Vocal cord palsy: causes, symptoms, voice therapy and treatment

To produce a normal voice the two vocal cords need to come together. They move apart when you breathe and come together in the middle when you speak or sing. The Bedfordshire Hospitals leaflet explains that if one of them does not move as it should, this is called a vocal cord palsy, and the voice may be affected. When one cord comes to the middle normally but the other does not, there is a gap between them which affects the sound of the voice.

The Royal Berkshire leaflet describes vocal cord palsy as a reduced ability to move the vocal cords, and notes that the cords can be partially or completely paralysed. Often it affects one of the cords, but sometimes both sides are affected. Which side, how much movement is lost and the position the cord is held in all influence the symptoms.

The Royal Berkshire leaflet lists the following possible causes, and adds that occasionally no known cause can be found.

• A viral infection.

• Stroke.

• Trauma to the head.

• Surgery to the thyroid, larynx (voice box) or throat.

In some people a vocal cord palsy causes little change to the voice, according to the Bedfordshire leaflet, but in others the voice becomes weak, breathy or hoarse. The Royal Berkshire leaflet adds that the tone of the voice may become variable, that it can be difficult to make yourself heard in a noisy environment, and that if both vocal cords are affected you may lose your voice.

Other symptoms can include difficulty swallowing and feeling breathless with noisy breathing. The leaflet is explicit that it is important to tell your doctor if you are experiencing breathing and swallowing difficulties so that they can advise on treatment options. Breathing difficulty that is severe or getting worse is an emergency, and you should call 999 rather than wait for a clinic appointment.

Your GP will usually refer a persistent voice change to an ENT clinic. The Royal Berkshire leaflet says you will be seen by a member of the Ear, Nose and Throat team, who will examine you and look at how the vocal cords are working, and that a speech and language therapist may also be present to assist.

The Bedfordshire leaflet says that, to look for the cause, an ENT specialist will examine the voice box with a flexible telescope in clinic, and you may also have scans of your head, neck and chest. It notes that the cause of a vocal cord palsy is often difficult to identify.

Many vocal cord palsies recover on their own. The Bedfordshire leaflet says this can take up to a year, and that speech therapy may be helpful during this period of watchful waiting. The Royal Berkshire leaflet describes voice therapy and surgery as the two common treatment options and stresses that following the exercises and advice given by the ENT team or speech and language therapist is very important and will help symptoms improve.

If you remain unhappy with your voice after the watchful waiting period, the Bedfordshire leaflet describes two options, neither of which can bring back movement to the paralysed cord. The aim of both is to move the cord towards the midline and hold it there so that the voice improves.

The same leaflet lists the risks of injection: a small risk from the general anaesthetic, occasional swelling of the voice box that can in rare cases lead to breathing difficulties, possible damage to teeth from the metal viewing scope, and a sore throat that usually settles in a few days. It says there is no guarantee of a perfect voice, although very often there is a significant improvement, advises not overusing the voice for the first week, and describes a review in the ENT clinic 3 months after the procedure.

Cambridge University Hospitals has a voice care leaflet from its speech and language therapy service. It says the vocal folds need to be moist to function properly and suggests aiming to drink about two litres of fluid a day, using steam inhalation (without adding oils such as Olbas, which it says irritate the vocal cords), and using sugar-free sweets or chewing gum to stimulate saliva.

It also warns that throat clearing can be very irritating, because it forcefully bangs the vocal cords together and the resulting inflammation can create a cycle of more throat clearing. Taking a sip of water or sucking a sugar-free sweet instead is its suggestion. These steps support a healthy voice generally; they do not treat the palsy itself.

On the NHS, the route is usually GP, then ENT clinic with a speech and language therapist, scans where needed, and voice therapy before any procedure. Some units offer injection or thyroplasty and others refer on, as the Bedfordshire leaflet illustrates.

A private ENT or voice specialist can sometimes offer a quicker first appointment or a particular procedure, and many specialists work in both sectors. The principles are the same: establish the cause, allow time for recovery where appropriate, use voice therapy, and reserve procedures for those whose voice remains unsatisfactory. Ask what is being done to look for an underlying cause, because the leaflets stress that scans of the head, neck and chest may be part of the assessment.