Acta Radiologica Diagnosis 27 (/986) Fasc, 6

FROM THE DEPARTMENT OF DIAGNOSTIC RADIOLOGY, MALMO ALLMANNA SJUKHUS, UNIVERSITY OF LUND,
S-21401 MALMO, SWEDEN.

POSTURE OF THE HEAD AND PHARYNGEAL SWALLOWING

O. EKBERG

Abstract elevator of the larynx and pharynx (3). It has been pro-
Closure of the laryngeal vestibule during swallowing is impor- posed that a weak swallowing function of the intrinsic
tant for protection of the airways. The present investigation musculature can be supported or compensated for by
included 53 patients with dysphagia examined cineradiographi- other muscles (2, 11).
cally with the head held in resting posture, flexion and extension.
The ability to protect the airways by the downward movement of
The aim of the present study was to investigate if pos-
the epiglottis and by obliteration of the laryngeal vestibule was ture of the head may influence the function of the pharynx
studied in different postures of the head. Of 35 patients with and larynx during swallowing with special reference to
normal laryngeal obliteration with the head in resting position 10 closure of the laryngeal vestibule and downward move-
showed a defective closure at swallowing in extension. In 18 ment of the epiglottis.
patients with defective closure of the laryngeal vestibule in rest-
ing position 9 were improved on flexion and two on extension of
the head. In one patient with defective closure of the laryngeal
vestibule in resting position swallowing in flexion showed an Material and Methods
aggravated dysfunction. In four other patients the defective clo- A total of 53 patients, 18 men and 35 women between 15
sure became more marked on extension. Four patients had less
effective downward movement of the epiglottis with the head in
and 87 years of age (mean 58) were included in this study.
extension. Of 10 patients with defective epiglottic movement with All patients had been referred to the Department of Radio-
the head in resting position two were improved on tilting the head logy due to dysphagia. They were examined in an upright
forwards. The results show that the position of the head influ- position in a.p, and lateral projections while swallowing
ences the closure of the airways during swallowing. Patients with medium sized boluses. Cine films were obtained at a
defective protection of the laryngeal vestibule should be instruct-
ed to swallow with the head tilted forwards. speed of 50 frames per second. Films in the lateral projec-
tion were obtained in ordinary resting position of the head
Key words: Pharynx, radiography.
as well as in flexed and extended postures. The patients
were instructed to tilt the head backwards and forwards,
respectively, as much as possible and to swallow the
The floor of the mouth, larynx, pharynx, muscles and
barium in that posture. The cine films were reviewed for
tendons of the neck as well as the adjacent skeletal frame-
the presence of functional abnormalities such as defective
work are all structures involved in the act of swallowing.
closure of the laryngeal vestibule, defective mobility of
Muscles within this system can be distinguished as intrin-
the epiglottis as well as other dysfunctions. Defective
sic or extrinsic. Intrinsic muscles are those emerging and
closure of the laryngeal vestibule was recognized as con-
inserting within the larynx and pharynx, i.a. the thyro-
trast medium entrance during swallowing.
epiglottic and thyroarytenoid muscles. Extrinsic muscles
emerge and insert at different levels within the system,
i.a. the stylopharyngeal muscle. The importance ofintrin- Results
sic muscles for protection of the airways during swallow-
The results are summarized in Figs 1 and 2. When
ing, i.e. closure of the laryngeal vestibule and downward
examining the act of swallowing in an ordinary resting
movement of the epiglottis has been elucidated (6, 8).
However, extrinsic muscles too are involved in the act of
pharyngeal swallowing, i.a. the stylopharyngeus as an Accepted for publication 14 January 1986.

691

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692
POSTURE OF FLEXION NEUTRAL EXTENSION
THE NECK
:xx,:
NORMAL 34 • 35 25
CLOSURE
DEFECTIVE
CLOSURE 18 16
Fig. I. Closure of the laryngeal vestibule during swallowing re-
lated to the posture of the head.
a b
Fig. 3. 54-year-old man with dysphagia. Sequence from a cinera-
diographic examination in lateral projection during a barium
swallow. a) Head in flexion, b) head in neutral position, c) head
position of the head 35 patients showed a normal and 18 a
defective closure of the laryngeal vestibule. When these
35 patients with normal swallowing in resting position of
the head swallowed following forward tilting of the head
one showed defective closure of the laryngeal vestibule
(Fig. 3) while the remaining 34 showed normal swallowing
patterns also in this posture.
However, when these 35 patients swallowed with the
head tilted backwards 10 showed defective closure of the
laryngeal vestibule (Figs 4, 5) while 25 remained normal in
their swallowing.
Of the 18 patients with defective closure of the laryn-
geal vestibule in resting position 9 had normal closure
when they had tilted the head forward (Fig. 6) while 2 had
normal closure of the vestibule at swallowing in extension
of the head (Fig. 7).
A normal downward movement of the epiglottis during
swallowing in resting position of the head was seen in 43
patients. Four had a less efficient movement during swal-
lowing in extension position (Fig. 8). Of 10 patients with a
defective movement of the epiglottis with the head in
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O. EKBERG
POSTURE OF FLEXION NEUTRAL
THE NECK EXTENSION
NORMAL 43 • 43 • 39
MOVEMENT
ABNORMAL
MOVEMENT
'~ ~.
8 - . - - - - 1 0 - - - - 10
Fig. 2. Movement of the epiglottis during swallowing related to
the posture of the head.
c
in extension. In neutral position and in extension closure of the
laryngeal vestibule is normal. With the head tilted forwards there
is defective closure of the laryngeal vestibule.
neutral POSItIon, the epiglottis moved normally during
flexion of the head in two.
Defective relaxation of the cricopharyngeal muscle was
registered in 6 patients. This was not influenced by the
posture of the head. A cervical esophageal web was seen
in 2 patients. The appearance of this phenomenon had no
relationship to the position of the head. In 2 patients with
paresis of pharyngeal constrictor musculature this was
unrelated to the posture of the head.
Discussion
It has been recommended that patients with functional
abnormalities of the pharynx should swallow with the
head tilted forwards (2, II). Such posture has been
thought to assist pharyngeal swallowing in two ways. The
alignment of the food-way should be preserved. With the
head in extension alignment is obtained instead with the
airways which may favour aspiration. Moreover, with the
head leaning forward the vallecular space is widened. In
this position a swallowed bolus will be held in the valle-
 POSTURE OF THE HEAD AND PHARYNGEAL SWALLOWING 693

a b c
Fig. 4. 58-year-old female. Cineradiography during barium swal- of the laryngeal vestibule is normal. With the head in extension
lowing. a) Head in flexion, b) head in neutral position, c) head in there is defective closure of the laryngeal vestibule.
extension. With the head in neutral position and flexion closure

a b c
Fig. 5. 50-year-old female. Cineradiography during barium swal- had entered it before the actual examination with positioning of
lowing. a) Head in flexion, b) head in resting position, c) head in the head. During swallowing with the head extended there is a
extension. During flexion and neutral position closure of the marked impairment of the closure of the laryngeal vestibule.
laryngeal vestibule is normal. The contrast medium in the trachea

cula long enough to initiate the reflex of pharyngeal swal-
lowing.This is helpful in patients with an abnormal volun-
tary initiation of pharyngeal swallowingat the level of the
faucial isthmus and/or transitory area between the soft
and hard palate (5). In these patients the larynx is open
when the bolus reaches the mesopharynx. A consequence
of this form of delayed initiation of swallowing is aspira-
tion. A third factor by which swallowing in patients with
pharyngeal dysfunction is improved by flexion of the head
is the laryngeal folding mechanism proposed by FINK &
DEMAREST (9). According to these authors the obliteration
of the larynx is improved by flexion of the head and
should better ensure protection of the airways.
The aim of the present investigation was to evaluate in
more detail the relationship of the posture of the head to
pharyngeal swallowing with special reference to the
mechanisms for protection of the airways during swallow-
ing, closure of the laryngeal vestibule and movement of
the epiglottis.
The results obtained made it clear that of the 18patients
with defective closure of the vestibule with the head in
neutral position 2 closed the vestibule at swallowing in

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694 O. EKBERG

a b c
Fig. 6. 69-year-old female with dysphagia. Cineradiography dur- bule. With extended head the defective closure became more
ing barium swallowing. a) Head in flexion, b) head in resting marked. With the head in flexion the closure of the laryngeal
position, c) head in extension. In resting position there is defec- vestibule is improved.
tive closure of the subepiglottic portion of the laryngeal vesti-

a b c
Fig. 7. 58-year-old woman. Cineradiography during barium swal- defective closure of the laryngeal vestibule. On extension of the
lowing. a) Head in flexion, b) head in neutral position, c) head in head the closure of the laryngeal vestibule is improved.
extension. With the head in flexion and neutral position there is

extension and 9 at swallowing in flexion. Moreover, it was
found that closure was achieved by intrinsic obliteration
of the laryngeal vestibule, i.e, it was not a result of the
movement of the epiglottis. The observation that 4 pa-
tients had more defective closure at extension and one at
flexion of the head strongly suggests that closure of the
larynx can be influenced by the posture of the head during
deglutition. Posture of the head should therefore be given
consideration during feeding training of patients with an
abnormal pharyngeal swallowing with entrance of bolus
material into the airways (2, II). Even if a few patients
benefitted from head extension the majority had advan-
tage of holding the head in a flexed position.
Flexion of the head enhances closure of the laryngeal
vestibule during swallowing probably by altering the vol-
ume and shape of the laryngeal vestibule. FINK & DEMAR-
EST (9) have suggested the denomination 'median thy-
rohyoid fold' for the epiglottis, hyoepiglottic ligament,
thyroepiglottic ligament, preepiglottic fat-pad and median
thyrohyoid ligament. The position and interrelationship of

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 POSTURE OF THE HEAD AND PHARYNGEAL SWALLOWING
a b
Fig. 8. Cineradiography during barium swallowing. a) In flexion
of the head. b) head in neutral position. c) head in extension.
With the head in neutral position and in flexion the downward
these structures are influenced by forward tilting of the
head. In this posture the distance between the mandible
and hyoid bone is reduced as well as the distance between
the hyoid bone and the thyroid and cricoid cartilages. As a
consequence the preepiglottic fat-pad, located between
the hyoid bone and the thyroid cartilages, changes form
and develops a more posterior bulging. This bulging effi-
ciently aids the obliteration of the laryngeal vestibule on
contraction of the thyroepiglottic and thyroarytenoid mus-
cles (3, 8).
Cineradiography revealed that a portion of the swal-
lowed barium was retained in the vallecula for a short
moment before the contrast medium reached the pharynx
proper. This indicates an abnormal initiation of pharyn-
geal swallowing which should have been elicited at the
faucial isthmus (6). By a forward flexion of the head the
laryngeal vestibule also angulates more prominently by
which the superior laryngeal inlet is more vertically posi-
tioned (I). Even if this altered posture of the superior
laryngeal inlet in relation to the pharynx is small it prob-
ably adds to the observed beneficial effect on laryngeal
protection when swallowing in this posture.
The results obtained in the investigation included an-
other interesting observation. Ten of the 35 patients who
during swallowing in the ordinary neutral position of the
head had a normal closure of the laryngeal vestibule
showed a defective closure when swallowing with exten-
sion of the head. Inability to close the laryngeal vestibule
in an excessive extension position of the head is a method
to reveal a so called 'compensated pharyngeal swallow-
ing' (4). Normally the pharynx and larynx have the ability
to adjust to different conditions during swallowing. BUCH-
HOLZ et coli. (4) have stressed that patients to a certain
degree can compensate a dysfunction of swallowing. This
compensation may include enhanced function of other
muscles within the pharynx and larynx which either act
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695
c
movement of the epiglottis (-+) is normal. With the head in
extension the epiglottis is halted in a transverse position and does
not complete its movement.
more strongly or replace functions (4). It has been as-
sumed that this occurs in patients with mild or moderate
dysfunction with a transient dysphagia. After a period of
time the patients become adjusted to their new pharyngeal
function and dysphagia is relieved. However, it is prob-
able that these patients are susceptible to new forms of
dysfunction. When lack of muscular strength or incoor-
dination surmounts a certain level the patient is no longer
able to compensate. It is probable that the II patients in
our series who showed defective closure of the laryngeal
vestibule during extreme posture of the head represent
subjects with 'compensated pharyngeal swallowing'. In
the same way II of 18 patients who were able to close the
laryngeal vestibule during extreme flexion of the head can
be regarded as 'decompensated' in neutral position but as
'compensated' during flexion or extension. Therefore, ex-
amination in flexion and extension of the head can be used
as a modality to disclose compensated dysfunction of the
pharynx. In an earlier study we did disclose pharyngeal
dysfunction in 80 per cent of dysphagic patients (7). It is
probable that some of the patients assessed to be normal
had such compensated swallowing which would have
been disclosed if the patients had been examined with the
head in extension or flexion.
In 4 patients the epiglottis moved improperly during
swallowing following extension of the head while in an-
other 2 the epiglottis moved more effectively during flex-
ion of the head compared with a neutral position. This
observation supports the assumption that extrinsic mus-
cles are of importance also for the final phase of move-
ment of the epiglottis. It has been assumed earlier that the
first movement of the epiglottis from an upright resting
position to the transverse position is exclusively due to
the altered position of the hyoid bone in relation to the
basicranium and thyroid cartilages (8). The altered epig-
lottic movement (from the transverse to the final inverted
696
position) indicates that also this second phase of epiglottic
movement is due to extrinsic muscle contraction. It might
well be that the position of muscular insertion and muscu-
lar fulcrums (with the epiglottis in the transverse posi-
tion), influences the final downward movement of the
epiglottis. However, it is obvious that the posture of the
neck has more influence on the closure of the laryngeal
vestibule in terms of an obliteration of the lumen, and that
the movement of the epiglottis only plays an accessory
role in closing the vestibule.
Only a few patients had cricopharyngeal muscle dys-
function and this was unrelated to the posture of the head.
It has been assumed that elevation of the pharynx is of
importance for the opening of the pharyngo-esophageal
segment (10). Supposedly the extension of the head
should add to such elevation. For this reason the role of
the cricopharyngeal muscle bulge should be less promi-
nent, a conclusion which gets no support from the present
investigation.
This investigation has shown that the posture of the
neck is of importance for pharyngeal swallowing in terms
of closure of the laryngeal vestibule and the tilting move-
ment of the epiglottis. The folding of the median thyro-
hyoid fold is enhanced and thereby the obliteration of the
laryngeal vestibule is assisted. Patients with defective
closure of the laryngeal vestibule during swallowing
should be instructed to swallow with their neck in a flexed
position. Laryngeal and pharyngeal function can be stud-
ied radiologically to great advantage with the patient hold-
ing his head in resting position and in extreme postures of
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O. EKBERG
flexion and extension of the head. By monitoring pharyn-
geal swallowing and function with cineradiography or vid-
eo recording it is possible to obtain a better understanding
of the pathogenetic mechanisms responsible for defective
closure of the laryngeal vestibule and how this should be
compensated for.
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