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The Effect of Head and Neck Positions on Oropharyngeal

Swallowing: A Clinical and Electrophysiologic Study
Cumhur Ertekin, MD, Arzu Keskin, MD, Nefati Kiylioglu, MD, Yesim Kirazli, MD, Arzu Yagiz On, MD,
Sultan Tarlaci, MD, Ibrahim Aydoǧdu, MD
ABSTRACT. Ertekin C, Keskin A, Kiylioglu N, Kirazli Y, obtained were not compared with other techniques (eg, video-
Yagiz On A, Tarlaci S, Aydoǧdu I. The effect of head and fluoroscopy), this simple electrophysiologic method for de-
neck positions on oropharyngeal swallowing: a clinical and scribing dysphagia limit may have a place in the evaluation of
electrophysiologic study. Arch Phys Med Rehabil 2001;82: dysphagia and its variability in various head and neck posi-
1255-60. tions.
Key Words: Deglutition; Dysphagia; Manometry; Rehabil-
Objectives: To determine the clinical usefulness of an elec- itation; Swallowing.
trophysiologic method for evaluating dysphagia and to identify © 2001 by the American Congress of Rehabilitation Medi-
the effects of various head and neck positions on oropharyngeal cine and the American Academy of Physical Medicine and
swallowing. Rehabilitation
Design: Experimental, with control group.
Setting: An electromyography laboratory.
HE EFFECTS OF VARIOUS head and neck positions on
Participants: Patients with neurogenic dysphagia (n ⫽ 51)
and healthy controls (n ⫽ 24). Patients were divided into 2 T oropharyngeal swallowing have been shown in human
subjects with videofluoroscopic and manometric methods.
1-7 8,9
groups: those patients with unilateral lower cranial lesions (n ⫽
9) and those without laterality in the function of the oropha- Researchers have made videofluoroscopic studies of the direc-
ryngeal muscles (n ⫽ 42). tion and speed of flow of swallowed barium material in differ-
Interventions: Subjects were instructed to swallow doses of ent head and neck positions and have also observed aspiration
water, gradually increasing in quantity from 1 to 25mL under occurring and being eliminated.3-7
5 conditions: neutral, chin up, chin tucked, head rotated right, Although manometric methods are much more rare, re-
and head rotated left. searchers8,9 have used them to measure the changes in pressure
Main Outcome Measures: Change in dysphagia limit of the pharynx cavity and upper esophageal sphincter. We are
through specified head and neck postures. Oropharyngeal swal- aware of no studies that describe the effects that different head
lowing was evaluated by laryngeal movements that were de- and neck positions have on swallowing, as determined by
tected by a piezoelectric sensor and electromyography of the electrophysiologic investigations. Piecemeal deglutition and
submental muscle complex. Laryngeal sensor signals occurring dysphagia limit, which express the presence of dysphagia or
within 8 seconds of a swallow were accepted as a sign of the the difficulty in swallowing, have been defined and used pre-
dysphagia limit. viously10 in various neurologic disorders. In the present study,
Results: In the control group, dysphagia limit did not change we attempted to quantify by electrophysiologic studies the
significantly with changes in head and neck postures, except effects of head position on swallow in healthy subjects and
for the chin-up posture ( p ⬍ .05) in which piecemeal degluti- dysphagic patients.
tion occurred when subjects swallowed volumes less than METHODS
20mL. Dysphagia limit improved significantly ( p ⬍ .05) in
67% of the patients with unilateral lower cranial lesions when
the head was rotated toward the paretic side. In dysphagic
patients with bilateral symptoms, a significant ( p ⬍ .01) im- Twenty-four healthy volunteers (10 men, 14 women; age
provement in dysphagia limit occurred in 50% of patients in range, 20 – 65yr; mean, 40.4yr) without complaint of dysphagia
chin-tuck position, but in the chin-up position, 55% of the or other oropharyngeal problems were included in the present
patients experienced a significant ( p ⬍ .01) decrease in dys- study. Three authors (AK, NK, AYO) also served as volun-
phagia limit. teers.
Conclusion: The electrophysiologic method of measuring All 51 patients (37 men, 14 women; age range, 14 –78yr;
dysphagia limit confirms neurogenic dysphagia and its severity mean, 56.3yr) were inpatients being treated at the neurologic
in the neutral head position. Changes in head and neck posi- department of the university hospital. Exclusion criteria in-
tions do not significantly alter dysphagia limit in unimpaired cluded diabetes mellitus, alcoholism, dementia, or any other
subjects except for the chin-up position. Although the results kind of mental disorder, local oropharyngeal disease, and lack
of cooperation. The patients were divided into 2 groups (table
1). Group 1 consisted of 9 patients in whom dysphagia was
attributed to unilateral lower cranial lesion. Group 2 consisted
From the Departments of Neurology (Ertekin, Kiylioglu, Tarlaci, Aydoǧdu), Clin- of 42 dysphagic patients who had no clinical evidence of
ical Neurophysiology (Ertekin, Aydoǧdu), and Physical Medicine and Rehabilitation laterality in pharyngolaryngeal function; these patients were
(Keskin, Kirazli, On), Ege University, Medical School Hospital, Izmir, Turkey.
Accepted in revised form November 16, 2000.
divided into 2 subgroups: (1) all the patients with bilateral
Supported by the Turkish Scientific and Technological Research Council (grant no. symptoms (n ⫽ 42), regardless of their ability to perform
SBAG-1739). various head and neck positions, and (2) the 16 patients able to
The author(s) has/have chosen not to select a disclosure statement. perform all head and neck positions systematically. The inves-
Reprint requests to Cumhur Ertekin, MD, Dept of Neurology, Ege University, Medical
Schl Hospital, Bornova, 35100, Izmir, Turkey, e-mail:
tigators and data analysis were not blinded. Informed consent
0003-9993/01/8209-6252$35.00/0 was obtained from all patients and the study was approved by
doi:10.1053/apmr.2001.25156 the local ethics committee.

Arch Phys Med Rehabil Vol 82, September 2001


Table 1: Dysphagia origins (n ⴝ 51) Table 2: Mean Dysphagia Limits of Healthy Subjects

Group n Head Position n Bolus size (mL)

Dysphagia from unilateral lower cranial lesion (n ⫽ 9) Neutral 24 25.0 ⫾ .00

Wallenberg syndrome (with unilateral medullary Chin-tuck 24 23.9 ⫾ 3.29
infarction) 5 Chin-up 24 20.6 ⫾ 5.77*
Isolated 9th and/or 10th cranial nerve involvement Rotated right 24 24.6 ⫾ 1.02
(extramedullary lesions) 4 Rotated left 24 24.7 ⫾ 1.41
Dysphagia with neurologically bilateral
pharyngolaryngeal dysfunction (n ⫽ 42) NOTE. Values are mean ⫾ standard deviation (SD).
* p ⬍ .05 (Wilcoxon test).
Cerebrovascular disease
Stroke* 17
Multi-infarcts 4 graph and bandpass filtered (.01–20Hz). The sensor registered
Parkinson’s disease 5 2 deflections during each swallow: first, the upward movement
Torticollis and oromandibular dystonia 4 of the larynx and, second, its downward movement.11,13,14
Motor neuron disease 4 The midregion of the first deflection was stabilized on the
Myasthenia gravis 4 oscilloscopic screen with a delay line technique, so that the
Myotonic dystrophy 1 deflections appeared at the same location of each sweep (⬃2s
Progressive pyramidal/extrapyramidal disorders of after sweep onset) throughout successive swallow recordings.
unknown etiology 3 Piecemeal deglutition occurs when a subject divides a bolus
of large volume into 2 or more parts and then swallows them
* Stroke patients had unilateral clinical symptoms with clinically successively.1 To investigate this phenomenon, we set the
normal oropharyngeal and laryngeal function, but they had trigger-
ing difficulties in voluntary swallowing.
recording systems sweep duration at 10 seconds and its delay
line to start recording at 2 seconds. Therefore, after an amount
of water was swallowed, the effect was followed for 8 seconds.
Unimpaired control subjects and patients were each given 1,
Procedures 3, 5, 10, 15, 20, and 25mL of water in a stepwise manner. With
Postural techniques were chosen and adjusted by 2 authors each bolus, they began to swallow immediately after being
(AK, YK), both specialists in rehabilitation. The head and neck instructed to do so by the examiner. Water was delivered into
postures were performed as described previously.1,4 the mouth behind the incisors by a graduated syringe; swallows
Electrophysiologic monitoring was applied in a manner de- were initiated with the water positioned on the tongue and the
scribed previously.10,11 We recorded muscle activity on an tongue tip touching the upper incisors. Oscilloscopic traces
electromyographa using bipolar silver chloride electroenceph- were started at the examiner’s order for the swallow.
alogram electrodes taped under the subject’s chin over the The laryngeal sensor signal and integrated signals of submen-
mylohyoid/geniohyoid-anterior digastric muscle complex in a tal-electromyographic activity were recorded at the beginning of
bilateral midline distribution, with a distance of 3cm between the oscillographic sweeps. As each quantity of water was swal-
the electrodes. The signal was filtered (100Hz–10kHz), ampli- lowed, single sensor and submental-electromyographic signals
fied, rectified, and then integrated. To detect laryngeal move- were recorded. We accepted electromyographic and laryngeal
ments, we placed a homemade sensor (a simple piezoelectric sensor signals related to swallowing within 8 seconds as piece-
wafer with a 4 ⫻ 2.5mm rubber bulge affixed at its center) meal deglutition or as a sign of dysphagia limit.10,13
between the cricoid and thyroid cartilages at the midline.12 The The examination was ended if piecemeal deglutition oc-
sensor output was connected to 1 channel of the electromyo- curred or if the investigator observed any sign of subglottic

Fig 1. Normal dysphagia limits (mL) obtained from a healthy subject (A) with water boluses of 3 to 25 mL and the head in neutral position
and (B) with water boluses of 20mL swallowed in each head position. Abbreviation: SM-EMG, submental electromyographic activity.

Arch Phys Med Rehabil Vol 82, September 2001


Fig 2. Changes in dysphagia limit (mL) obtained

from normal subjects. (A) With the head in neutral
position, the limit in all subjects was 25mL. (B) In
chin-up position, the dysphagia limit decreased
significantly. (C) In chin-tuck position, no signifi-
cant change occurred.

aspiration, such as coughing or wet voice. Subjects were in-

structed to speak between each test. If there was any suspicion
of piecemeal deglutition, the procedure was repeated and re-
corded for a second time with the same quantity of water.
Because piecemeal deglutition occurs in physiologically
healthy subjects when they swallow more than 20mL of water,
the occurence of swallows at or below that size water bolus is
referred to as the “dysphagia limit.”10,13
Electrophysiologic measurements were recorded with the
patient sitting on the chair in the upright position. The first
measurement was with the head in neutral position. Measure-
ments were repeated with chin tucked, chin up, head rotated
right, and head rotated left positions, as described by Loge-
mann1 and Ertekin et al.14

Table 3: Dysphagia Limits of Patients with Unilateral

Lower Cranial Lesion

Head Position n Bolus size (mL)

Neutral 9 12.9 ⫾ 8.0

Chin-tuck 8 15.1 ⫾ 8.9
Chin-up 6 9.6 ⫾ 6.6
Rotated to paretic side 9 18.6 ⫾ 8.6*
Rotated to nonparetic side 9 14.5 ⫾ 8.9

Fig 3. Bolus was divided into 2 pieces with volumes equal to 20mL NOTE. Values are mean ⫾ SD.
in a healthy subject in chin-up position (arrow). * p ⬍ .05 (Wilcoxon test).

Arch Phys Med Rehabil Vol 82, September 2001


Fig 4. Dysphgia limit (mL) in a patient with unilateral lower cranial lesion. (A) With head rotated to the nonparetic side, multiple swallows
was observed (arrows) at 20mL. (B) With the head rotated to the paretic side, moderately improved dysphagia limit was observed.

The changes in dysphagia limit in various head postures of Patient Groups

healthy volunteers and patients were analyzed with the Wil- Group 1: Patients with unilateral lower cranial dysfunction
coxon paired 2-tailed test. Statistical significance was defined (n ⴝ 9). Dysphagia limits obtained in different head posi-
by 2-tailed p values of less than .05. tions are shown in table 3. Dysphagia was a symptom in all
patients except 1, and dysphagia limit was significantly ( p ⬍
.05) less in neutral position in patients than in the healthy
subjects. Dysphagia limit increased from 12.9 ⫾ 8.0mL to
Healthy Volunteers 18.6 ⫾ 8.6mL when the head was rotated to the paretic
All volumes of water, increasing in quantity, were swal- side—in other words, significant ( p ⬍ .05) improvement in
lowed as 1 bolus in the unimpaired subject in the neutral dysphagia was shown electrophysiologically. Although there
position of the head and neck (fig 1A). The same subject could was an improvement with chin-tuck position, it was not sig-
swallow 20mL of water in a single bolus (the upper normal nificant ( p ⬎ .05).
limit) in these positions: chin tuck, chin up, head rotated right, In a similar way, head rotation to the nonparetic side resulted
and head rotated left (fig 1B). In other words, piecemeal in moderate improvement in dysphagia limit compared with the
deglutition (recurrence of swallows) did not occur. In fact, neutral position, but did not reach significant levels ( p ⬎ .05).
healthy subjects’ dysphagia limits did not change significantly Regarding individual results, head rotation to the paretic side
for any position except for a decrease in the chin-up position also produced significant positive results (fig 4).
(table 2; fig 2). Their dysphagia limit dropped to 20.6 ⫾ 5.7mL Head rotation to the paretic side caused a 67% improvement
in the chin-up condition. Apparently, the bolus was divided in dysphagia limit. Interestingly, head rotation to the nonparetic
into 2 pieces in 8 seconds, when the subject swallowed a bolus side also caused moderate improvement in dysphagia limit
less than 20mL (fig 3). In 50% of the healthy subjects, piece- compared with the neutral position (45%), but also produced a
meal deglutition occurred in the chin-up condition when they deterioration in 22% and no effect in 33% of the patients.
swallowed volumes less than 20mL ( p ⬎ .05). Taken together, head rotation to the paretic side improved

Table 4: Dysphagia Limits of Patients with Bilateral Symptoms

Table 5: Dysphagia Limits of Patients Who Could Perform
Head Position n Bolus Size (mL)
All Head Maneuvers

Neutral 42 9.9 ⫾ 8.3 Head position n Bolus Size (mL)

Chin-tuck 36 14.1 ⫾ 10.3* Neutral 16 13.9 ⫾ 9.0
Chin-up 20 8.9 ⫾ 7.3* Chin-tuck 16 16.5 ⫾ 9.7*
Rotated right 24 11.0 ⫾ 8.0 Chin-up 16 9.1 ⫾ 8.1†
Rotated left 21 9.8 ⫾ 8.3
NOTE. Values are mean ⫾ SD.
NOTE. Values are mean ⫾ SD. * p ⬍ .05 (Wilcoxon test).
*p ⬍ .01 (Wilcoxon test). †
p ⬍ .01 (Wilcoxon test).

Arch Phys Med Rehabil Vol 82, September 2001


Fig 5. Dysphagia limit (mL) changes in chin-up and chin-tuck positions (A) for patients with bilateral symptoms (n ⴝ 16), ie, those who could
complete all of range in various head positions, and (B) for all the patients (n ⴝ 42).

swallowing by 67%, without any deterioration or decrease in agic patient is shown. Even aspiration was eliminated (fig 6A,
dysphagia limit, whereas head rotation to the nonparetic side B) when the chin-tuck position was adopted. This patient’s
resulted in deterioration or no efficacy in 55% of the subjects. findings were typical of those for all patients with bilateral
Group 2: Patients with bilateral oropharyngeal symptoms symptoms.
(n ⴝ 42). The first subgroup consisted of 42 patients, some of Dysphagia limit did not increase in chin-tuck position in the
whom could not perform all of the head postures. All the head case of severe dysphagia, where the dysphagia limit was be-
positions were, however, applied systematically to the 16 pa- tween 1 and 3mL, and in patients whom the dysphagia limit
tients in the second subgroup. Table 4 shows the mean dys- was normal (20mL). In patients with dysphagia limits between
phagia limits obtained from the patients in the first subgroup. A 5 and 15mL, significant improvement was obtained in chin-
very significant increase in dysphagia limit ( p ⬍ .01) was tuck position, while deterioration occurred in chin-up position.
obtained with the chin-tuck position, and a decrease in dyspha-
gia limit ( p ⬍ .01) occurred with the chin-up position. No DISCUSSION
significant change was obtained with head rotation ( p ⬎ .05). In the present study, healthy adults did not experience piece-
Similarly, the chin-tuck posture improved the dysphagia meal deglutition or aspiration when they held their heads in 90°
limit significantly ( p ⬍ .05) while the chin-up posture de- neutral position and swallowed different volumes of water, includ-
creased ( p ⬍ .01) the dysphagia limit in the patients who could ing 20mL of water as 1 bolus. This finding is in accordance with
perform all the maneuvers (table 5). Figure 5 shows the dys- other studies.10,15 Head extension, however, performed during
phagia limits obtained in chin-up and chin-tuck position for the chin-up position caused physiologic dysphagia. Double swallow
2 subgroups. In chin-tuck position, the improvement was in the occurred in 50% of the healthy subjects attempting to swallow
range of 40% to 50%. In chin-up position, the deterioration was various volumes of water less than 20mL. The chin-up posture is
in the range of 50% to 55%. not usually performed in studies because it might endanger the
In figure 6, the improvement in dysphagia limit of a dysph- process of swallowing and cause aspiration.

Fig 6. Swallowing pattern in a patient with bilateral symptoms. (A) In neutral position, double swallow (arrow) was observed with 10mL of
water and aspiration (bold line) also occurred. (B) In chin-tuck position, the patient’s dysphagia limit improved, from 10mL (A) to 20mL (B).

Arch Phys Med Rehabil Vol 82, September 2001


Ekberg7 proved that closure of the laryngeal vestibule is verely dysphagic patients with dysphagia limits between 1 and
defective in subjects swallowing with the neck extended. Cas- 3mL.10,13 Similar observations have also been reported with
tell et al8 showed that head extension produces mechanical videofluoroscopic studies.6
widening of the laryngeal vestibule and narrowing of vallecu- Our present study was conducted in a typical electromyography
lae, in addition to the significant decrease in upper esophageal laboratory to evaluate neurogenic dysphagia objectively. Al-
sphincter relaxation. The development of piecemeal deglutition though the sensitivity is less than that of the videofluoroscopic
with 20mL of water in 50% of unimpaired controls confirms methods, this simple and noninvasive electrophysiologic method
the belief that head extension should not be assessed during for describing dysphagia limit may have a place in the evaluation
swallowing procedures. of persons with dysphagia and may reveal how the dysphagia is
The chin-tuck posture has been widely used in neurogenic affected by various head and neck positions.
patients with dysphagia, especially in individuals in whom
delays in triggering the reflex pharyngeal swallow were ob- References
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Arch Phys Med Rehabil Vol 82, September 2001