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 (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.

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 (2 of 5)

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

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 (3 of 5)

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

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 (4 of 5)

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

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 (5 of 5)

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

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 (1 of 7)

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

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 (3 of 7)

Here, the patient has just swallowed a cheese cracker.

Post-swallow (3 of 7)

Here, the patient has just swallowed a cheese cracker.

Reflux of cracker (4 of 7)

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

Reflux of cracker (4 of 7)

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

VFSS (5 of 7)

Just after the patient has swallowed a bolus of barium.

VFSS (5 of 7)

Just after the patient has swallowed a bolus of barium.

X-Ray (6 of 7)

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

X-Ray (6 of 7)

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

Continued reflux (7 of 7)

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

Continued reflux (7 of 7)

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

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