A patient has poor upper esophageal sphincter opening due to decreased hyolaryngeal excursion after a lateral medullary stroke. Which of the following would be the most appropriate initial treatment?

• A. Thermotactile stimulation
• B. Mendelsohn maneuver
• C. Thickened liquids
• D. Chin-down posture (head/neck flexion)

Answer: (B)

The key idea is to address the mechanism that limits opening of the upper esophageal sphincter: hyolaryngeal elevation. When hyolaryngeal excursion is reduced after a lateral medullary stroke, the cricopharyngeus (the UES) doesn’t open adequately to let the bolus pass. The technique that best targets this problem is one that trains the patient to lift and hold the larynx and hyoid during the swallow, prolonging the elevation so the UES stays open longer. That’s exactly what the Mendelsohn maneuver does: it enables a deliberate, extended hyolaryngeal elevation during swallowing, increasing and sustaining UES opening to improve bolus transit.

Thermotactile stimulation mainly aims to trigger the swallow reflex rather than improving the mechanics of hyolaryngeal elevation. Thickened liquids are a compensatory strategy to slow the bolus and reduce aspiration risk but don’t address the underlying issue of insufficient UES opening. Chin-down posture can alter swallow dynamics but doesn’t specifically enhance hyolaryngeal elevation and may not improve UES opening in this context.