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Post-swallow Hypopharyngeal Reflux

Post-swallow hypopharyngeal reflux refers to when, shortly after a person swallows, some swallowed material returns from below the esophageal entrance back up into the hypopharynx. This finding is an almost certain diagnostic indicator of cricopharyngeal dysfunction, usually with an associated Zenker’s diverticulum.

If this reflux occurs during a videoendoscopic swallowing study, the clinician will see that, though there may be little to no hypopharyngeal residue immediately after the swallow, a moment later some swallowed material (e.g., blue-stained applesauce or water) reappears and wells up in the post-arytenoid area and into the pyriform sinuses. If this reflux occurs during a videofluoroscopic swallowing study, the clinician will see barium remaining in the Zenker’s sac and, immediately after each swallow, moving back upward into the hypopharynx.

Suspect Zenker’s even if no Prior Radiographic Proof

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Dysphagia and possible Zenker's

Dysphagia and possible Zenker's (1 of 5)

This middle-aged man has solid > liquid dysphagia, and x-rays elsewhere (not available at this visit) reportedly showed a Zenker’s diverticulum. Even without that prior knowledge, the highly organized hypopharyngeal salivary pooling is strongly suggestive of this diagnosis, but subsequent photos of VESS even more so.
After a complete swallow

After a complete swallow (2 of 5)

During VESS, after completing a swallow of blue-stained applesauce, note the residue in the post-arytenoid area.
Additional material

Additional material (3 of 5)

A third of a second later, additional material has emerged from below, likely ejected upwards from the Zenker’s sac.
Hypopharyngeal residue

Hypopharyngeal residue (4 of 5)

At the end of another swallow of the blue applesauce, the hypopharyngeal residue is again seen, but more important is that...
Two seconds later

Two seconds later (5 of 5)

...again, about 2 seconds later, the left pyriform sinus fills from below as the material in the sac is ejected upwards.

Post-swallow Hypopharyngeal Reflux (Zenker’s Diverticulum): VESS vs. VFSS

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VESS

VESS (1 of 7)

In a patient with a known Zenker's Diverticulum, who has just finished swallowing blue-stained applesauce during VESS.
Reflux

Reflux (2 of 7)

Less than a second later, the applesauce and some saliva bubbles reflux upwards from the Zenker's sac into the postarytenoid area.
Post-swallow

Post-swallow (3 of 7)

Here, the patient has just swallowed a cheese cracker.
Reflux of cracker

Reflux of cracker (4 of 7)

About a second and a half later, this material, mixed with saliva, returns from the sac.
VFSS

VFSS (5 of 7)

Just after the patient has swallowed a bolus of barium.
x-ray

X-Ray (6 of 7)

A second later, barium is "squishing" upwards from the sac.
Continued reflux

Continued reflux (7 of 7)

Additional barium has come upwards into the postarytenoid area (compare with Photos 2 and 4).

Post-swallow Return of Saliva into the Hypopharynx

This man began to experience solid food lodgment a few years earlier, along with gurgling noises every time he swallows. Even on an initial examination, Zenker’s diverticulum can be strongly suspected based on the findings of the videoendoscopic swallow study (VESS). Upon review of a videofluoroscopic swallow study (VFSS), a Zenker’s diverticulum is indeed the explanation for the findings below, which went away completely (return of saliva, gurgling noises, and food lodgment) after myotomy.

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Pooling of saliva is seen in the post-arytenoid area.

Pooling of saliva (1 of 4)

Upon first visualization of the hypopharynx and larynx, organized pooling of saliva is seen in the post-arytenoid area.
Right after swallowing, all of the saliva disappears.

Saliva disappears after swallow (2 of 2)

Right after swallowing, all of the saliva disappears. The following 2 photos can be harvested within one second of completion of the swallow.
Saliva begins to return

Saliva begins to return (3 of 3)

Here, the saliva begins to return from a presumed Zenker’s diverticulum.
Saliva is ejected upwards swallow

Saliva is ejected upwards from Zenker’s sac (4 of 4)

Either spontaneously, or by gentle pressure on the low neck, much more saliva is ejected upwards from the presumed Zenker's sac. This is seen commonly when there is a Zenker’s diverticulum, which, again, was subsequently diagnosed here. All of his symptoms and these findings vanished after myotomy.
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