What positions can the vocal folds assume when paralyzed?

Positions of Paralyzed Vocal Cords

Paralyzed vocal cords can assume three distinct positions: midline, paramedian, or lateral, with the specific position depending on the degree and type of nerve injury. 1

Anatomical Positions in Vocal Cord Paralysis

Three Primary Positions

The paralyzed vocal cord(s) can be fixed in:

• Midline position (52.8% of cases): The vocal cords are positioned at or near the center, creating a phonating position 1
• Paramedian position (44.4% of cases): The vocal cords are positioned slightly lateral to midline 2, 1
• Lateral position (2.8% of cases): The vocal cords are positioned in a more abducted state 1

Clinical Significance of Position

The position of paralyzed vocal cords determines the clinical presentation and severity:

Bilateral paralysis in adduction (midline/paramedian):

• Creates life-threatening airway obstruction with inspiratory stridor 2, 3
• Paradoxically maintains relatively normal phonation since cords are approximated 4
• Requires urgent intervention, often tracheostomy 2, 3
• The flaccid midline position places cords in phonating position while simultaneously obstructing the airway 4

Bilateral paralysis in abduction (lateral):

• Results in severe breathiness and aspiration risk 4
• Minimal airway obstruction 4
• Significant phonation deficits 2

Key Clinical Pitfall

The combination of normal phonation with severe respiratory distress is pathognomonic for bilateral vocal cord paralysis in the midline/paramedian position. 4 This paradoxical presentation frequently causes diagnostic delays because clinicians may not suspect vocal cord paralysis when voice quality is preserved. The stationary midline position allows adequate vocal cord approximation for phonation while critically narrowing the glottic airway 4.

Unilateral vs Bilateral Paralysis

• Unilateral paralysis: The affected cord typically assumes a paramedian position, causing breathiness and aspiration but rarely airway compromise 5
• Bilateral paralysis: When both cords are paralyzed in adduction (midline/paramedian), this creates severe airway obstruction requiring emergency tracheostomy 2, 3