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Symptoms of Vocal Fold Paresis/Paralysis
What do patients experience when they have vocal fold paresis or paralysis?
In general, vocal fold paresis and paralysis share many of the same symptoms – but differ in terms of severity. Symptoms associated with paresis tend to be less severe due to the fact that the vocal folds maintain some degree of mobility.
Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.
| Voice |
- Hoarseness – croaky or rough voice
- Breathy voice – a lot of air with the voice, voice sounds like whispering
- Effortful phonation – extra effort on speaking
- Air wasting – needs lots of air pressure to produce usual conversational voice, such that patient runs out of air when speaking notes
- Double voice (diplophonia) – voice sounds like a "gargle"
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| Airway |
- Shortness of breath with exertion
- Noisy breathing (stridor)
- Ineffective or poor cough
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| Swallowing |
- Choking or coughing when swallowing food, drink or even saliva (aspiration)
- Food sticking in throat
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 Key Information
Note on Patient Complaints
- Patients may complain of any one or more of the above.
- Patient complaints (symptoms) vary. There are many factors that affect what happens to the voice when vocal fold paresis or paralysis is present, such as:
- Vocal fold position within the voice box
- Which nerves and the number of nerves affected
- Remaining (residual) strength or tone of the affected vocal fold(s)
 Red FlagBreathing difficulties and/or swallowing difficulties should be attended to immediately.
How do vocal fold paralysis and paresis affect voice and breathing?
Vocal Fold Paralysis
Vocal fold paralysis results in incomplete opening and closing of the opening to the airway (glottis) due to the inability of the vocal folds to move.
- Importance of Vocal Fold Opening: Inability of the paralyzed vocal fold to open results in poor glottal opening which leads to breathing problems (airway symptoms) that can be life threatening.
- Importance of Vocal Fold Closing:
- For normal speaking and singing, both vocal folds need to be aligned in the midline, "closed." In this position, the air pressure from the lungs passes through the vocal folds making them vibrate. Vocal fold vibration allows periodic puffs of air to pass through – producing a voiced sound frequently described as "buzzy." This voiced sound is then modified by the throat, mouth, and nasal cavities (vocal tract resonators) and converted to words (distinguishable sound) by the tongue, lips, and palate (vocal tract articulators). (For more information, see Anatomy & Physiology of Voice Production.)
- When vocal folds are not aligned in the midline, vocal vibration is hampered – hence the voice disorder.
- For normal swallowing, vocal folds close to protect the windpipe below it. Failure to close causes swallowed food, drink, or saliva to enter the windpipe causing choking (aspiration).
Vocal Fold Paresis
- Weak and Low Tone, But Moving: Vocal fold paresis results in a vocal fold that can still move – albeit weakly and with less tone than normal.
- Subtle Complaints: Typically, patient complaints are more subtle in vocal fold paresis than paralysis – primarily because the vocal folds still retain some ability to open and close normally. Rather than hoarseness, patients with paresis may just complain of:
- voice tiring with moderate or heavy use (vocal fatigue)
- voice cracking (voice instability or voice break)
- normal speaking voice sometimes, depending on muscles involved, but inability to sing high notes (loss of pitch range)
- Breathing and swallowing problems are much less common.
Does it matter whether one or both vocal folds is affected?
- Vocal fold paresis and paralysis can affect either one or both of the vocal folds.
- Whether one or both vocal folds are afflicted with paresis/paralysis determines patient complaints as well as considerations for treatment plan.
One Side Affected
Unilateral Paresis/Paralysis |
Both Sides Affected
Bilateral Paresis/Paralysis |
What's Wrong – Pathology
Depending on the muscle involved, paresis/paralysis of one vocal fold could result in one or more of the following:
- Poor closing or failure to come to midline
- Reduced or no vocal fold tension or tone
- Poor opening
- Vocal fold asymmetry
- Loss of or decreased muscle mass (vocal fold atrophy)
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What's Wrong – Pathology
Depending on the muscles involved, paresis/paralysis of both vocal folds would result in:
- Vocal fold immobility
- Poor opening or failure to open
- Poor closing or failure coming to midline
- Loss of tone
- Vocal fold atrophy
- Vocal fold asymmetry
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| Effect on Voice – Common Complaints
Inability or difficulty of one vocal fold to come to midline, poor or no vocal fold tone, poor tone control, vocal fold asymmetry, decrease
vocal fold mass, result in one or more of the following–in any combination and in a wide range of varying degrees:
- Abnormal vocal fold vibration – hoarseness, harsh voice, abnormal voice quality (timbre), strained voice, weak voice, difficulty projecting voice, "double" voice (diplophonia)
- Air leakage during voice production – breathy voice, air wasting
- Abnormal vocal fold vibration and air leakage result in compensatory effort – effortful phonation and vocal fatigue
- Loss of pitch slide and control – loss of glissando
- Loss of vocal range especially high notes – loss of pitch
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Effect on Voice – Common Complaints
- If paralyzed vocal folds are in "close approximation" patients may still have voice – but may have problems with breathing (see below)
- If paralyzed vocal folds are in "open position" – same effects as in unilateral paresis/paralysis, BUT worse ***
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| Effect on Breathing
- Mild, if any, breathing difficulty
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Effect on Breathing
- Significant airway problems result from poor opening of the vocal folds – requires immediate management.
- Noisy breathing on inspiration – inspiratory stridor
- Difficulty breathing
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| Effect on Swallowing
- Choking on swallowing (aspiration)
- Aspiration leads to risk of lung infection
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Effect on Swallowing
- If paralyzed vocal folds rest in "open position," same effects as in unilateral paresis/paralysis, but worse
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Key Information
Swallowing Difficulties
A person's ability to feel in the voice box and throat may also be abnormal in cases of vocal fold paresis/paralysis. Loss of ability to feel can make aspiration worse.
Breathing Difficulties
Any breathing difficulty requires immediate medical attention.
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