We thank Bigliardi and colleagues for their comments. The authors identified 1 case among 350 patients diagnosed with ALS in the province of Modena from 1990 to now that presented with stridor and hoarseness due to a bilateral vocal cord abductor paralysis at onset. Therefore, based on their own experience, they conclude that vocal cord dysfunction is quite rare at onset. Furthermore, Bigliardi et al refer to a publication by Puls et al1 in which a large family is described with lower motor neuron disease caused by a dynactin mutation. Affected members of this family developed early bilateral vocal cord paralysis. Bigliardi et al hypothesize that vocal cord dysfunction in ALS may be specifically related to a dynactin dysfunction.
Maria van der Graaff M, de Visser M. Bilateral Vocal Cord Paralysis: A Rare Onset of Amyotrophic Lateral Sclerosis—Reply. Arch Neurol. 2010;67(7):897-899. doi:10.1001/archneurol.2010.142