SASS Clinical Note #3: Saliva Accumulation in the Pharynx — What Does it Mean, If Anything?

How often does a FEES study begin with white, frothy secretions in the pharyngeal cavities, and/or in the larynx vestibule?  In some, it is thin and very fluid, while, in others, it is thick and tacky.  We often say, “It’s poor secretion management,” note it, and proceed with the study.   As it turns out, saliva accumulation or pooling gives an early, pre-study clue to possible underlying biomechanical and/or biosensation problems.

Rodrigues et al., 2011 showed that hypoesthesia of the larynx and pharynx structures with diminished protective reflexes played a role in silent aspiration and larynx penetration.

Yamaguchi, Mikushi, & Ayuse (2019) investigated if decreased biomechanical factors also resulted in saliva accumulation.  Using MBS and FEES studies on the same day, they examined 47 subjects with dysphagia. They used the Secretion Severity Scale (Murray et al., 1996) to rate each FEES study. They reported a significant correlation between greater amounts of saliva accumulation and saliva penetration.  Using MBS, they reported greater amounts of saliva accumulation with the absence of contact between the base of the tongue and the posterior pharyngeal wall, reduced anterior displacement of the hyoid bone, reduced anterosuperior displacement of the larynx, and a smaller opening of the UES.  These findings suggest underlying biomechanical or muscle weakness affecting all swallow motor functions: tongue base retraction, hyoid elevation, thyroid cartilage elevation, pharyngeal constriction, pharyngeal shortening, and subsequent UES opening diameter.  Saliva accumulation suggests muscle weakness affecting the timing of muscle contraction and structure movement, the reduced force of muscle contraction reducing pressure on the saliva to clear the pharynx, and reduced amplitude and speed of structural movements allowing larynx penetration of pooling saliva.