Internal carotid artery [ICA] dissection is a rare cause of vocal cord palsy. This cause is not always considered in the initial differential diagnosis and such cases often get classed as idiopathic. We report a case of right ICA dissection, where the patient had presented with symptoms of right vocal cord palsy. This was a 52-year-old woman who presented to ENT department with a 3 week history of hoarse voice, sore throat and dysphagia. She was found to have a right vocal cord palsy and oropharyngeal dysphagia. Her neurological examination at the time of assessment was normal except for a mild reduced elevation of right side of her palate. At that time, the aetiology was thought to be idiopathic. Due to an incidental sphenoid wing meningioma on the CT head and neck, she underwent an MRI head, which demonstrated a thrombosed right ICA. Subsequently, her CT images were reconstructed to demonstrate a rat-tail stenosis of the lower right ICA consistent with dissection, for which she was started on clopidogrel. Therefore an internal carotid artery dissection should be considered in a case of ‘idiopathic’ vocal cord palsy, as they may not necessarily be idiopathic.