Vocal cord paralysis occurs when there is interruption of nerve impulses to the laryngeal muscles, resulting in impaired or absent movement of the vocal cords. It can be caused by issues with the recurrent laryngeal nerve, superior laryngeal nerve, or both. Unilateral paralysis may cause hoarseness while bilateral paralysis risks airway obstruction and aspiration. Treatment depends on severity and includes watchful waiting, injection augmentation, framework surgery, and in severe cases, tracheostomy. Proper evaluation involves assessing symptoms, medical history, and direct laryngeal examination along with imaging tests.

1. VOCAL CORD PARALYSIS

2. INTRODUCTION
• Vocal cord Paralysis : defined as total
interruption of nerve impulse resulting in no
movement of laryngeal muscles.
• Vocal cord Paresis : defined as partial
interruption of nerve impulse resulting in weak or
abnormal movement of laryngeal muscles.

3. • Vocal cord paresis/paralysis can occur at any age
or sex.
• Effect of VC paralysis may vary & depends on the
patient’s use of his or her voice.
• A mild vocal cord paresis can be the end to a
singer's career but it have only marginal effect on
any other professional career life.
• Vocal cord Paralysis is a sign of a disease & not a
diagnosis by itself.

4. ANATOMY OF LARYNX

5. LARYNGEAL CARTILAGES

7. LARYNGEAL MUSCLES

8. NERVE SUPPLY OF LARYNX

10. NERVE SUPPLY OF LARYNX
MOTOR
• All the muscles which move
the vocal cords (abductors,
adductors or tensors) are
supplied by the Recurrent
Laryngeal Nerve except the
cricothyroid muscle, which
is supplied by Superior
Laryngeal Nerve.
• Both of these are branches
of the Vagus Nerve.
SENSORY
• Above the vocal cords,
larynx is supplied by
Internal Laryngeal Nerve –
a branch of Superior
Laryngeal Nerve & below
the vocal cords by
Recurrent Laryngeal Nerve.

11. RECURRENT LARYNGEAL NERVE
• Rt. Recurrent laryngeal nerve
arises from the Vagus nerve at the
level of Subclavian artery, hooks
round it & then ascends between
the trachea & oesophagus.
• The Lt. Recurrent laryngeal nerve
arises from the Vagus in the
Mediastinum at the level of Arch of
aorta, loops round it & then
ascends into the neck in the
tracheo-oesophageal groove.
• Thus, Lt. Recurrent Laryngeal
Nerve has a much longer course
which makes it more prone to
paralysis as compared to the right
one.

12. SUPERIOR LARYNGEAL NERVE
• It arises from Inferior
Ganglion of the Vagus
nerve, descends behind
Internal Carotid artery & at
the level of Greater cornu of
Hyoid bone, divides into
External & Internal
branches.
• The external branch supplies
cricothyroid muscle while
the internal branch pierces
the thyrohyoid membrane &
supplies sensory innervation
to the larynx &
hypopharynx.

13. FUNCTIONS OF VOCAL CORDS
Vocal cord mainly has the following movements :
• Adduction : approximation of vocal cord with
each other.
• Abduction : movement of vocal cord away from
each other.

14. ADDUCTION OF VOCAL CORDS

15. ADDUCTION OF LARYNX

16. ABDUCTION OF LARYNX

17. CLASSIFICATION OF LARYNGEAL PARALYSIS
• Laryngeal paralysis can be :
Unilateral or Bilateral & may involve –
1. Recurrent laryngeal nerve
2. Superior laryngeal nerve
3. Both (Combined / Complete)

18. CAUSES OF LARYNGEAL PARALYSIS
In topographical manner they are :
1. Supranuclear : Rare
2. Nuclear : Vascular disease, Neoplastic disease, Motor neuron disease,
Polio & Syringobulbia, MG, Arnold chiari
3. High vagal lesions : Post. fossa tumors, Tubercular meningitis, Fracture of
skull base, Nasopharyngeal cancer, Glomus tumor, Penetrating injury of
neck, Parapharyngeal tumors, Metastatic neck nodes, Lymphoma
4. Low vagal or recurrent laryngeal nerve
5. Systemic causes : Diabetes, Syphilis, Diptheria, Typhoid, Viral infections,
Lead poisoning
6. Idiopathic

19. • Cancer 31%: lung, thyroid, esophagus, and other
• Surgery 29%: thyroidectomy, cervical spine
A. Thyroidectomy is commonest cause of bilateral laryngeal paralysis.
• Non surgical treauma 7%: penetrating neck injury
• Cardiovascular: aortic aneurysm, cardiac hypertrophy, etc
• Inflammatory 4%: collagen vascular disorders, sarcoidosis, Lyme
disease, and syphilis
• Central lesions 1%: Arnold-Chiari malformation, multiple sclerosis,
etc
A. Isolated laryngeal paralysis due to other central lesions (such as
stroke) is rare,as other cranial nerves are usually affected.
• Idiopathic 24%: in about 20% of cases

20. Imaging:
• Although rarely obtained today for the workup of unilateral vocal fold paralysis
(UVFP), chest radiography is sometimes the first screening evaluation for a patient
with UVFP of unknown etiology, ordered by a physician for other comorbid chest
symptoms. This may reveal a chest malignancy as the cause of the UVFP. A
Pancoast tumor, mediastinal mass, or even massive cardiomegaly may be found.
The latter has rarely been shown to be a cause of UVFP when enlargement of the
left atrium that causes a stretch injury to the left recurrent laryngeal nerve is
present (Ortner syndrome).
• CT scanning or MRI of the path of the vagus/recurrent laryngeal nerve should be
performed as part of a workup for a UVFP of unknown etiology. The imaging
should include the entire path of the vagus/recurrent laryngeal nerve involved. A
left UVFP involves imaging from the base of skull to the mid chest (through the
arch of the aorta). The right UVFP evaluation should extend from the base of the
skull through the clavicle. Although CT is usually the test of choice, the decision
between CT scanning and MRI is personal and can be decided by the
otolaryngologist and radiologist.

21. Laryngeal electromyography (LEMG)
• LEMG is an electrophysiologic evaluation of the muscles of the larynx. This
test is performed using an EMG needle percutaneously under local or no
anesthesia. The LEMG most often involves an evaluation of the
thyroarytenoid/lateral cricoarytenoid muscle complex, which is reflective of
the recurrent laryngeal nerve innervation and the cricothyroid muscle,
which is indicative of the superior laryngeal nerve status/function.
• LEMG findings can be diagnostic and prognostic and can therefore be a
useful tool to guide therapy. LEMG can be used to differentiate between
vocal fold immobility caused by cricoarytenoid joint pathology and that
caused by vocal fold paralysis. The timing of LEMG is crucial in accurately
determining the prognosis of spontaneous recovery of the paralyzed vocal
fold. LEMG is most predictive of outcome if performed 6 weeks to 6 months
after the onset of symptoms. LEMG can shorten the time until permanent
treatment is implemented, subsequently reducing the time of the patient's
dysphonia and the number of temporary treatments required.
• In evaluating a patient with bilateral vocal fold immobility (BVFI), EMG
provides the potentially useful information in the following:
 Differentiating between fixation and paralysis
 Differentiating between neurapraxia and axonal transection
 Determining the presence of neuromuscular disorders or peripheral neuropathy

22. VOCAL CORD POSITIONS

23. THEORIES ON POSITION OF VOCAL
CORD IN VOCAL CORD PARALYSIS
• SEMON’S LAW : states that, in all progressive organic
lesions, abductor fibres of the nerve which are
phylogenitically newer are more susceptible & thus the
first to be paralysed as compared to adductor fibres
• WAGNER & GROSSMAN HYPOTHESIS : is the most
widely accepted theory. It states that complete
paralysis of the recurrent laryngeal nerve results in the
vocal cord being in paramedian because of an intact
cricothyroid muscle, which adducts the vocal cord.
When the Superior laryngeal nerve is also paralysed,
the vocal cord will be in intermediate or cadaveric
position because of loss of this adductive force.

24. RECURRENT LARYNGEAL NERVE PARALYSIS
(A) UNILATERAL
• Unilateral injury to recurrent
laryngeal nerve results in ipsilateral
paralysis of all the intrinsic muscles
of larynx ecxept the cricothyroid.
• The vocal cords thus assumes a
median or paramedian position &
doesn’t move laterally on deep
inspiration.
• Clinical features :
- Asymptomatic
- Change in voice
- Bovine cough
- Tiredness of voice with use if
the other cord is
compensating (low voice)
 The voice in unilateral
paralysis gradually improves
due to compensation by
healthy cord which crosses
midline to meet paralysed
one.
• Treatment : Generally no
treatment is required.

26. Treatment:
• Nonsurgical Measures
Expectant treatment is recommended when
there is no underlying malignant growth. Most
unilateral cord palsies compensate within 6–
18 months. Patient age, occupation, and
preference as to how aggressively the vocal
cord paralysis should be treated should all
influence the treatment plan.

27. Surgical treatment:
• A range of surgical measures is available the aim of which
is to allow contact with the opposite cord during phonation
and swallowing and to improve the patients’ ability
to cough. Procedures may be static or dynamic. Dynamic
procedures consist of re-innervation or laryngeal pacing
with an implantable device; they are performed in
relatively few centers worldwide and will not be discussed
further. The two principal static measures are injection
laryngoplasty and laryngeal framework surgery.

28. • Injection laryngoplasty—It
involves injecting a material
laterally into the vocal fold to
displace it medially. An ideal
injectable material would lack
an antigenic response, have
similar viscoelastic properties to
the vocal fold, be resistant to
resorption or migration, and be
easy to prepare and inject with
precise control. Substances
commonly used include
collagen, Vox, calcium
hydroxyapatite, polyacrylamide
gel, and fat. Gelfom is better
when full recovery expected.

29. • Laryngeal framework surgery—Laryngeal framework
surgery (in the form of medialization thyroplasty) involves
the placement of a Silastic implant or Gore-tex lateral to
the vocal fold via a window cut in the thyroid cartilage.
The Silastic displaces the vocal fold medially, ensuring
adequate glottic closure.

30. (B) BILATERAL (B/L Abductor paralysis) :
• Position of vocal cords : All the intrinsic muscles of
larynx are paralysed, vocal cords lie in median or
paramedian position due to unopposed action of
cricothyroid muscles.
• Clinical features :
- Dyspnoea ,voice may be normal
- Stridor
• Cause:
• Usually after thyroidectomy
• Treatment: traciostomy
cordotomy, arytenoidectomy

31. Movement of Vocal cord during
inspiration & expiration

32. • Treatment :
• Usually 6 months is an adequate time to wait for
any spontaneous recovery.
• In acute stridor, Tracheostomy may be required.
- If patient doesn’t want tracheostomy following
option can be considered :
• Lateralisation of the vocal cord: Aim is to move &
fix the cord in a lateral position to improve the
airway. The various procedures are:
(a) Arytenoidectomy
(b) Vocal cord lateralisation through endoscope.
(c) Thyroplasty type II
(d) Cordectomy
(e) Nerve muscle implant

33. PARALYSIS OF SUPERIOR LARYNGEAL NERVE
(A) UNILATERAL
• Paralysis of cricothyroid muscle & ipsilateral
anaesthesia of the larynx above the vocal
cord.
• Causes :
- Thyroid surgery
- Thyroid Tumors
- Diptheria.
• Clinical features :
- Weak voice with decreased pitch
- Anaesthesia of the larynx on one side
- Occassional aspiration.
 Laryngeal findings include :
- Askew position of glottis - Ant. Comissure is
rotated to healthy side.
- Shortening of V.C. with loss of tension & V.C.
appears wavy
- Flapping of the paralysed vocal cord – V.C. sags
down during inspiration & bulges up during
expiration.
(B) BILATERAL
• An uncommon condition. Both the cricothyriod
muscles are paralysed along with anaesthesia
of upper larynx.
• Causes:
- Surgical or accidental trauma
- Diptheria
- Cervical lymphadenopathy
- Neoplastic disease
• Clinical features:
- Both V.C. paralysis
- Anaesthesia of larynx
- Cough
- Chocking fits
- Weak & husky voice
Treatment:
- Tracheostomy with a cuffed tube & an
oesophageal feeeding tube.
- Epiglottopexy is an operation to close the
laryngeal inlet to protect the lungs from
repeated aspiration. It is a reversible
precedure.

34. COMBINED/COMPLETE VOCAL CORD PARALYSIS
(Recurrent & Superior Laryngeal Nerve Paralysis)
(A) UNILATERAL :
• Paralysis of all the muscles of the larynx on one side except
interarytenoid which also receives innervation from opposite side.
Aetiology :
• Thyroid surgery
• Lesions of nucleus ambigus which may lie medulla, post. cranial fossa,
jugular foramen or parapharyngeal space.neurological causes, om of
skull base, wallenberg, MS, syringomyelia
Clinical features :
• All the muscles of larynx on one side are paralysed
• V.C. lie in cadeveric position ie. 3.5mm from the midline
• Glottic incompetence results in hoarseness of voice & aspiration of
liquids

35. • Treatment (injection therapy not adequate)
1. Speech therapy
2. Procedures to medialise the cord- Aim is to bring the
paralysed vocal cord towards the midline so that healthy cord
can meet it. This is achieved by :laryngeal framework surgery
and approximation of arytenoids:
(a) Injection of teflon paste (usually not adequate)
(b) Muscle or cartilage implant
(c) Arthrodesis of cricoarytenoid joint
(d) Thyroplasty type I

36. (B) Bilateral:
• Both recurrent & superior laryngeal nerves on both sides are
paralysed.
• Rare condition.
• Both cords lie in cadaveric position.
• Total anaesthesia of the larynx.
Clinical features :
-Aphonia: As V.C. cords doesn’t meet at all.
-Aspiration: due to incompetent glottis & laryngeal anaesthesia.
-Inability to cough: due to inability of V.C. to meet which results in retention of
secretions in the chest.
-Bronchopneumonia- due to repeated aspirations & retention of secretions.

37. Treatment:
1. Tracheostomy
2. Epiglottopexy
3. Vocal cord plication
4. Total laryngectomy

38. CONGENITAL VOCAL CORD PARALYSIS
UNILATERAL
• More common
• Causes :
- Birth trauma
- Congenital anomaly of great
vessels or heart
BILATERAL
• Causes :
- Hydrocephalus
- Arnold-Chiari malformation
- Intracerebral haemorrhage
- Meningocele
- Cerebral agenesis
• Clinical features :
- Dyspnoea
- Stridor

39. EVALUATION OF VOCAL CORD PARALYSIS PATIENT
• History
• Symptoms:
(a) Change in voice
(b) Hoarseness
(c) Aphonia
(d) Vocal fatigue
(e) Neck pain
(f) Aspiration
(g) Cough
• Past Medical & Surgical History :
• Social History :
• General Examination :
• Local Examination :
(a) Examination of larynx & laryngopharynx – IDL,
FOL
(b) Neck examination
(c) Cranial nerve examination
• Investigations :
- Nasopharyngolaryngoscopy
- Videostroboscopy
- Chest X-ray PA view
- C.T. with contrast- may evaluate the entire
course of recurrent laryngeal nerve
- MRI

40. DIFFERENTIAL DIAGNOSIS
1. Cricoarytenoid Fixation: caused by joint
subluxation or dislocation with ankylosis.
- Joint fixation by rheumatoid arthritris or gout.
2. Laryngeal malignancy: