The Mendelsohn Maneuver, or voluntary prolongation of hyolaryngeal elevation at the peak of the swallow, has been used to treat patients with pharyngeal dysphagia for many years1–3--sometimes as a compensatory strategy to help the bolus pass more efficiently through the pharynx4–6 and sometimes as part of a rehabilitative exercise program7–10. Early reports on the Mendelsohn maneuver suggested use of the maneuver increases laryngeal elevation and maximal hyoid superior displacement and provides an immediate effect in prolonging the duration of opening of the upper esophageal sphincter (UES) but not the diameter1–6. Since the initial reports, more data have emerged supporting the physiologic effects of the Mendelsohn maneuver on the act of swallowing, but most papers consider only the immediate effects of the maneuver on small numbers of normal participants or patients11–14.
Rehabilitation, like compensation, addresses deficits in swallowing physiology15, but rather than providing an immediate change in the physiology of swallowing, an exercise designed to rehabilitate should provide a lasting effect on swallowing. A few studies provide outcome data on patients with dysphagia who have used the Mendelsohn maneuver as part of a collection of exercises with the goal of rehabilitation, but none have used the maneuver in isolation and reported on change in swallowing physiology as a result7–9. While use of the maneuver shows promise when included as part of a broader regimen of treatment, the specific physiologic effects of the Mendelsohn maneuver on patients with dysphagia cannot be determined without investigation of the maneuver in isolation. The studies reporting positive outcomes incorporating the maneuver also employed techniques, such as head turns, chin tucks, supraglottic swallows, effortful swallows, and the Shaker exercise, amongst others. Moreover, while outcome data from these studies reported improved oral intake in most patients without development of pneumonia or other negative health consequences, specific changes in swallow physiology were not reported, leaving open questions regarding the functional and physiologic changes which may have occurred, as well as the actual cause of those changes (i.e., time, swallowing food and liquid, doing exercises—and which exercises). These studies have clearly demonstrated that dysphagia rehabilitation is possible in certain patients post-stroke; but without specifically examining the use of individual exercises in isolation, the contribution of any particular exercise cannot be clearly defined. In other words, while the Mendelsohn maneuver appears to have an immediate effect on hyolaryngeal movement and duration of UES opening, no data exist to define what, if any, lasting effect use of the Mendelsohn maneuver over time may have on the physiology of swallowing when the Mendelsohn maneuver is no longer employed.
Based on the reports regarding the immediate effects of the Mendelsohn maneuver on swallowing, we would anticipate that if long term changes result from use of the Mendelsohn as an exercise, they would include duration of hyolaryngeal elevation, anteriorly an/or superiorly, and, consequently, duration of opening of the upper esophageal sphincter.1–6 When swallowing, the hyoid bone and thyroid cartilage begin to rise, then the hyoid bone begins to move superiorly and anteriorly in a quick burst of movement. The path of this movement can vary but is often triangular, moving superiorly, then anteriorly and then back to rest or vice-versa (anteriorly, then superiorly, then back to rest). These durations can be measured as “duration of hyoid maximum anterior excursion” (DOHMAE) and “duration of hyoid maximum elevation” (DOHME)16. These do not measure the duration of hyoid movement from start to finish but rather the duration that the hyoid remains at it’s maximum anterior and superior points. Duration of hyoid movement from start to finish is measured as “pharyngeal response duration” (PRD). Movement of the hyoid, especially the anterior movement, should create a traction pull on the cricoid cartilage which allows for prolonged opening of the UES2, which can be measured as “duration of UES opening” (DOUESO)16.
The purpose of this investigation was to determine if any lasting changes would occur in swallowing physiology as a result of intensive exercise using the Mendelsohn maneuver. Our hypothesis was that measures of the duration of hyoid movement and the duration of UES opening would significantly improve. We also hypothesized that measures of bolus flow—penetration/aspiration and pharyngeal residue—would improve as a result of these changes. In addition, we wanted to obtain some preliminary information regarding dose-response, which could be examined by comparing results after 10 sessions and 20 sessions of treatment. Other measures of oral and pharyngeal swallowing duration were analyzed, as well as outcomes on the Dysphagia Outcome and Severity Scale17.