This FEES Friday, we’re diving into swallow initiation zones. In the video, our patient is eating a mixed texture (diced peaches in syrup). The liquid component progresses all the way down to the pyriform sinuses while the patient is still chewing the solid pieces. Delayed swallow, right? Actually, no!
This is a completely normal finding for mixed textures. The liquid naturally progresses to the pharynx while the solid component is still being chewed. This patient eventually triggers a well-coordinated swallow that clears everything without any penetration or aspiration. No airway compromise, no significant residue- just normal swallowing!
Mixed textures add complexity because we’re managing two consistencies at once. If we misinterpret normal liquid flow as delayed initiation and start restricting mixed textures unnecessarily, we’re taking away foods based on our misunderstanding of normal physiology. That’s a problem.
Here’s where it gets interesting. Research by Bhutada and colleagues looked at swallow initiation timing in 195 healthy adults and found that the swallow initiation zone ranged everywhere from the ramus of the mandible all the way down to the pyriform sinuses. Even more surprising, Dr. Humbert and colleagues found that swallow initiation as deep as the pyriform sinuses is a normal variation among ALL tested textures- not just mixed consistencies. Martin-Harris et al. found that 80% of healthy adults triggered their swallow after the bolus had already passed the ramus of the mandible on at least one trial. So much for the ramus of the mandible being a clear marker of dysfunction.
The takeaway? Seeing material in the pyriform sinuses before the swallow triggers isn’t automatically a red flag. What matters is whether the swallow initiation location and timing is clinically impactful. For example, if the bolus dwells in the pyriform sinuses for several seconds and runs into the airway, resulting in aspiration before the swallow, then we may need to consider restrictions or dysphagia treatment to address this. Context is everything. When you’re looking at swallow initiation, don’t get tunnel vision. Look at the whole picture- overall swallowing safety and efficiency.
Next time you see a bolus hanging out in the pyriform sinuses before the swallow initiates, pause before writing “delayed initiation” in your report. Ask yourself: is this actually causing a safety issue, or is this just a normal variation? Let the research guide you, not outdated rules about where swallows “should” happen. Normal is a range, not a rigid checkpoint.
Research cited:
Bhutada, A. M., Dey, R., Martin-Harris, B., & Focht Garand, K. L. (2020). Factors Influencing Initiation of Pharyngeal Swallow in Healthy Adults. American journal of speech-language pathology, 29(4), 1956–1964. https://doi.org/10.1044/2020_AJSLP-20-00027
Humbert, I. A., Sunday, K. L., Karagiorgos, E., Vose, A. K., Gould, F., Greene, L., Azola, A., Tolar, A., & Rivet, A. (2018). Swallowing Kinematic Differences Across Frozen, Mixed, and Ultrathin Liquid Boluses in Healthy Adults: Age, Sex, and Normal Variability. Journal of speech, language, and hearing research: JSLHR, 61(7), 1544–1559. https://doi.org/10.1044/2018_JSLHR-S-17-0417
Martin-Harris, B., Brodsky, M. B., Michel, Y., Lee, F. S., & Walters, B. (2007). Delayed initiation of the pharyngeal swallow: normal variability in adult swallows. Journal of speech, language, and hearing research: JSLHR, 50(3), 585–594. https://doi.org/10.1044/1092-4388(2007/041)
