Between May 1997 and May 2001 all patients presenting with a unilateral vocal fold palsy at Gartnavel General hospital were entered into a prospective observational study. The sex, age, side of palsy and aetiology were documented. The aim of the study was to assess the current aetiology of vocal fold palsy in a large teaching hospital in the West of Scotland, and to compare this with the established aetiology in other parts of the world. Seventy-seven patients were studied. Eighty-three per cent were found to have a left and 17 per cent a right vocal fold palsy. The male to female ratio was 2:1, with an age range of 23–85, mean 61. Forty-three per cent of all vocal fold palsies were secondary to an underlying bronchogenic carcinoma and a further nine per cent due to other malignancies. This contrasted with figures quoted in other studies, that gave lung cancer causes of vocal fold palsies ranging from four to 22 per cent. Surgical trauma accounted for 24 per cent and in 11 per cent no cause was found. In conclusion, in our hospital population there is a high rate of vocal fold palsy secondary to bronchogenic carcinoma. This is likely to be associated with the high levels of smoking found in Scotland. Lung cancer rates in Scotland are 1.6 times greater for men, and two times greater for women than the world standard. Malignancies overall cause over 50 per cent of our vocal fold palsies. Vigilance is required in any patient presenting with a vocal fold palsy to ensure a malignancy is not overlooked.