patients with symptoms compatible with helps have either obvious unilateral throat contractions when the pharynx is involved or non-lateralized throat contractions when the larynx is involved. those with clinically obvious lateralized contractions can be managed with ipsilateral botox injection in the affected muscles. an mri should be ordered to confirm the presence of a vessel juxtaposed to the ipsilateral vagus nerve. patients with clinically non-lateralized contractions should have botox injected on one side of the throat and then, when the effect has worn off, botox should be injected on the opposite side. a unilateral benefit should prompt an mri to look for a vessel juxtaposed to the vagus nerve on the side that botox was effective.