Excerpts from "Dysphagia" by Nam-Jong Paik, MD, PhD update for E-medicine.com August 19, 2004 Lip exercises can facilitate the patient's ability to prevent food or liquid from leaking out of the oral cavity.

Tongue exercises are used to facilitate manipulation of the bolus and its propulsion through the oral cavity or to facilitate retraction of the tongue base. Passive ROM and active-assistive ROM exercise concepts also can be applied in this technique.

Jaw exercises help to facilitate the rotatory movements of mastication.

Respiratory exercises (eg, resistive straw sucking, coughing, incentive spirometer) are recommended to improve respiratory strength.

Vocal cord adduction exercises can promote strengthening of weak vocal cords.

Tongue-holding maneuvers facilitate compensatory anterior movement of the posterior pharyngeal wall.

Head lift exercises increase anterior movement of the hyolaryngeal complex and opening of the upper esophageal sphincter. (Patients lie flat and are instructed to keep their shoulders on the floor as they raise their heads high enough to see their toes and maintain this position for 1 minute. They repeat this activity 3 times, followed by 30 consecutive repetitions of the same action. Patients should perform this exercise 3 times a day for several weeks.)

Deep pharyngeal neuromuscular stimulation (DPNS) is a therapeutic program that uses the afferent-efferent cycle (ie, sensory stimulation-motor response) to improve pharyngeal swallow. DPNS focuses on stimulating 3 reflex sites with frozen lemon-glycerin swabs. The first site is the bitter taste buds and tongue base for improving tongue base retraction. Second is the soft palate for palatal elevation, and the third is the superior and medial pharyngeal constrictor for improving pharyngeal peristalsis and cricopharyngeal opening.

Thermal or tactile stimulation can be used to increase the speed of swallow. Rub the bilateral anterior facial arch with laryngeal mirror placed in ice for 10 seconds.

The bite reflex can be inhibited by applying sustained pressure to the tongue with a rubber seizure stick in chin tuck position.

Facilitation of the hypoactive gag reflex by applying a tongue depressor or quick tap to the arch of the soft palate. Meanwhile, a hyperactive gag can be desensitized by using firm pressure with a tongue depressor advancing farther back in the mouth.

Chin tuck position decreases the space between the base of the tongue and the posterior pharyngeal wall, creating increased pharyngeal pressure to move the bolus through the pharyngeal region. Chin tuck often is helpful for patients with delayed swallow reflex since it narrows the airway entrance and increases the vallecular space, thereby increasing probability that the bolus will remain in the vallecular prior to triggering of the pharyngeal swallow, decreasing risk of aspiration.

Rotation of the head to the affected side closes the pyriform sinus on that side and directs food down the opposite or stronger side. This posture also adds external pressure on the damaged vocal cord and moves it toward the midline, improving airway closure.

Tilting the head to the stronger side tends to direct bolus down that side, both in the oral cavity and in the pharynx. This technique also is effective for patients who have unilateral tongue dysfunction or unilateral pharyngeal disorders.

Lying on one's side or back during swallowing sometimes prevents aspiration after the swallow. This posture often is helpful for patients who aspirate after swallow because of residue in the pharynx. They aspirate because gravity drops the residual food into the airway when they inhale after the swallow.

The supraglottic swallow is a technique designed to close the airway voluntarily before and during the swallow, protecting the trachea from aspiration. This technique can be useful for patients who have reduced laryngeal closure. Most patients can master this technique. Advise the patient to practice the following 4 steps:

  1. Take a deep breath and hold your breath.
  2. Keep holding your breath and lightly cover your tracheostomy tube, if applicable.
  3. Keep holding your breath while you swallow.
  4. Cough immediately after the swallow.

The extended supraglottic [aka supersupraglottic] swallow add a Valsavla effect and is helpful for patients with severe reductions in tongue mobility or severely reduced tongue bulk due to surgical procedures for oral cancer because they essentially have little or no oral transit. Advise these patients to learn the following techniques:

  1. Hold your breath firmly.
  2. Put the entire 5-10 mL of liquid in your mouth.
  3. Continue to hold your breath and toss your head back, thus dumping the liquid into the pharynx as a whole.
  4. Swallow 2-3 times or as many times as needed to clear the majority of the liquid while continuing to hold your breath.
  5. Cough to clear any residue from the pharynx.

The effortful swallow technique is designed to improve tongue-base movement posteriorly and thus improve clearance of the bolus from the valleculae. Patients are instructed to swallow hard.

The Mendelson maneuver is used to improve laryngeal elevation and cricopharyngeal opening during the swallow.

Patients are instructed to swallow and to hold the swallow for 2-3 seconds, then to complete the swallow and relax when the pharynx is in the uppermost stage.

Repeated swallow and washing food through the pharynx may be helpful to patients who have excessive residue in the pharynx after the swallow.

Biofeedback can be useful for oral motor and facial exercises. The patient also receives feedback on the actual swallow.