Voice Therapy for Vocal Fold Paralysis: A Pathophysiology-Based Clinical Decision-Making Framework

Vocal fold paralysis (VFP) results from injury to the vagus or recurrent laryngeal nerve and leads to impaired vocal fold mobility, incomplete glottic closure, and inefficient voice production. Beyond dysphonia, VFP may compromise airway protection and swallowing safety, underscoring the need for integrated clinical decision-making. Traditionally, management has emphasized surgical or injection-based medialization to restore glottic closure, while voice therapy has often been described as a postoperative adjunct. However, accumulating evidence suggests that voice therapy can play a central and, decision-shaping role across the entire treatment continuum, including as a preferential first-line intervention in selected patients. This narrative review reexamines the role of voice therapy in VFP from a pathophysiology-based perspective. The underlying mechanisms of voice impairment following neural injury are outlined, and the spectrum of hypofunctional and hyperfunctional phonatory patterns is described. A figure-based clinical decision-making pathway is proposed that prioritizes aspiration risk and functional voice characteristics to guide the timing and integration of voice therapy and medialization procedures. Particular emphasis is placed on differentiating pre-medialization voice therapy, post-medialization voice assessment, and post-medialization voice therapy as distinct yet interconnected components of care. By conceptualizing voice therapy as a function-oriented intervention grounded in neural plasticity and motor learning, this review highlights its potential to improve phonatory efficiency, reduce maladaptive compensatory behaviors, and optimize functional outcomes. The proposed framework aims to support individualized, flexible treatment planning for patients with VFP in contemporary clinical practice.