Vocal Cord Paralysis

Vocal cord paralysis can manifest itself as hoarseness. However, many patients are able to maintain a relatively normal voice because of compensation from the opposite vocal cord. Patients can present with shortness of breath while conversing, cough when swallowing, aspiration, or recurrent pneumonia. They may complain of the inability to hold a breath while exerting against a closed glottis (Valsalva maneuver). Visualization of the larynx by indirect or flexible fiberoptic nasolaryngoscopy usually reveals an immobile, sluggish vocal cord in a paramedian position.

Paralysis can result from peripheral (recurrent laryngeal or vagus) nerve involvement or a CNS disorder (e.g., CVA). Approximately 90% of vocal cord paralyses result from dysfunction of the peripheral nerve. Most causes of paralysis are found after a careful history and physical examination (see eBox 19-9 online). Because of the course of the recurrent laryngeal nerve around the arch of the aorta on the left and around the subclavian artery on the right, a chest x-ray film is initially necessary to rule out compression from an intratho-racic process invading or compressing the nerve. CT or MRI may be useful for imaging the brain or the course of the recurrent laryngeal nerves. VLS is very useful and often yields further diagnostic and prognostic information.

Surgical trauma remains the most common cause of unilateral vocal cord paralysis. This is common after thy-roidectomy, carotid artery surgery, or transcervical spine procedures. Neoplastic processes, including thyroid, lung, and esophageal cancers, must always be ruled out as a cause of either compression or invasion. Skull base tumors and medi-astinal lesions are less common causes of paralysis. Careful palpation of the neck to rule out masses and evaluation of other cranial nerves help identify these problems.

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