To the Editor, Endoscopic ultrasound (EUS) is generally a safe procedure. However, the longer, rigid tip of the echoendoscopes raises concern about cervical esophageal perforation during intubation.1 Iatrogenic injury of the recurrent laryngeal nerve is the most common cause of vocal cord paralysis.2 We report a case of esophageal perforation and vocal cord paralysis associated with EUS. A 67-year-old man was referred to our hospital because of progressive dysphagia. The endoscopic ultrasound revealed a normal esophagus. The patient developed neck pain and painful swelling after the examination. Physical examination demonstrated that it was not cervical crepitus, and neck radiograph revealed air in the retropharyngeal space. Indirect laryngoscopy showed paralysis of the right vocal cord. The left vocal cord was normal with no ulceration or growth. Assessment and diagnosis of the vocal cord paralysis by otorhinolaryngologists after EUS included interviews and flexible fiberscopy. There were no previous clinical symptoms of neuropathy and no positive history for inherited neuropathies. Computed tomography (CT) scan of the neck and thorax showed perforation of the right pyriform sinus and the presence of a right-sided large laryngocele. Oral intake was withheld and high-dose antibiotics and prednisone (40 mg/day) were administered through the central venous system over 10 days. The patient reported that voice quality and perforation improved suddenly after 10 days of medication. Subsequent laryngoscopy and flexible fiber optic endoscope showed normal movement of the left vocal cords. Control CT scan of the neck and chest obtained 10 days after the first one did not show gas or fluid collection in the right pyriform sinus. Oral intake was restarted on the 10th day and the patient was discharged on the 11th day. EUS have become important tools in evaluation of patients who have various gastrointestinal and non-gastrointestinal disorders, and are being increasingly utilized at many centers.3 EUS is generally a safe procedure. Complications can occur but are rare.2 Vocal cord paralysis may occur for many reasons. The most common cause of esophageal perforation is injury to the esophagus during a medical procedure, such as intubation with inadvertent placement of the tracheal tube in the esophagus, nasogastric tube placement, upper gastrointestinal endoscopy and transesophageal echocardiograph.4 To our knowledge, this is the first reported case of vocal cord paralysis in a patient undergoing EUS. The cause of the complication was damage to the right recurrent laryngeal nerve, which occurred during insertion of the EUS into the esophagus.