Unilateral vocal cord paralysis is a common finding in the practice of otolaryngology. Multiple etiologies have been described and have not changed appreciably in the last century. We attempted to characterize the contemporary evaluation of unilateral vocal cord paralysis, with consideration given to cost-effectiveness. Thirty-one board-certified otolaryngologists were interviewed to determine their typical evaluation protocol. The average cost of an evaluation totaled $1706.18, with a range of $112.56 to $3439.52. Otolaryngologists with more years of experience tended to pursue briefer and less expensive evaluations. The charts of 187 patients with a diagnosis of vocal paralysis from 1983 to 1991 were reviewed, of which 113 were evaluable. Eighty-four of these 113 (74%) were unilateral. In 48 of 84 cases (57%), the cause was apparent at the time of diagnosis. In 36 of 84 cases (43%), an evaluation was necessary. A diagnosis was achieved in 27 of these 36 instances (75%), with the most useful test being a chest roentgenogram (n = 13, 48%). The most common cause of unilateral vocal cord paralysis in our series was neoplasm (n = 34, 40%), followed by surgical trauma (n = 29, 35%). In no instance was a malignancy discovered subsequent to the initial evaluation. The most cost-efficient, inclusive diagnostic evaluation of unilateral vocal cord paralysis involves a stepwise progression through the tests that are most likely to yield a diagnosis, with endoscopy reserved for those cases in which simpler, less invasive tests have not indicated a cause.