Examqo › Examqo library › Speech-language pathology and audiology › Voice and resonance
Vocal fold paralysis
Vocal fold paralysis is defined by the nerve injured and the position in which the fold stops: one-sided recurrent nerve paralysis gives a breathy voice and aspiration risk, the closer the fold is to the midline the better the voice, and bilateral abductor paralysis endangers the airway.
Why it matters in the exam
Questions present a patient after thyroid, heart or carotid surgery, or a smoker with hoarseness, and ask which nerve was injured, in which position the fold sits, what the prognosis is and what the treatment is. A recurring principle: a fold in the median or paramedian position gives a better voice and a better prognosis for voice therapy, and a fold far from the midline gives a very breathy voice and aspiration.
You also need the techniques: in one-sided paralysis with a gap between the folds, pushing and effort exercises that improve closure, head turning and laryngeal pressure are used, not relaxing exercises such as chewing. Bilateral abductor paralysis leaves both folds near the midline — the voice is fair but breathing is obstructed and a tracheostomy is sometimes needed. In a smoker with unexplained left-sided paralysis, chest imaging is required.
Key points
- One-sided: breathy voice and aspiration; the closer the fold to the midline, the better the voice.
- Bilateral abductor: fair voice, obstructed breathing, sometimes a tracheostomy.
- Closure gap: pushing, effort, head turn, and injection as needed.
- Superior nerve: pitch difficulty; high vagus lesion: hypernasality too.
- Unexplained paralysis in a smoker: chest imaging.
Summary table
| Condition | Finding | Effect on voice and swallowing | What is done |
|---|---|---|---|
| One-sided recurrent nerve paralysis, fold median or paramedian | The healthy fold manages to reach it | Fair voice, sometimes diplophonia, little aspiration | Voice therapy; good prognosis |
| One-sided paralysis, fold far from the midline | A large closure gap | Very breathy voice, aspiration of liquids | Pushing and effort exercises, head turn; injection or surgery to medialise the fold |
| Bilateral abductor (PCA) paralysis | Both folds near the midline | Near-normal voice, shortness of breath and stridor | Secure the airway, sometimes a tracheostomy |
| Bilateral adductor paralysis | Both folds open | Aphonia and aspiration | Protect the airway and feeding, medical treatment |
| Superior laryngeal nerve injury | Weak cricothyroid | Difficulty raising pitch, narrow range | Voice therapy for pitch range |
| High vagus lesion (above the pharyngeal branch) | The palate and pharynx are weak too | Breathy voice and hypernasality | Combined voice and swallowing therapy; medical assessment |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- What matters for the exam
The full version is open to subscribers of: Speech and hearing (communication disorders).
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- Colton, Casper & Leonard, Understanding Voice Problems, 4th edition (2011) — Neurogenic voice disorders: vocal fold paralysis
- Stemple, Roy & Klaben, Clinical Voice Pathology: Theory and Management, 6th edition (2018) — Vocal fold paralysis and its management
- ASHA Practice Portal, 2024 — Voice Disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.