Hypopharynx pooling
Shows trace of blue-stained applesauce remaining behind after the patient has swallowed.

Pooling occurs when a person’s swallow does not successfully send the entire mass of food or liquid into the esophagus, so that some or all of the material remains in the hypopharynx. In such cases, the material commonly pools in the vallecula and pyriform sinuses. It can also cling to the base of the tongue or the pharyngeal walls. Pooling is often caused by presbyphagia, and its occurrence may put a patient at risk of aspiration.

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 Demonstrating Presbyphagia, Chin Tuck Maneuver, Hypopharyngeal Pooling, Laryngeal Penetration and Effective Cough

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VESS (1 of 5)

The patient swallowed a bolus of blue-stained applesauce to verify basic (though abnormal) capability. This photo follows 4 additional boluses delivered in a rapid, pressured fashion, intentionally seeking the patient’s “limits.” Note pooled blue applesauce, but without soiling of the laryngeal vestibule.

Chin tuck maneuver (2 of 5)

Moments later, the patient was asked to swallow again, but with chin tucked down towards chest. Note how effective this maneuver was in clearing away the residual material seen in the prior photo.

Aspiration (3 of 5)

Due to its lower viscosity, blue-stained water flows more quickly than applesauce, and enters the laryngeal vestibule. Fortunately, the patient is closing the vocal cords simultaneously, so that aspiration does not occur.

Laryngeal penetration (4 of 5)

Just after the swallow is completed, one can see a trace of blue-stained water just above the not-yet-opened cords. This is technically penetration, and not aspiration.

Air is blasted out of vestibule (5 of 5)

Using “stored” pulmonary air, this trace of penetrated water is “blasted” up and out of the laryngeal vestibule, and is never aspirated.”