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An 82 year-old male admitted with PNA, required multiple intubations and eventual tracheostomy. Fiberoptic endoscopic evaluation of swallowing (FEES) completed with #5XLT proximal/cuffless tracheostomy (patient capped on room air) and Dobhoff feeding tube in place. FEES revealed a severe pharyngeal dysphagia. There is pooling of secretions throughout pharynx/larynx (valleculae and pyriform sinuses) with aspiration of secretions. With pureed texture there is residue throughout the pharynx suggestive of generalized reduced pharyngeal contraction. The residue in the valleculae is a result of reduced base of tongue retraction, epiglottis dysfunction, and poor hyoid elevation. The residue in the pyriform sinuses is a result of cricopharyngeus dysfunction/inadequate upper esophageal sphincter opening. There is a delayed pharyngeal swallow response with nectar consistency with bolus spilling to the pyriform sinuses resulting in + aspiration before/during/after the swallow response due to reduced arytenoid tilt and vocal fold adduction. (Used with permission of Randy Dubin.)