A patient presents with a breathy voice and reports choking on water during a evaluation. Which nerve is most likely damaged?

• A. glossopharyngeal nerve
• B. external superior laryngeal nerve
• C. internal superior laryngeal nerve
• D. right recurrent laryngeal nerve

Answer: (D)

The ability to shape voice depends on how well the vocal folds come together and vibrate, which is controlled by the intrinsic laryngeal muscles. Those muscles are mainly innervated by the recurrent laryngeal nerve, a branch of the vagus, which supplies all intrinsic laryngeal muscles except cricothyroid. If the right recurrent laryngeal nerve is damaged, the right vocal fold can’t move medially to close properly during phonation. This incomplete glottal closure lets air escape as you speak, producing a breathy voice. Swallowing safety also relies on timely vocal fold closure, so nerve injury can contribute to choking on liquids. The other nerves listed aren’t typically responsible for this voice change: the glossopharyngeal nerve mainly affects swallowing and sensation; the external branch of the superior laryngeal nerve controls cricothyroid tension (pitch) and isn’t the culprit for breathiness; the internal branch of the superior laryngeal nerve is sensory above the vocal folds and affects sensation more than voice.