The pharynx (loosely “throat”) has a “foodway” function to convey food and liquid from the mouth to the esophagus. It also serves as part of the “airway,” also from mouth into the larynx and trachea. These foodway/airway functions are kept separate so food and liquid do not enter the airway towards the lungs. At the moment of swallowing, vocal cords clamp firmly together and epiglottis drops over the entrance of the larynx to divert food and liquid into the esophagus. During each swallow, lasting perhaps a second, breathing is briefly suspended. Once the food/liquid has gone by, the larynx re-opens and breathing resumes.

A thin sheet of muscle surrounds the pharynx, and squeezes to narrow the pharynx and help to propel swallowed material. That contraction lasts for approximately one second, each time the person swallows. The muscle is innervated bilaterally by the pharyngeal branch of the vagus nerve and so one side or both sides can be paralyzed by tumor, fracture at the base of the skull, viral injury, etc.

This diagnosis is often overlooked, because clinicians may not be clear on how to make the diagnosis. The best way is to obtain a clear panoramic view of the laryngopharynx as seen in the photo series below, and ask the patient to produce a very high pitch. This maneuver “recruits” contraction of the pharynx outside of the act of swallowing and allows the examiner to see clearly the difference in the contraction of the two sides. The paralyzed side is pulled to the non-paralyzed side, again as seen below.

Some with unilateral pharynx paralysis can compensate and continue to swallow (with limitations). Others are completely unable to surmount the impediment of this kind of paralysis.

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.

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.

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).

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).

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).

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).

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.

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.

Pharyngeal Paralysis, Seen with Pharynx Contraction

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Pharyngeal paralysis (1 of 2)

View of the laryngopharynx. This patient has pharyngeal paralysis on one side, which is already slightly evident because the posterior pharyngeal wall's midline (dotted line) is deviating here slightly to one side, even at rest.

Pharyngeal paralysis (1 of 2)

View of the laryngopharynx. This patient has pharyngeal paralysis on one side, which is already slightly evident because the posterior pharyngeal wall's midline (dotted line) is deviating here slightly to one side, even at rest.

Pharyngeal paralysis, more obvious with pharynx contraction (2 of 2)

The pharynx is contracted, and the posterior pharyngeal wall (midline again at dotted line) now deviates dramatically toward the non-paralyzed side of the pharynx. This pharynx contraction was elicited via extremely high-pitched voicing.

Pharyngeal paralysis, more obvious with pharynx contraction (2 of 2)

The pharynx is contracted, and the posterior pharyngeal wall (midline again at dotted line) now deviates dramatically toward the non-paralyzed side of the pharynx. This pharynx contraction was elicited via extremely high-pitched voicing.

Pharyngeal Paralysis

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Pharyngeal paralysis (1 of 1)

Panorama of the laryngopharynx. Note the capacious left pyriform sinus (right of photo), one strong indicator of paralysis of the pharynx on that side.

Pharyngeal paralysis (1 of 1)

Panorama of the laryngopharynx. Note the capacious left pyriform sinus (right of photo), one strong indicator of paralysis of the pharynx on that side.
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Pharyngeal paralysis (1 of 1)

Blue-stained water swallowed by the patient has preferentially pooled in the left pyriform sinus (right of image), due to weakness of the left inferior pharyngeal constrictors.

Pharyngeal paralysis (1 of 1)

Blue-stained water swallowed by the patient has preferentially pooled in the left pyriform sinus (right of image), due to weakness of the left inferior pharyngeal constrictors.