In the palate there may be no symptoms from unilateral paresis. However, on examination the arch on the paretic side is lower.

Ask the patient to quickly say "ah."

The midline of the palate will go over to the normal side, the normal arch will lift and curve, and the paretic side will remain lower and straighten (Figure 9-1A and B). The uvula is not important. It is soft and floppy and sometimes hangs in the midline or to the right or left. Ignore it.

Bilateral palatal paralysis causes nasal regurgitation and a nasal voice, and it is difficult for the patient to pronounce b and g. You can hear air coming out of his nose as he talks.

Figure 9-1. A. Normal palatal arches. B. Paretic left arch. As the patient says "ah," the midline shifts to the right and the right arch rises and curves, while the left remains lower and straight.

The gag reflex was described with the glossopharyngeal nerve. Many people normally have no gag reflex, while others will start gagging as soon as you put a tongue blade on the tongue and before you have touched the palate or pharynx. There is physiological testing of the gag reflex every time the patient swallows. If he can manage liquids without nasal regurgitation, his palate lifts.

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