Vocal Cord Paralysis

What is vocal cord paralysis (vocal fold paralysis)?

Vocal cord paralysis involves one or both vocal cords (vocal folds) not moving as they should. Your vocal cords are two bands of muscle inside your voice box (larynx) located atop your windpipe (trachea). They open when you breathe so air can pass through. They close when you swallow to prevent food and drink from slipping into your windpipe. When you speak or sing, your vocal cords touch. Your lungs send air through them, causing them to vibrate and make sounds.

With vocal cord paralysis, nerve damage prevents the muscles inside your vocal cords from opening and closing properly. As a result, you may have trouble speaking, swallowing or even breathing — all functions that depend on your vocal cords moving.

What are the types of vocal cord paralysis?

Vocal cord paralysis can affect one vocal cord (unilateral) or both vocal cords (bilateral):

• Unilateral vocal cord paralysis: Only one vocal cord is paralyzed. When one vocal cord isn’t moving as it should, you may have trouble speaking or (in more serious cases) swallowing. Breathing problems don’t usually happen when only one vocal cord is paralyzed.
• Bilateral vocal cord paralysis: Both vocal cords are paralyzed. When both cords are paralyzed, they usually end up very close together, causing a dangerously narrow airway. You may have trouble breathing, which may be life-threatening without treatment.

How common is vocal cord paralysis?

Unilateral vocal cord paralysis is much more common than bilateral vocal cord paralysis. It’s rare for both vocal cords to become paralyzed. Still, both types can affect anyone of any age.

How serious is vocal cord paralysis?

Unilateral vocal cord paralysis ranges in severity from mild to severe. For instance, mild cases may make speaking difficult. In more severe cases, you may experience shortness of breath when speaking. You may cough or choke when eating or drinking.

With bilateral vocal cord paralysis, your vocal cords may get too close together, making it difficult to breathe. Your swallowing can also be affected. Food or drink can slip into your windpipe and lungs, causing aspiration pneumonia.

See a healthcare provider immediately if you’re having trouble breathing or swallowing.

What are the symptoms of vocal cord paralysis?

Symptoms depend on the extent of the paralysis and the position of your vocal cords in relation to each other.

Symptoms may include:

• A voice that sounds hoarse, weak, scratchy or breathy.
• Changes in your vocal pitch (how high or low your voice sounds).
• Changes in your vocal volume (how loud or soft your voice sounds).
• Shortness of breath (dyspnea) or losing your voice.
• Noisy breathing (wheezing or a raspy sound).
• Trouble swallowing (dysphagia).
• Inability to clear your throat by coughing.
• Choking when you try to swallow.

What does a paralyzed vocal cord feel like?

You may not feel sensations from the vocal cord directly. Instead, you’ll feel the symptoms resulting from a paralyzed vocal cord. The sensation may feel like fatigue as you exhaust your energy, trying to draw more air into your lungs or get your voice to sound as you’d like. It may feel like choking if food or drink slips into your windpipe. Some people with paralyzed vocal cords feel like they always have mucus in their throats that they can’t clear.

Can you speak with vocal cord paralysis?

Many people with vocal cord paralysis can still speak, but it may require more effort. You may notice changes in how your voice sounds. You may get winded when you talk. If your paralysis is more severe, you may lose your voice.

What causes vocal cord paralysis?

Multiple conditions can damage the nerves that control how your vocal cords move, including:

• Autoimmune diseases: Diseases that interfere with how nerves communicate with muscles, such as myasthenia gravis (MG), can lead to vocal cord paralysis.
• Infections: Lyme disease, herpes, the Epstein-Barr virus and COVID-19 can cause inflammation that damages the nerves that control vocal cord movement.
• Injury: Trauma to your neck, head and chest can cause nerve damage.
• Neurological diseases: Conditions that involve nerve deterioration and damage, including multiple sclerosis (MS), Parkinson’s disease and stroke, can impact the nerves that control your vocal cords.
• Poisonous substances: Toxins, including lead, mercury and arsenic, can harm nerve tissue.
• Surgery: Surgeries in your head and neck, including thyroid gland removal (thyroidectomy), parathyroid surgery, heart surgery and cervical spine surgery, can lead to complications, like nerve injury. Using a breathing tube during surgery can sometimes damage the nerves in your voice box.
• Tumors: Cancerous (malignant) tumors and noncancerous (benign) tumors can push on the nerves in your voice box, causing damage. Both thyroid cancer and thyroid nodules can damage these nerves.

Sometimes, a vocal cord can get paralyzed after a cold or upper respiratory infection. Healthcare providers can’t always determine the exact cause. These cases of vocal cord paralysis are called idiopathic, or post viral.

How do healthcare providers diagnose vocal cord paralysis?

Medical experts in ear, nose and throat conditions (otolaryngologists), including providers who specialize in conditions involving your throat and voice box (laryngologists), often diagnose and treat vocal cord paralysis. First, they’ll ask about your symptoms and health history. To confirm a diagnosis, your provider may order the following:

• Imaging studies: An MRI or CT scan shows detailed images of your brain, throat, vocal cords, voice box, thyroid gland and chest. They can help providers identify growths that may damage nerves in your voice box. Your provider may also order an X-ray of your esophagus or chest.
• Laryngoscopy: A laryngoscopy allows healthcare providers to view your voice box and vocal cords directly. Your provider will insert a long, thin tube called a laryngoscope into your nose to examine your throat. The flexible tube has a camera that takes images of your voice box and vocal cords. Images from the camera appear on a monitor your provider can view.
• Videostroboscopy: A videostroboscopy allows healthcare providers to view how your vocal cords vibrate and how much they come together when you’re talking. The procedure is similar to a laryngoscopy. Often, laryngoscopy and videostroboscopy happen together. Videostroboscopy uses a special camera to show your vocal cords moving in slow motion when you make sounds. It allows your provider to see problem areas.
• Laryngeal electromyography (LEMG): This test measures how your nerves control the muscles in your voice box. It evaluates and records the electrical impulses of these muscles.
• Blood tests: Your provider may order blood work if they suspect your vocal cord paralysis is related to an infection or an autoimmune disease.

How do providers treat vocal cord paralysis?

Treatment depends on the severity of the paralysis and your symptoms. If paralysis is mild, you may need voice therapy to improve how your vocal cords work. During therapy, you do special exercises that strengthen your vocal cords, help you control muscles that help you speak and improve how you breathe when speaking.

More severe vocal cord paralysis may require surgery.

Unilateral vocal cord paralysis treatment

With unilateral vocal cord paralysis, providers often choose to delay surgery for up to a year to allow time for the condition to improve. Sometimes, the vocal cord is just bruised or strained and needs time to repair itself. This can take months. Voice therapy administered by a speech-language pathologist with expertise in voice care can sometimes be very effective and help strengthen your voice if the problem is mild/moderate.

A laryngologist may recommend surgery or a vocal fold injection to help improve voice, swallowing and breathing problems. The options include:

• Inject a filler (vocal cord injection): Your provider may inject a filler material through a needle. There are several types of safe filler materials. The filler closes the gap between your vocal cords.
• Insert a voice box implant (laryngeal framework surgery): Your provider places an implant into your voice box. Most implants are silicone. The implant holds the paralyzed vocal cord in place and helps both vocal cords close. Procedures include medialization laryngoplasty (thyroplasty).
• Perform nerve (reinnervation) surgery: Your provider takes a nerve that connects to other muscles in your neck and reattaches it to the nerve that moves your vocal cords. This procedure doesn’t cause any problems with the other muscles in your neck.

Bilateral vocal cord paralysis treatment

People with two paralyzed vocal cords can have a dangerously narrow airway. They’ll often need a tracheostomy (tracheotomy or “trach”) to open their airway and help with breathing.

During this procedure, a healthcare provider makes an incision and inserts a tube into your neck. The tube opens the airway and helps you breathe. Sometimes, your provider may remove a portion in the back of one or both vocal cords with a laser to widen the airway, creating more space to breathe through. Another procedure to help you breathe long term if you have a trach, is a tube-free tracheostomy.

Can a paralyzed vocal cord be repaired?

Sometimes, the vocal cords repair themselves. This may take months. With voice therapy, vocal cord injections or implants, your voice may get stronger and allow people to hear you better when you talk. You may also feel that treatment improves your swallowing and breathing. Ask your healthcare provider how much of your vocal cord function you’ll likely regain with treatment.

How can I prevent vocal cord paralysis?

You can’t always prevent vocal cord paralysis. Talk to your healthcare provider if you have a condition that increases your risk. They may recommend regular checkups to test your vocal cords. You may need voice therapy to improve how your vocal cords work.

What is the outlook for people with vocal cord paralysis?

Many cases of vocal cord paralysis can improve by themselves with time. Voice therapy and sometimes filler injections can help make your symptoms better while waiting for your vocal cords to recover. If your vocal cord is permanently paralyzed, an implant to keep your vocal cord in place is the treatment of choice. Rarely, your provider may need to readjust the implant if it moves out of place.

With treatment, many people regain the ability to talk and swallow after vocal cord paralysis. Your prognosis depends on several factors, including whether the paralysis affected one or both vocal cords and if it’s mild or severe.

When should I see my healthcare provider about vocal cord paralysis?

Talk to a healthcare provider if you have signs of vocal cord paralysis. Voice changes, unexplained hoarseness, noisy breathing, shortness of breath when talking, or coughing and choking with food or liquids aren’t normal. Starting treatments early can prevent your condition from worsening. In some cases, noninvasive treatments, like voice therapy, can prevent you from having surgery.

When should I go to the ER?

Seek care immediately if you’re having trouble breathing or swallowing. Not getting enough air is a sign of bilateral vocal cord paralysis, the most serious type. Inhaling food or drink because your vocal cords aren’t closing properly can lead to aspiration pneumonia, which is fatal without treatment.

A note from Cleveland Clinic

See a healthcare provider if you have signs of vocal cord paralysis, including trouble breathing, voice changes or difficulty swallowing. Talk to your provider if you have a condition or illness that increases your risk of vocal cord paralysis. These can include multiple sclerosis or Parkinson’s, or recent chest or neck surgery. Voice therapy may prevent your condition from worsening and improve your vocal cord function.