Carefully examine the glottis for lesions, vocal fold mobility, and vocal fold atrophy. Common glottic lesions include nodules, cysts, papilloma, leukoplakia, and neoplasm. Atrophic vocal folds are associated with prominence of vocal process of arytenoid due to loss of muscle bulk of the membranous portion of vocal fold and deepening of laryngeal ventricle. Vocal folds should lengthen symmetrically. Inability of the vocal folds to lengthen is indicative of bilateral superior laryngeal nerve paralysis.
Unilateral paralysis is manifested as inability to lengthen the ipsilateral vocal cord.
In patients with vocal fold paralysis, the atrophic paralyzed vocal fold may lie caudal to the healthy vocal cord. Detection of such a level of mismatch may be important in optimizing the results of vocal fold medialization. This produces alternating maximal adduction and abduction of vocal folds, which allows for detection of subtle movement abnormalities. For example, recovered vocal fold paralysis may demonstrate subtle decrease in abduction that could otherwise be missed. In situations where lack of vocal fold movement is observed during attempts at phonation and a functional etiology is suspected, ask the patient to cough.