Can Lyme Disease Cause Vocal Cord Paralysis?

Lyme disease can rarely affect nerves controlling the vocal cords
Hoarseness, voice loss, and difficulty swallowing may occur
Multiple cranial nerves may sometimes be involved

Can Lyme disease cause vocal cord paralysis? Although uncommon, Lyme disease has been reported in association with paralysis of the recurrent laryngeal nerve and other neurologic complications affecting the voice. Patients may develop hoarseness, difficulty speaking, swallowing problems, or, in rare cases, vocal cord paralysis.

Lyme neuroborreliosis can affect cranial and peripheral nerves. When nerves involved in the larynx or swallowing are affected, symptoms may extend beyond facial weakness to include dysphonia, vocal cord weakness, choking, aspiration, or difficulty swallowing.

Because vocal cord paralysis and dysphagia have many possible causes, Lyme disease may not be considered during the initial evaluation. However, published case reports and clinical series suggest that it can be part of the differential diagnosis in patients with compatible neurologic findings and possible exposure to Lyme disease.

Singer Shania Twain helped bring public attention to the potential neurologic effects of Lyme disease after describing how the illness affected her voice. Twain has said that physicians eventually attributed her vocal problems to nerve damage involving her vocal cords and that she later underwent surgery to improve her ability to sing.

Shania Twain’s Experience With Lyme Disease

Twain has publicly described developing Lyme disease after a tick bite while horseback riding. She subsequently experienced major changes in her singing voice and has said that it took years before physicians connected the vocal problem to nerve damage associated with Lyme disease.

In media interviews, Twain has described how a neurologist eventually connected her vocal difficulties to nerve damage involving her vocal cords. Infectious disease specialist Amesh A. Adalja, MD, has also explained that Lyme disease can affect nerves responsible for controlling the muscles of the vocal cords, while emphasizing that this is an uncommon manifestation.

Twain’s experience should not be interpreted as evidence that voice changes in general are caused by Lyme disease. Rather, it illustrates why neurologic causes may need to be considered when otherwise unexplained vocal dysfunction develops.

What Is Vocal Cord Paralysis?

Vocal cord paralysis occurs when one or both vocal folds cannot move normally because of dysfunction or injury involving the nerves that control the larynx. Symptoms may include:

• Hoarseness
• Weak or breathy voice
• Difficulty swallowing
• Choking while eating or drinking
• Shortness of breath
• Difficulty projecting the voice

Depending on the underlying cause, symptoms may develop suddenly or gradually. Bilateral vocal cord paralysis can be particularly serious because it may interfere with breathing and, in severe cases, require airway intervention.

Can Lyme Disease Cause Vocal Cord Paralysis?

A study published by White and colleagues evaluated laboratory testing in 231 patients with vocal fold paralysis or paresis. Several medically important diagnoses were identified through laboratory testing, including diabetes, thyroid disease, syphilis, myasthenia gravis, and Lyme disease.¹

The investigators reported that Lyme disease was identified more often in their patient population than would have been expected based on population data. However, the study was not designed to determine whether Lyme disease directly caused the vocal fold paralysis or paresis.¹

This distinction is important. A positive Lyme test in a patient with vocal cord paralysis does not by itself establish that Lyme disease caused the neurologic problem. The complete clinical picture—including exposure history, other neurologic findings, timing, laboratory results, and alternative explanations—must be considered.

Published Cases of Vocal Cord Paralysis in Lyme Disease

Several published case reports provide more direct examples of vocal cord or recurrent laryngeal nerve involvement occurring with Lyme disease.

Vocal cord paralysis first on one side and later the other

Finck and colleagues reported an unusual case involving a 70-year-old man who developed sudden dysphonia caused by right vocal fold paralysis.⁶ He did not recall a tick bite or erythema migrans rash, and CT and MRI imaging did not identify a structural explanation for the paralysis.

Lyme serology showed Borrelia burgdorferi IgG antibodies. His voice gradually recovered without Lyme-directed antibiotic treatment. However, 19 months later, he developed another episode of dysphonia—this time caused by paralysis of the left vocal fold.⁶

During the second episode, Lyme serology was positive for IgG and IgM and confirmed by immunoblot. Cerebrospinal fluid testing demonstrated Borrelia-specific IgG with a markedly elevated intrathecal antibody index, supporting possible or probable Lyme neuroborreliosis.⁶

Importantly, the cerebrospinal fluid did not show pleocytosis. Under European diagnostic criteria, the absence of inflammatory cells in the CSF meant that the case did not meet criteria for definite Lyme neuroborreliosis. This illustrates why neurologic Lyme disease may require interpretation of the entire clinical and laboratory picture rather than reliance on any single test.

The patient was treated with oral doxycycline 200 mg daily for 21 days. His vocal function progressively improved, and complete vocal fold mobility was documented eight weeks later.⁶

The authors described this as the first reported case of successive right- and left-sided laryngeal nerve palsy associated with two episodes of possible Lyme neuroborreliosis. They could not determine whether the later episode represented reinfection, reactivation, or relapse.⁶

Bilateral vocal cord paralysis

Martínez-Balzano and Greenberg described a 90-year-old man who developed dysphonia and right-sided weakness. His illness progressed to bilateral vocal cord paralysis and respiratory failure requiring a tracheostomy.²

Testing detected IgM and IgG antibodies against Borrelia burgdorferi by enzyme immunoassay and Western blot. The patient was treated with intravenous ceftriaxone for two weeks and experienced complete recovery of motor and vocal function over the following two months.²

Two patients with recurrent laryngeal nerve palsy

Martzolff and colleagues reported two patients with recurrent laryngeal nerve palsy and positive Lyme serology. Both had favorable outcomes following antibiotic treatment.³

In one patient, lymphocytic meningitis and intrathecal production of specific antibodies provided additional evidence of neuroborreliosis. The authors emphasized that diagnosis requires consideration of epidemiologic, clinical, and laboratory findings rather than reliance on a single feature.³

A singer who developed recurrent laryngeal nerve paralysis

An earlier report published in The Lancet described recurrent laryngeal nerve paralysis associated with Lyme disease in a middle-aged woman who was a singer.⁴

Taken together, these reports show that recurrent laryngeal nerve and vocal cord involvement have been described in Lyme disease, although this remains an uncommon neurologic manifestation.

Can Lyme Disease Cause Difficulty Swallowing?

Difficulty swallowing, or dysphagia, has also been reported as an unusual neurologic manifestation of Lyme disease. Swallowing requires coordinated activity involving several cranial nerves and muscles, so neurologic Lyme disease affecting multiple cranial nerves can potentially interfere with this process.

In a 2024 case report, Kim and colleagues described a 63-year-old man who developed bilateral hearing impairment, left facial palsy, pain, and eventually left vocal cord paralysis with severe dysphagia.⁵ There was no confirmed history of a tick bite, and the presentation was initially attributed to other possible neurologic, inflammatory, and infectious conditions.

The patient’s swallowing impairment was substantial. A videofluoroscopic swallowing study showed aspiration with both puree and liquid textures, impaired pharyngeal function, decreased epiglottic movement, and upper esophageal sphincter dysfunction.⁵

The clinical picture suggested involvement of several cranial nerves. In addition to facial palsy, the patient had hearing impairment, decreased gag reflex, vocal cord paralysis, and dysphagia. The authors considered involvement of the facial, vestibulocochlear, glossopharyngeal, and vagus nerves as a possible explanation for the combination of symptoms.⁵

Lyme serology was subsequently reported as positive, and the patient received doxycycline 100 mg twice daily for three weeks. Follow-up swallowing studies two months after discharge showed substantially less aspiration and residue, allowing him to resume an oral diet.⁵

However, the improvement should be interpreted cautiously. The patient had received several other interventions before Lyme treatment, including repetitive transcranial magnetic stimulation and injection laryngoplasty. The authors acknowledged that delayed effects of these earlier interventions could also have contributed to his recovery.⁵

The case therefore does not establish that Lyme disease is a common cause of dysphagia. It does demonstrate that Lyme disease may deserve consideration when otherwise unexplained swallowing difficulty occurs together with facial palsy, vocal cord paralysis, hearing changes, or other cranial neuropathies.

How Could Lyme Disease Affect Swallowing and the Voice?

Voice production and swallowing depend on coordinated activity involving several cranial nerves. The vagus nerve and its branches are particularly important for laryngeal movement and swallowing, while other cranial nerves contribute to facial movement, sensation, gag response, tongue movement, and coordination of swallowing.

Lyme neuroborreliosis is best known for facial nerve palsy, but other cranial nerves can also be affected. Multiple cranial neuropathies can therefore produce combinations of symptoms that extend beyond facial weakness.

For a broader discussion of this pathway, see Can Lyme Disease Affect the Vagus Nerve?

What Else Can Cause Vocal Cord Paralysis?

Lyme disease is only one of many possible causes of vocal cord paralysis. Identifying the underlying condition is important because treatment depends on the cause.

Potential causes include:

• Head and neck surgery or other iatrogenic nerve injury
• Head, neck, or thoracic tumors
• Idiopathic vocal cord paralysis
• Neurologic disorders
• Inflammatory diseases
• Infections

A comprehensive evaluation may be necessary because some underlying causes are serious while others are potentially treatable.

Neurologic Causes of Vocal Cord Paralysis

Neurologic disorders that can impair the nerves responsible for vocal cord movement include:

• Amyotrophic lateral sclerosis (ALS)
• Brainstem disorders
• Myasthenia gravis
• Multiple sclerosis
• Parkinson disease
• Severe cervical neurologic disease
• Stroke

Neurologic Lyme disease may also be considered when vocal cord paralysis occurs with compatible neurologic symptoms and appropriate epidemiologic exposure.

Inflammatory and Infectious Causes

Inflammatory disorders that may be associated with vocal cord paralysis include:

• Amyloidosis
• Polyarteritis nodosa
• Sarcoidosis
• Systemic lupus erythematosus

Infectious causes can include:

• Epstein-Barr virus
• Herpes simplex virus
• Lyme disease
• Syphilis
• Varicella-zoster virus
• West Nile virus

Metabolic disorders, including diabetes and thyroid disease, may also be identified during the evaluation of otherwise unexplained vocal fold dysfunction.

Why Lyme Disease Should Be Considered

Lyme disease should not automatically be assumed to explain unexplained hoarseness, dysphagia, or vocal cord paralysis. These findings have many other causes, including malignancy, surgical injury, neurologic disease, and other infections.

Nevertheless, published cases demonstrate that Lyme neuroborreliosis can occasionally involve the recurrent laryngeal nerve or multiple cranial nerves. The possibility becomes more relevant when vocal symptoms or swallowing difficulty occur together with facial palsy, hearing changes, radicular pain, meningitis, other neurologic abnormalities, or plausible exposure to infected ticks.

The Finck case is particularly useful because the patient did not recall a tick bite or erythema migrans rash and structural imaging did not explain his vocal fold paralysis. During the later contralateral episode, intrathecal Borrelia antibody production provided additional evidence supporting neuroborreliosis.⁶

The 2024 dysphagia case provides another example in which a patient did not have a confirmed tick exposure or typical skin manifestation. His presentation instead consisted primarily of multiple cranial neuropathies and severe swallowing dysfunction.⁵

Together, these cases illustrate an important clinical point: the absence of a recognized tick bite or classic Lyme rash does not necessarily exclude Lyme disease when otherwise unexplained cranial neuropathies develop.

Frequently Asked Questions

Can Lyme disease cause vocal cord paralysis?

Yes, but it appears to be uncommon. Published case reports describe recurrent laryngeal nerve palsy and unilateral or bilateral vocal cord paralysis occurring in patients with Lyme disease.

Can Lyme disease cause hoarseness?

Yes. Hoarseness or dysphonia can occur when the nerves controlling vocal cord movement are affected. However, hoarseness is common and has many causes, so Lyme disease should not automatically be assumed to be responsible.

Can Lyme disease make you lose your voice?

Lyme disease can rarely affect nerves controlling the larynx, potentially causing hoarseness, dysphonia, vocal weakness, or significant loss of voice.

Can Lyme disease cause difficulty swallowing?

Yes. Dysphagia has rarely been reported with Lyme neuroborreliosis. A 2024 case described severe swallowing impairment and aspiration in a patient with facial palsy, hearing impairment, vocal cord paralysis, and suspected involvement of multiple cranial nerves.

Can Lyme disease cause choking or aspiration?

Severe neurologic swallowing dysfunction can lead to choking or aspiration. These symptoms are not specific to Lyme disease and require prompt medical evaluation because many neurologic and structural conditions can interfere with swallowing.

Can Lyme disease affect the vagus nerve?

Lyme neuroborreliosis can affect cranial nerves, and case reports involving vocal cord paralysis and dysphagia raise the possibility of vagal or recurrent laryngeal nerve involvement. However, vagus nerve dysfunction has not been established as a common manifestation of Lyme disease.

Can Lyme disease cause paralysis?

Lyme disease can affect the nervous system and cause facial palsy and other motor neurologic abnormalities. Involvement of other cranial or peripheral nerves is less common but has been reported.

Is vocal cord paralysis from Lyme disease reversible?

Recovery varies. Published Lyme disease case reports describe improvement in vocal function following antibiotic treatment, including complete recovery in some patients. These individual cases cannot predict the outcome for every patient.

Clinical Takeaway

Vocal cord paralysis, hoarseness, and difficulty swallowing are uncommon but reported neurologic manifestations associated with Lyme disease.

Published cases describe recurrent laryngeal nerve palsy, bilateral vocal cord paralysis, severe dysphagia, and successive paralysis affecting opposite vocal folds. The Finck case adds an unusual example in which right vocal fold paralysis was followed 19 months later by left vocal fold paralysis, with intrathecal Borrelia antibody production documented during the second episode.⁶

These symptoms have many more common causes, so Lyme disease should not automatically be assumed to be responsible. However, when unexplained hoarseness, vocal cord paralysis, or dysphagia occurs with other cranial neuropathies and plausible Lyme exposure, Lyme disease may deserve consideration in the differential diagnosis.

Related Articles

Learn more about cranial nerve involvement and other neurologic manifestations of Lyme disease.

Bell’s Palsy and Lyme Disease

Neurologic Lyme Disease Symptoms: How Lyme Affects the Nervous System

Can Lyme Disease Affect the Vagus Nerve?

Lyme Disease Brain Fog: Causes, Symptoms, and Treatment

Lyme Disease Symptoms: Why They Come and Go

References

1. White M, Meenan K, Patel T, Jaworek A, Sataloff RT. Laboratory Evaluation of Vocal Fold Paralysis and Paresis. J Voice. 2017;31(2):168-174. doi:10.1016/j.jvoice.2016.07.022. PMID: 27777055.
2. Martínez-Balzano CD, Greenberg B. Bilateral vocal cord paralysis requiring tracheostomy due to neuroborreliosis. Chest. 2014;146(5):e153-e155. doi:10.1378/chest.14-0515. PMID: 25367481.
3. Martzolff L, Bouhala M, Dukic R, Saraceni O, Wilhelm JM, Bombaron P, Kieffer P. [Recurrent nerve palsy due to Lyme disease: report of two cases]. Rev Med Interne. 2010;31(3):229-231. doi:10.1016/j.revmed.2009.07.012. PMID: 20079561.
4. Schroeter V, Belz GG, Blenk H. Paralysis of recurrent laryngeal nerve in Lyme disease. Lancet. 1988;2(8622):1245. doi:10.1016/S0140-6736(88)90826-4. PMID: 2903968.
5. Kim P, Lim SH, Lee JI, Namgung HG, Kim D, Lee EJ. Dysphagia due to Lyme Disease: A Case Report. Brain Neurorehabil. 2024;17(3):e25. doi:10.12786/bn.2024.17.e25. PMID: 39649707.
6. Finck C, Gambron T, Benchimol L, Camby S, Morsomme D. Case report: Successive ipsilateral and contralateral laryngeal nerve palsy as probable manifestation of neuroborreliosis. Heliyon. 2023;9(10):e20869. doi:10.1016/j.heliyon.2023.e20869. PMID: 37876487; PMCID: PMC10590778.

This article is for informational purposes only and does not constitute medical advice. Patients with difficulty swallowing, choking, breathing problems, new weakness, or other significant neurologic symptoms should seek appropriate medical evaluation.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention