|Year : 2019 | Volume
| Issue : 1 | Page : 68-71
Does tongue-hold maneuver affect respiratory–Swallowing coordination? Evidence from healthy adults
Radish Kumar Balasubramaniam, Sonia Babu, Malavika Anakkathil Anil, Aiswarya Liz Varghese, Zeba Raisa Hussain, Dasmine Fraclita Dsouza
Department of Audiology and Speech Language Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
|Date of Web Publication||4-Feb-2019|
Malavika Anakkathil Anil
Department of Audiology and Speech Language Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Swallowing experts often implement techniques that alter the breath and swallowing mechanism. However, there is limited understanding regarding the effect of these techniques on the coordination of swallowing and respiration. Hence, the present study examined the respiratory–swallowing coordination in normal adults using tongue-hold maneuver. Materials and Methods: The study follows a cross-sectional study design, wherein 25 healthy individuals (8 males and 17 females) within the age range of 18–25 years performed 10 ml water swallow with and without tongue-hold maneuver. Nasal respiratory flow was recorded, and the duration of the swallow apnea and the phase of respiratory pattern were analyzed. Results: The results of paired t-test revealed a significant difference for the duration of swallow apnea with tongue-hold maneuver (mean = 0.782, standard deviation [SD] =0.329) when compared to swallow without tongue-hold maneuver (mean = 0.60972, SD = 0.188) at P < 0.05. Moreover, the phase of respiration bracketing the swallowing was predominantly expiration in both the swallows. Conclusion: The outcome of the study suggests that tongue-hold maneuver improves the duration of swallow apnea.
Keywords: Phase of respiration, swallow apnea duration, tongue-hold maneuver
|How to cite this article:|
Balasubramaniam RK, Babu S, Anil MA, Varghese AL, Hussain ZR, Dsouza DF. Does tongue-hold maneuver affect respiratory–Swallowing coordination? Evidence from healthy adults. J Nat Sc Biol Med 2019;10:68-71
|How to cite this URL:|
Balasubramaniam RK, Babu S, Anil MA, Varghese AL, Hussain ZR, Dsouza DF. Does tongue-hold maneuver affect respiratory–Swallowing coordination? Evidence from healthy adults. J Nat Sc Biol Med [serial online] 2019 [cited 2020 Jul 16];10:68-71. Available from: http://www.jnsbm.org/text.asp?2019/10/1/68/251509
| Introduction|| |
Respiration and swallowing are the two complex mechanisms that are physiologically linked to each other for the effortless exchange of air during oronasal breathing and to prevent aspiration during swallowing. This close coordination of respiration and swallowing is determined through a period of swallow apnea. Swallow apnea is a brief period of cessation of respiration that occurs immediately and during the pharyngeal phase of swallowing. Swallow apnea occurs at any of the following stages in breathing such as during expiration, during inspiration, at the transition between inspiration and expiration, or between expiration and inspiration. At present, there is overwhelming evidence that points to the coupling of swallowing with the exhalation phase of respiration using nasal airflow monitoring studies during swallowing.
This process of apnea acts as a protective mechanism for the lower airway tract during deglutition. In individuals with dysphagia owing to discoordinated breathing and swallowing functions, the lower airway protection is compromised and may result in the occurrence of aspiration pneumonia. Hence, professionals dealing with the management of swallowing disorders focus on modifying abnormal swallowing physiology through techniques that alter breathing and swallowing. A few of the widely used maneuvers in dysphagia intervention program include mendelsohn maneuver, supraglottic maneuver, and tongue-hold maneuver. These maneuvers improve the swallowing physiology by strengthening the neuromuscular substrates of swallowing., One of the maneuvers which has been commonly used as a pharyngeal strengthening exercise and possibly affects the respiratory swallowing coordination is the tongue-hold swallow.
Since its introduction, the tongue-hold maneuver (Masako maneuver or tongue-hold swallow) has been used as a routine pharyngeal muscle strengthening exercise in many clinical settings. This maneuver involves placing the tip of the tongue anteriorly between the frontal incisors and then swallowing. The rationale of this maneuver is that there is increased posterior pharyngeal wall (PPW) contraction during the tongue-hold swallow. Researchers have reported that there was reduced pharyngeal pressure during tongue-hold swallowing as compared to noneffortful saliva swallow through pharyngeal manometry., This finding was in contrast to what one might expect of increased anterior movement of the PPW, leading to increased pressure. The reduced pharyngeal pressure can be due to reduced base of tongue (BOT) retraction during tongue-hold swallows. This suggests that in some individuals, increased anterior movement of the PPW during tongue-hold swallow may have potential to compensate, at least in part, for decreased BOT retraction. In a preliminary study of three patients with dysphagia due to head and neck cancer, BOT-PPW contact pressures were found to be significantly higher during tongue-hold swallows compared with normal saliva swallows.
In the field of swallowing rehabilitation, tongue-hold maneuver has gained significant clinical importance as a pharyngeal muscle strengthening exercise., Moreover, there is likely a stoppage of nasal airflow before the swallow itself. This respiratory swallow coordination can be measured through the occurrence of swallow apnea and the phase at which this apnea occurs. However, there is limited evidence that explains the effect of tongue-hold maneuver on the respiration swallow coordination. Hence, the present study aimed at investigating the respiratory–swallowing coordination in normal adults using tongue-hold maneuver and the phase of the swallow bracketed by swallow apnea.
| Materials and Methods|| |
The present study was a cross-sectional study using snowball sampling procedure.
Twenty-five healthy participants (8 males and 17 females) in the age range of 18–25 years (mean age = 21 years) were participated in the study based on sample size calculations for single-group cross-sectional study. All the participants were free from speech, language, and neurological problems affecting their swallowing abilities. None of the participants had history of any surgery done to the oropharyngeal apparatus. All the procedures performed in the studies involving human participants were in accordance with the ethical standards of the institution.
All swallowing examinations were recorded using nasal airflow module available in the Digital Swallowing WorkStation (KayPENTAX Corporation, Lincoln Park, NJ, USA) connected to the swallowing signal laboratory. The Kay Digital Swallowing Workstation with signal laboratory is a computer-integrated system of swallowing measurement facilities including cervical auscultation, surface electromyography, and nasal airflow monitoring.
The participants were seated comfortably on a straight back chair, and a nasal catheter was fitted comfortably at the entrance of the nares using a 1.8-m nasal cannula coupled to the swallow signal laboratory hardware and software to create a digital display of the respiratory phase and apnea duration.
Examinations were carried out as two types of swallow; swallow without tongue-hold maneuver and swallow with tongue-hold maneuver. The participants were given 10 ml of water in a cup to swallow without using tongue-hold maneuver. For the tongue-hold maneuver, participants were instructed to place their tongue “maximally, but comfortably” between the incisors and to swallow with the tongue in this position. Throughout data collection, the participants were encouraged to protrude their tongue as far as possible, while still being able to swallow comfortably, although specific feedback was not provided. There was no formal assessment of the absolute degree of tongue protrusion. Participants were allowed to practice the maneuver before data collection, and all participants were able to perform the maneuver after only a few trials. In general, tongue-hold maneuver is carried out with dry swallow only; however, in the present study, tongue-hold swallow was attempted with thin liquids as the participants were normal healthy adults. [Figure 1] shows the tongue-hold maneuver and the positioning of the nasal cannula.
Calibration of the nasal cannulas for each participant was conducted to enable accurate measures. The airflow direction was indicated through a green-positive trace representing expiration and a red-negative trace representing inspiration. Each participant was instructed to swallow 10 ml of water in one complete action while performing tongue-hold maneuver. [Figure 2] shows the graphical representation of respiratory–swallow relationship.
Respiratory information (inhalation/exhalation) displayed as a line tracing was recorded for all swallowing attempts. Respiration points were temporally related to the electromyographic activity. Respiration points included were (1) onset of inspiration, defined as a downward line tracing; (2) swallowing apnea, defined as a horizontal line on the respiratory tracing indicating the absence of airflow; and (3) expiration onset, defined as the upward line tracing associated with an open glottic position. Vertical cursors were placed on the onset and offset of the swallow apnea for each task, and the duration of the apnea (ms) was measured. The apnea duration was further analyzed in terms of respiratory–swallow phase relationship. The possible phase relationships include expiration bracketing the swallow, inspiration bracketing the swallow, swallow preceded by expiration and succeeded by inspiration, and swallow preceded by inspiration and succeeded by expiration.
The data were tabulated and subjected to statistical analysis using SPSS (Version 20, SPSS Statistics, SPSS Inc, Chicago). Descriptive statistics were used to obtain mean and standard deviation (SD) of duration of apnea during swallow. Percentages were calculated for the respiratory–swallow phase relationships. Paired t-test was performed to assess the significance of the tongue-hold maneuver on the respiration–swallow coordination. Intraclass correlation coefficient was obtained for the reliability measures.
| Results|| |
The present study aimed at measuring the swallow apnea duration and respiratory–swallow phase relations in healthy adults with and without tongue-hold maneuver. Descriptive statistics were employed to obtain mean and SD of swallow apnea duration with and without tongue-hold swallow and the respiratory–swallow phase relationships. The mean value of swallow with and without tongue-hold maneuvers was 0.782 (SD = 0.329) and 0.60972 (SD = 0.188), respectively. The results of paired t-test revealed a significant difference between the swallows with and without tongue-hold maneuver on the swallow apnea duration (t(1,24) = 3.023; P < 0.05), indicating that tongue-hold maneuver increases the swallow apnea duration.
The intra- and inter-judge reliability for swallow apnea duration without tongue-hold swallow was 95% and 98%, respectively, and with tongue-hold exercise was 93% and 95%, respectively. Expiration bracketing the swallow was predominant in both with (80%) and without tongue-hold swallow (84%). The rest of the participants (20% and 16%) exhibited swallow bracketed at the mid cusp between expiration and inspiration. This suggests that the respiratory–swallow phase relationship is not affected with tongue-hold maneuver. The presence of swallow with and without the tongue-hold maneuver was confirmed with the presence of visual examination of hyolaryngeal elevation.
| Discussion|| |
Effectiveness of tongue-hold maneuver in improving the PPW contraction was well reported in the literature. However, there is limited evidence that explains the effect of tongue-hold maneuver on the respiration–swallow coordination. Hence, the present study aimed at investigating the respiratory–swallowing coordination in normal adults with tongue-hold maneuver using nasal airflow monitoring. The results revealed that the swallow apnea duration increased with the tongue-hold maneuver. According to Fujiu and Logemann., there is a contraction of the PPW during tongue-hold maneuver. This contraction is important because, when PPW contract, it comes into contact with the BOT which generates the pressure necessary for swallowing. Moreover, PPW contraction shortens the pharyngeal opening to provide better protection and efficiency. In general, swallowing-related respiratory pause is elicited during oral phase just before the pharyngeal phase as a mechanism that triggers a laryngeal excursion reflex. During tongue-hold maneuver, there can be more difficult to trigger the pharyngeal swallow with the tongue anchored further anteriorly, and there is likely an apneic period/stoppage of nasal airflow before the swallow itself. Clinically, this is frequently seen when patients attempt to swallow using the tongue hold. However, this finding was not complemented through videofluoroscopy and/or fiberoptic endoscopic evaluation of swallowing. There is literature which also reports that the prolonged apnea duration is not necessarily associated with closure of the laryngeal vestibule, false or true vocal folds. Costa and Lemme reported similar swallow apnea pattern in people with and without larynx, indicating that this preventive apnea is independent of the vocal folds closure. Therefore, increasing the duration of the apneic period will not necessarily translate to airway protection. However, in the present study, none of the participants experienced any signs of aspiration during the thin liquid swallow using tongue-hold maneuver.
Other evidence suggests that the protruded positioning of the tongue during tongue-hold swallows would reasonably limit BOT retraction and would thus decrease BOT-PPW contact pressure during swallowing. The observed decrease in pharyngeal pressure generation can potentially be overcome with repeated tongue-hold exercise. Therefore, a period of tongue-hold training may strengthen the pharyngeal constrictors, even if the initial decrease in pharyngeal pressure during tongue-hold swallowing is not completely compensated for by increased PPW contraction.
The results also revealed that expiration bracketing the swallowing was the predominant pattern during both normal as well as the tongue-hold swallow, suggesting that respiratory–swallowing phase relationship is not affected by tongue-hold swallow. The expiratory phase of respiration during the tongue-hold swallow implies paramedian positioning of the vocal folds. This posture during the early and late pharyngeal swallow aids in facilitating airway closure and ensures that the swallowing is safe during both normal and tongue-hold swallow. It was also interesting to note that 4% of the participants shifted their respiratory–swallow phase relationship from midcusp between expiration and inspiration to expiration bracketing the swallow during tongue-hold swallow condition. This finding coupled with the increased apnea duration suggests the airway closure in these groups of healthy participants
Although it is a preliminary study, the results suggest that the tongue-hold maneuver is an effective technique in airway protection in healthy adults. However, these results need to be supported with gold standard techniques such as videofluoroscopy using more number of participants across different age groups and gender. It would also be interesting to investigate the long-term effect of tongue-hold maneuver in healthy individuals and individuals with swallowing impairments. However, use of this maneuver in individuals with swallowing impairments is cautioned due to increased risk of aspiration as a result of the retraction of the BOT. Tongue hold is not a compensatory technique intended to change bolus flow. Because the tongue hold is not to be used with a bolus, any change observed in swallow apnea duration cannot be generalized as indication of the tongue hold as an intervention for persons with aspiration due to impaired laryngeal closure.
| Conclusion|| |
The present study was an initial attempt at measuring the effect of tongue-hold maneuver on respiratory–swallow coordination in healthy adults. The results indicated a significant increase in swallow apnea duration when swallowed with tongue-hold maneuver. The results also revealed that expiration bracketing the swallowing was the predominant pattern during both normal as well as the tongue-hold swallow. Further studies should be attempted to investigate the same in individuals with compromised airway protection strategies using gold standard measures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loch WE, Loch WE, Reiriz HM, Loch MH. Swallow apnea – Rhinomanometric manifestation and classification. Rhinology 1982;20:179-91.
Martin-Harris B, Brodsky MB, Price CC, Michel Y, Walters B. Temporal coordination of pharyngeal and laryngeal dynamics with breathing during swallowing: Single liquid swallows. J Appl Physiol (1985) 2003;94:1735-43.
Lazarus C, Logemann JA, Song CW, Rademaker AW, Kahrilas PJ. Effects of voluntary maneuvers on tongue base function for swallowing. Folia Phoniatr Logop 2002;54:171-6.
Bülow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia 2001;16:190-5.
Fujiu M, Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 1996;5:23-30.
Kahrilas PJ, Logemann JA, Lin S, Ergun GA. Pharyngeal clearance during swallowing: A combined manometric and videofluoroscopic study. Gastroenterology 1992;103:128-36.
Ding R, Larson CR, Logemann JA, Rademaker AW. Surface electromyographic and electroglottographic studies in normal subjects under two swallow conditions: Normal and during the Mendelsohn manuever. Dysphagia 2002;17:1-2.
Doeltgen SH, Witte U, Gumbley F, Huckabee ML. Evaluation of manometric measures during tongue-hold swallows. Am J Speech Lang Pathol 2009;18:65-73.
Umeki H, Takasaki K, Enatsu K, Tanaka F, Kumagami H, Takahashi H, et al.
Effects of a tongue-holding maneuver during swallowing evaluated by high-resolution manometry. Otolaryngol Head Neck Surg 2009;141:119-22.
Costa MM. Videofluoroscopy: The gold standard exam for studying swallowing and its dysfunction. Arq Gastroenterol 2010;47:327-8.
Costa MM, Lemme EM. Coordination of respiration and swallowing: Functional pattern and relevance of vocal folds closure. Arq Gastroenterol 2010;47:42-8.
Schmidt J, Holas M, Halvorson K, Reding M. Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia 1994;9:7-11.
[Figure 1], [Figure 2]