Clinical Research, Division of Otolaryngology, Head and Neck Surgery, Cedars Sinai Medical Center, USA.
Aspiration is most commonly associated with neurologic impairment, pulmonary disease, impaired swallowing coordination, or esophageal dysfunction [2]. However, rare anatomical abnormalities may also contribute. We present the case of a 60-year-old male who experienced chronic aspiration events triggered by mucus accumulation in his throat. Fiberoptic laryngoscopy surprisingly revealed that an elongated (approximately six-inch), non-swollen uvula was positioned anterior to the epiglottis and encircles its base, preventing the epiglottis from completing its essential role of covering the glottis during swallowing and thereby protecting the larynx from aspiration. Notably, a video fluoroscopic swallow study using barium pudding failed to reveal aspiration, likely due to the test’s focus on solids rather than liquids, despite the patient’s primary symptoms occurring with liquids and phlegm. This case highlights the importance of considering unusual anatomical causes of aspiration.
Manuscript Information: Received: Sep 27, 2025 Accepted: Oct 20, 2025 Published Online: Oct 27, 2025
Journal: Annals of Surgical Case Reports & Images
Online edition: https://annscri.org
Copyright: © Moradzadeh D (2025). This Article is distributed under the terms of Creative Commons Attribution 4.0 International License.
Cite this article: Moradzadeh D, Schenck NL. An Unusual Cause of Aspiration: A Case Report. Ann Surg Case Rep Images. 2025; 2(2): 1101.
A 60-year-old male presented with several months of frequent throat clearing, persistent phlegm accumulation, and a sensation of saliva or mucus entering the airway, resulting in cough and choking. He described intermittent aspiration events occurring unpredictably, even while sitting upright. He reported frequent coughing fits, particularly when phlegm was present in the throat, as it would often “go down the wrong pipe” (larynx), triggering significant laryngeal cough reflex. His medical history was otherwise unremarkable, with no prior neurologic, esophageal, or pulmonary disease. A video fluoroscopic swallow study (modified barium swallow) was performed but did not indicate aspiration. However, the test used barium pudding (thick consistency), not thin liquids, which the patient reported as the true triggers for his aspiration episodes.
On fiberoptic laryngoscopy, string-like tissue was observed anterior to and partially encircling the epiglottis. The tissue was identified as a non-swollen, elongated uvula measuring nearly six inches, which obstructed the normal closure of the epiglottis during swallowing.
Aspiration is most often caused by neurologic impairments such as stroke and Parkinson’s disease that disrupt swallowing [1]. In dementia, cognitive decline and impaired swallowing reflex increase the risk of aspiration by reducing airway protection [4]. Other well-described causes include structural or functional abnormalities such as Zenker’s diverticulum, strictures, esophageal dysmotility, oropharyngeal tumors, and impaired swallow coordination due to systemic disease [2]. Additionally, patients with chronic lung disease or gastroesophageal reflux disease may present with aspiration [3].
However, these commonly cited causes do not include an elongated uvula as a potential etiology [2]. In this patient, none of the common underlying conditions were present. There was no history of anaphylactic reaction. The absence of neurologic deficits, esophageal pathology, or head and neck masses made the findings on video laryngoscopy particularly notable. The nearly six-inch long uvula created a rare but significant mechanical obstruction to epiglottic closure, leading to aspiration events (Figures 1A & 1B).
This case highlights the importance of direct visualization via video laryngoscopy in patients complaining of aspiration or choking. Standard diagnostic tools, such a swallow study, may fail to reproduce symptoms, possibly due to the use of testing materials (solids vs. liquids). Recognition of this unusual anatomical cause is crucial, as it may be easily overlooked in favor of more common etiologies. Partial surgical removal of the uvula (uvulectomy) is expected to resolve the patient’s symptoms.
This case illustrates an unusual anatomical cause of chronic aspiration: An elongated uvula obstructing the epiglottis. Unlike the more common etiologies, this presentation was mechanical rather than neurologic or functional. Although a standard swallow study using barium pudding did not show aspiration, the patient continued to aspirate liquids and phlegm, leading to persistent coughing fits. The diagnosis was ultimately made through fiberoptic laryngoscopy, highlighting the value of direct visualization. The patient is scheduled to undergo a partial uvulectomy, which is anticipated to provide definitive symptom relief. Clinicians should remain alert to rare etiologies such as this, especially when patients exhibit aspiration symptoms not explained by conventional tests.
Funding: Cedars Sinai Sinus Center.