The palate is a structure which serves as both the roof of the mouth and the floor of the nasal cavity and nasopharynx. It has two parts: the hard palate and the soft palate. The hard palate, which is the anterior two-thirds of the palate, begins just behind the upper central teeth and is made up of bone. The soft palate, which is the posterior one-third of the palate, is made up of muscle; the soft palate is therefore movable, and it elevates to help with swallowing and speech.

See also: palate paralysis; palate deviation

High Vagus Nerve Injury

The vagus (10th cranial) nerve originates from the medulla (part of the brainstem), exits from the base of the skull through the jugular foramen, and among other things, supplies branches to the musculature of palate, pharynx, and larynx. Location of vagus nerve injury is sometimes evident by palate and pharynx findings. But these findings are sometimes overlooked as in this case, especially if palate and pharynx are weak but not completely paralyzed.

Case study: This 50-something woman developed a weak voice and moderate difficulty swallowing upon awakening 5 months prior to this visit. Fortunately, her symptoms of weak voice and difficulty swallowing were not devastating, and are improving. But up to this examination, there has been no diagnosis. This examination reveals a “lesion” of her right vagus nerve and it has to be at the base of the skull because palate, pharynx, and larynx muscles are all weak. Voice is functional but lacks the ability to project and has a “soft-edged” quality. A sophisticated listener can also hear mild hypernasality. The examination below prompts a scan with special attention to base of skull to be sure there is no mass lesion there.

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Nasopharynx (1 of 7)

This view of the nasopharynx shows that soft palate elevates and deviates to the left (curved arrow). The right side of the palate is atrophic and there is a gap (straight arrow) when she speaks. Saliva on the back wall of the nasopharynx (where it doesn’t belong) is also a clue.

Saliva pooling in right pyriform sinus (2 of 7)

Initial view of the hypopharynx shows saliva pooling preferentially in the right pyriform sinus at *. This is a typical finding of right pharynx paresis or paralysis.

Pharynx contracts (3 of 7)

To “prove” that the pharynx is weak on the right, the patient is asked to produce a very high pitch to recruit pharynx contraction. The midline (dashed line) has deviated far to the left (right of photo). Pharynx contracts on the left (arrows), closing the pyriform sinus on that side. There is no corresponding contraction on the patient’s right (left of photo).

Swallowing blue applesauce (4 of 7)

Blue-stained applesauce the patient has attempted to swallow replaces the saliva in the right pyriform sinus, but there is no soiling of the laryngeal vestibule (initial opening to the airway).

Unilateral pharynx contraction (5 of 7)

Elicitation of the “pharyngeal squeeze” with high pitched voice re-demonstrates unilateral pharynx contraction (arrows).

Right vocal cord paresis (6 of 7)

Closer inspection of larynx shows right vocal cord paresis (LCA and TA seem mostly intact explaining reasonably functional voice).

Vocal cord is paretic, not paralyzed (7 of 7)

Phonation shows fairly good vocal cord approximation, again showing that the cord is paretic rather than paralyzed, and explaining the fairly functional voice. Despite having swallowed several boluses of blue applesauce and water, the laryngeal vestibule shows no soiling, explaining why the patient is managing her swallowing even though she is aware that it is abnormal.

VESS Assesses Equipment, Secretions, then Swallowing Ability

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Part Ia: Palate elevates normally (1 of 7)

This man has symptoms of cricopharyngeus muscle dysfunction (CPD), with frequent lodgment of solid food (never soft or liquid material) at the level of mid-to-low neck. This VESS sequence demonstrates his propulsive or “pitcher” ability. Here in VESS part Ia, palate elevates normally (arrows). Left palate is not drooping and there is no deviation.

Part Ib: phonation (2 of 7)

In Part Ib of VESS, the patient makes voice, to prove normal movement and good closure of the vocal cords. In addition, no secretional pooling is seen in vallecula or pyriform sinuses.

Part Ic: High pitch elicited (3 of 7)

Part Ic: Very high pitch is elicited. Pharyngeal walls contract inward (arrows), closing the pyriform sinuses. Part Ia,b, and c (Photos 1, 2, and 3) verify that there is good function of swallowing equipment, i.e. palate, pharynx, and larynx (and tongue).

Part IIa: applesauce (4 of 7)

Part IIa: Blue-stained applesauce is first, because puree is the “easiest” material for the majority of patients, whatever their diagnosis. Here, one sees only minimal residue after several boluses are swallowed.

Part IIb: cracker (5 of 7)

Part IIb: After an orange (cheese) cracker, lodgment in the vallecula, and…

Part IIb: continued (6 of 7)

...on the pharyngeal walls (arrows).

Part IIc: water (7 of 7)

Part IIc: After several boluses of blue-stained water, all cracker is washed away and there is no blue staining or residue within the laryngeal vestibule, subglottis, or high trachea. Given this man’s CPD symptoms, VFSS may show a cricopharyngeus muscle bar, indicating incomplete relaxation of the upper esophageal sphincter.