This was an interesting article explaining the current methods used to try and improve dysphagia and in some cases associated problematic aspiration following vagal injury. These patients are often those with other associated cranial neuropathies, with skull base lesions, brain stem lesion and stroke. In severe cases, patients may become gastrostomy dependant and if aspiration pneumonitis continues to remain a significant problem, drastic measures separating the larynx and pharynx are described. However, the authors have experience of a specific group of patients with high vagal paralysis (HVP), without the other associated morbidities, so the drastic surgeries once described are inappropriate in this group, depriving these otherwise well patients of speech, airway and swallow. They therefore advocate a technique of hypopharyngeal pharyngoplasty after noting on MRI that the paralysed pharynx acted like a diverticulum, preventing onward progression of the food bolus into the oesophagus. They therefore performed a pharyngectomy of the piriform mucosa but to improve their results further, they advanced the inferior constrictors onto the thyroid cartilage. The article continues with patient selection and the operative steps, accompanied with line drawings. The author has a personal series of 30 patients but little is known regarding their outcomes from this paper, especially since the procedure appears to be combined with other, simultaneously performed procedures to improve their symptoms. Theoretically it sounds like it would work, but the absence of reliable data in isolation from other procedures, currently does not support its use.