Hoarseness and Vocal Cord Palsy
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Direct answer
Hoarseness is any change in voice quality and, when persistent beyond three weeks in an adult, demands laryngeal examination to exclude malignancy. Vocal cord paralysis follows recurrent laryngeal or vagal nerve damage — left more often than right because of its intrathoracic course — leaving the cord in median, paramedian or cadaveric position. A unilateral palsy causes a breathy voice and aspiration; a bilateral palsy, cords near the midline, presents with stridor and surprisingly good voice.
What you must remember
- Causes of hoarseness: acute viral laryngitis and voice abuse, laryngopharyngeal reflux, smoker's polyps and Reinke oedema, vocal nodules at the junction of the anterior third and posterior two-thirds of the cord, papillomas, granulomas, tuberculosis and carcinoma.
- Red flags: hoarseness lasting more than three weeks, especially with smoking, alcohol, dysphagia, otalgia, weight loss or neck nodes, warrant urgent endoscopy and biopsy.
- Nerve injuries: the left nerve is most often involved because it loops around the aortic arch — thyroid surgery, thyroid, oesophageal or lung apex malignancy, and idiopathic neuritis; skull base lesions hit the vagus itself.
- Cord positions: paramedian — the usual position in complete recurrent laryngeal palsy; intermediate or cadaveric — when vagal or superior laryngeal involvement is added; median — when only the abductors fail, as in evolving bilateral palsies.
- Semon's law: an evolving nerve lesion paralyses the abductor function before the adductors, which is why damaged cords drift toward the midline and bilateral palsies obstruct the airway.
- Bilateral palsy: cords lie paramedian with a narrow glottic chink, so the voice is near normal but inspiration is stridulous; tracheostomy may be needed, with later arytenoidectomy or cord lateralisation.
- Management of unilateral palsy: treat the cause, speech therapy while awaiting recovery over months, and medialisation by injection or type I thyroplasty for persistent glottic gap and aspiration.
Common confusion
Hoarseness of a few days with a cold is laryngitis; hoarseness persisting three weeks is a red flag — state that rule. Also remember the paradox of bilateral palsy: the voice sounds nearly normal because the cords almost meet, while the patient fights for air — a good voice with stridor should raise this diagnosis.
Exam-focused takeaway
For theory, classify the causes, state the red-flag rule, then describe cord positions, Semon's law and the contrasting pictures of unilateral and bilateral palsy. In viva, expect why left palsy is commoner, the cord position in complete injury and the surgery for bilateral palsy. In the posting, watch endoscopy of every hoarse voice and describe mobility in standard terms.
Frequently asked questions
When is hoarseness a danger sign?
Hoarseness beyond three weeks in an adult, particularly a smoker or drinker, or with dysphagia, ear pain, weight loss or a neck lump, requires laryngoscopy to exclude carcinoma.
Why is left vocal cord palsy commoner?
The left recurrent laryngeal nerve travels into the thorax and loops around the aortic arch, exposing it to lung apical tumours, aneurysms and thyroid or oesophageal surgery.
What is Semon's law?
In a progressive nerve lesion, abductor fibres are affected before adductor fibres, so the cord drifts to paramedian position and bilateral lesions narrow the airway.
How does bilateral abductor palsy present?
With stridor and respiratory distress because both cords lie near the midline, but with an almost normal voice — the reverse of unilateral palsy, which is breathy with a good airway.
What is medialisation thyroplasty?
Type I thyroplasty: an implant pushes the paralysed cord towards the midline to close the glottic gap, improving voice and aspiration.
Where do vocal nodules form?
At the junction of the anterior third and posterior two-thirds of the cords, the point of maximal vibration; they usually resolve with voice rest and therapy.