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Simon is a 58 year old patient with malignant hypertension and morbid obesity who was admitted to the ICU in an unconscious state 24-hours ago. Today he is awake, but drowsy, answering questions appropriately after delays of up to 30 seconds. Your pertinent examination data is as follows: • Patient is using suction to control all secretions. • Speech is clearly articulated with normal rate, but voice is low volume and moderately breathy. • On a general physical inspection you note left eye ptosis and miosis. • Mild overshooting is observed when the patient attempts to use his left upper extremity. • Examination of oral/facial structures and function demonstrated absent gag on left. • All facial and oral musculature is judged to be symmetrical at rest and functionally within normal limits. • There is absence of palpated laryngeal excursion on attempted dry swallows. • Laryngeal inspection (using a rigid fiberoptic laryngoscope) was significant for left true vocal fold paralysis and copious accumulated secretions throughout the hypopharyngeal cavity. • Voluntary and reflexive cough is judged to be inadequate for airway protection and clearance. What is the most likely physiological basis for Simon’s swallowing difficulties? A. Given that his motor speech, with the exception of his voice, is within normal limits, the patient’s difficulties in swallowing likely stem from a non-neurological condition. The findings that are often associated with neurological conditions, e.g., absent gag on the left and unilateral vocal fold paralysis, are most likely due to either an inflammatory condition or complications from his morbid obesity, e.g., nerve impingement. B. Simon has obvious neurological deficits that affect his left arm, his gag response, and vocal fold functions. The fact that this was a sudden event and his speech is mostly spared suggests that he has experienced an acute vascular event causing a unilateral hemispheric lesion, most likely in the non-language right hemisphere. C. In patients with morbid obesity and uncontrolled hypertension, there is a high likelihood that Simon has experienced compression on his vagus nerve on the left side. His findings of unilateral impairment in gag reflex, vocal fold paralysis on the left side, and his clumsy left arm can all be explained on the basis of unilateral nerve compression. D. The fact that this was an acute event leading to temporary loss of consciousness and residual impairments involving his left eye, gag reflex, vocal fold function, and swallowing initiation suggests that Simon has most likely suffered a brainstem infarct affecting specific cranial nerves and the central pattern generator for swallowing

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