Response from the Authors

Dear Sir: We would like to express appreciation for the comments given as well as for sharing your research findings in relation to the case. We agree that a neurological problem must be properly ruled out most expecially when there is a delayed onset of neurological symptoms with progression over time.   Indeed, the presence of vocal fold dysfunction in children should make one consider CNS pathologies most common of which is the Arnold- Chiari Malformation. However, the following are our reasons for concurring with the pediatric neurology service in not requesting imaging: Aside from vocal fold paralysis, no other neurological symptom or finding was noted such as presence of swallowing and feeding difficulties, dizziness or uncoordination usually present in brainstem pathologies manifesting with vocal fold paralysis such as Chiari Type I1,2 Previous and subsequent neurological examinations showed a bilaterally intact gag reflex which somewhat made the possibility of a CNS lesion affecting the vagus unlikely. No findings indicative of cerebellar dysfunction (such as dysdiadokinesia) were noted Thank you very much.   Reylan B. David, MD reylandavid@gmail.com William L. Lim, MD