury in about 1.4% 2
• Carotid endarterectomy: RLN damage in up to 6% 2

Non-surgical causes:

• Neoplasm (29% of cases) - malignancy must be excluded before labeling as idiopathic 6
• Intubation trauma (8% of cases) 6, 3
• Inflammation (21% of cases) 3
• Neurologic diseases including stroke, Parkinson's disease, and Shy-Drager syndrome 1, 5
• Idiopathic (13-31% of cases) - diagnosis of exclusion only 6, 3
• Rare: esophageal compression from achalasia or dilation 7

Timeline and Natural History

Recovery patterns:

• Changes in voice, breathing, and swallowing in acute unilateral paralysis are usually evident within 24 hours after injury 4
• Voice may stabilize in a few months, but laryngeal nerves may take over a year to completely heal 1
• Recovery from RLN injury usually occurs within 1-3 months 2
• Most unilateral injuries show compensation from the opposite vocal cord over time 2
• Intubation-related paralysis can be temporary (resolving within 6 months) or permanent 4
• Nerves may never fully recover in some cases 1

Essential Diagnostic Approach

Laryngoscopy is mandatory for diagnosis: 1, 2

• Laryngoscopy should be performed in all patients with persistent voice changes 2
• Routine laryngeal exam after surgery can detect vocal fold paralysis in twice as many patients as selective examination 2
• Visualization allows assessment of vocal cord position: midline (52.8%), paramedian (44.4%), or lateral (2.8%) 6

Imaging considerations:

• Do NOT obtain CT or MRI prior to visualizing the larynx 1
• After laryngoscopy confirms paralysis, imaging from skull base to thoracic inlet/aortic arch is warranted to evaluate the entire recurrent laryngeal nerve path 1
• Chest X-ray is positive in 39% of cases and is the most useful initial diagnostic test 3

Management Framework

Initial management priorities:

• For bilateral paralysis: secure airway immediately, consider tracheostomy 2, 4
• For unilateral paralysis: counsel patient about rehabilitation options 1

Rehabilitation options (in order of invasiveness): 1

1. Voice therapy by speech-language pathologist - noninvasive, provides temporary or permanent improvement through exercises and compensation strategies 1

2. Injection laryngoplasty - temporary effect (typically months), restores vocal fold position and bulk, can be performed in office or operating room 1

3. Framework procedures - permanent, near-immediate restoration of voice, requires operating room and neck incision 1

4. Reinnervation surgery - permanent, final outcome takes up to a year, often combined with injection for interim voice rehabilitation 1

Critical Pitfalls to Avoid

• Never assume idiopathic etiology without excluding malignancy through complete workup 6
• Do not delay laryngoscopy in patients with bilateral symptoms - this is an airway emergency 2
• Avoid obtaining imaging before laryngoscopy, as it adds cost without diagnostic benefit 1
• In older adults or those with stroke history, consider neurodegenerative diseases like Parkinson's or Shy-Drager syndrome, especially if bilateral paralysis develops 1, 5
• Remember that no current treatments restore normal vocal fold movement - all are rehabilitative rather than restorative 1