This course offers a practical guide to decision-making in the evaluation and treatment of vocal fold paralysis. It presents a summary of the existing evidence regarding causes, mechanism, and natural course of vocal fold paralysis. Areas where evidence is absent or scanty are highlighted, and 'best practice' guidelines are extracted from available literature. Current thinking about spontaneous recovery, including aberrant innervation or synkinesis, is also explained, and evidence supporting these views is reviewed. The impact of such thinking on clinical decision-making is emphasized. Practical topics covered include appropriate workup, timing of intervention, selection of intervention (injection versus framework surgery). The significance of specific clinical findings like vocal fold position, arytenoid asymmetry, supraglottic hyperfunction, and posterior glottic gap is reviewed. A flexible, individualized approach to each patient, guided by current concepts of pathophysiology and nerve recovery, is emphasized throughout.