Paradoxical vocal cord motion (PVCM) is characterized by the inappropriate adduction of the true vocal cords during inspiration. Multiple causes have been proposed for this group of disorders, which share the common finding of mobile vocal cords that adduct inappropriately during inspiration and cause stridor by approximation. Management of this group of disorders has been complicated by the lack of a classification scheme to include all types of PVCM. We propose that PVCM be classified according to its underlying etiology and recognize the following causes of the disorder: 1. brainstem compression; 2. cortical or upper motor neuron injury; 3. nuclear or lower motor neuron injury; 4. movement disorder; 5. gastroesophageal reflux; 6. factitious or malingering disorder; 7. somatization/conversion disorder. Case reports are presented to illustrate the characteristic features and diagnostic evaluation used in assessing patients with PVCM. Management varies depending on the cause of PVCM and entails speech therapy, pharmacologic therapy, behavioral modification, and/or surgical intervention. Recognition of the multiple causes of PVCM allows otolaryngologists to formulate well-directed diagnostic evaluation and treatment.

Congenital midline cervical cleft is a rare disorder with a wide range of presentations. To date, there have been fewer than 35 cases reported in the English-language literature. A rarer finding is the association of bronchogenic cysts or respiratory epithelium with the midline cleft. The clinical presentation of congenital midline cervical cleft with a cephalic skin tab, atrophic cleft, and caudal sinus may distinguish it from other conditions of the midline neck. We present an 18-month-old girl with congenital midline cervical cleft to illustrate its clinical presentation and the proper treatment of this condition.

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DISCUSSIONMass effect on the PPS plays a central role in determining the origin of suprahyoid neck masses. Knowledge of the space of origin is then useful in deriving a differential diagnosis.l-' Because of the limited contents of the PPS (fat, branches of cranial nerve V3, internal maxillary artery, ascending pharyngeal artery, and pharyngeal venous plexus), pri-shows that the pharyngeal mucosal space is compressed, but there is no evidence of invasion. The parotid and masticator spaces appear to be uninvolved (Fig 2). A fine-needle aspiration was positive for lymphoma. INTRODUCfIONKnowledge of the parapharyngeal space (PPS) is paramount in understanding disorders of the suprahyoid neck. The PPS may be thought of as a fatty shaft that extends from the skull base superiorly to the hyoid bone inferiorly with direct communication into the submandibular space. 1 This anatomic arrangement allows tumors or infections from adjacent spaces to spread upward to the skull base or inferiorly into the submandibular space. 1 Because primary lesions of the PPS are rare, the majority of cases thought to be primary to the PPS can be shown to arise from one of the neighboring deep facial spaces.' The critical step in localizing a mass of the suprahyoid neck to the pharyngeal mucosal space, masticator space, parotid space, or carotid space is to establish the epicenter of the lesion relative to the PPS and then evaluate the displacement of the PPS fat. 2 CASE REPORTA 70-year-old man presented with a 3to 4-week history of dysphagia and mild voice alterations. Physical examination demonstrated bulging mucosae involving the left nasopharynx. There was no ulceration or pulsation. The neck examination revealed a fullness near the tail of the left parotid gland. A computed tomographic scan of the head performed at another institution was initially interpreted as demonstrating a PPS mass (Fig 1). On review ofthis study it was noted that the epicenter of the mass was posterior to the PPS. There was a loss of planes between the PPS and the prevertebral muscles. Therefore, the lesion was felt to be more consistent with a carotid space mass. A magnetic resonance examina-Fig 1. Computed tomogram in axial plane showing normal tion with gadolinium-diethylenetriamine pentaacetic parapharyngeal space (curved arrow) and carotid artery on acid was obtained. Tl-weightedimages demonstrated right (short arrow). Soft tissue density on left is inseparable from carotid space, pharyngeal mucosal space, andthe left carotid artery encased by a 6 x 6 x 5-cm mass prevertebral muscles. Thin fat plane is lateral to mass centered in the left carotid space (Fig 2). Figure 2 (long arrow).From the Departments of Otolaryngology (Maschka) and Radiology (Mueller, Dolan),