This is a case of a 35-year-old who had complained of noisy breathing for 15 years, and had been on treatment for ‘chronic asthma’. She presented to the Accident and Emergency department with an acute episode of difficulty with breathing, and on admission was found to have stridor and bilateral abductor vocal fold palsy. Further workup revealed a syringomyelia with an associated Chiari type 1 malformation. It is important to consider the above diagnosis in the differential of young adults with breathing difficulties. A discussion of syringomyelia, Chiai malformations and bilateral vocal fold palsy follows.