1255
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,
Yagiz On A, Tarlaci S, Aydoǧdu I. The effect of head and
neck positions on oropharyngeal swallowing: a clinical and
electrophysiologic study. Arch Phys Med Rehabil 2001;82:
1255-60.
Objectives: To determine the clinical usefulness of an elec-
trophysiologic method for evaluating dysphagia and to identify
the effects of various head and neck positions on oropharyngeal
swallowing.
Design: Experimental, with control group.
Setting: An electromyography laboratory.
Participants: Patients with neurogenic dysphagia (n ⫽ 51)
and healthy controls (n ⫽ 24). Patients were divided into 2
groups: those patients with unilateral lower cranial lesions (n ⫽
9) and those without laterality in the function of the oropha-
ryngeal muscles (n ⫽ 42).
Interventions: Subjects were instructed to swallow doses of
water, gradually increasing in quantity from 1 to 25mL under
5 conditions: neutral, chin up, chin tucked, head rotated right,
and head rotated left.
Main Outcome Measures: Change in dysphagia limit
through specified head and neck postures. Oropharyngeal swal-
lowing was evaluated by laryngeal movements that were de-
tected by a piezoelectric sensor and electromyography of the
submental muscle complex. Laryngeal sensor signals occurring
within 8 seconds of a swallow were accepted as a sign of the
dysphagia limit.
Results: In the control group, dysphagia limit did not change
significantly with changes in head and neck postures, except
for the chin-up posture ( p ⬍ .05) in which piecemeal degluti-
tion occurred when subjects swallowed volumes less than
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-
provement in dysphagia limit occurred in 50% of patients in
chin-tuck position, but in the chin-up position, 55% of the
patients experienced a significant ( p ⬍ .01) decrease in dys-
phagia limit.
Conclusion: The electrophysiologic method of measuring
dysphagia limit confirms neurogenic dysphagia and its severity
in the neutral head position. Changes in head and neck posi-
tions do not significantly alter dysphagia limit in unimpaired
subjects except for the chin-up position. Although the results
From the Departments of Neurology (Ertekin, Kiylioglu, Tarlaci, Aydoǧdu), Clin-
ical Neurophysiology (Ertekin, Aydoǧdu), and Physical Medicine and Rehabilitation
(Keskin, Kirazli, On), Ege University, Medical School Hospital, Izmir, Turkey.
Accepted in revised form November 16, 2000.
Supported by the Turkish Scientific and Technological Research Council (grant no.
SBAG-1739).
The author(s) has/have chosen not to select a disclosure statement.
Reprint requests to Cumhur Ertekin, MD, Dept of Neurology, Ege University, Medical
Schl Hospital, Bornova, 35100, Izmir, Turkey, e-mail: erteker@unimedya.net.tr.
0003-9993/01/8209-6252$35.00/0
doi:10.1053/apmr.2001.25156
obtained were not compared with other techniques (eg, video-
fluoroscopy), this simple electrophysiologic method for de-
scribing dysphagia limit may have a place in the evaluation of
dysphagia and its variability in various head and neck posi-
tions.
Key Words: Deglutition; Dysphagia; Manometry; Rehabil-
itation; Swallowing.
© 2001 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HE EFFECTS OF VARIOUS head and neck positions on
T oropharyngeal swallowing have been shown in human
subjects with videofluoroscopic and manometric methods.
1-7 8,9
Researchers have made videofluoroscopic studies of the direc-
tion and speed of flow of swallowed barium material in differ-
ent head and neck positions and have also observed aspiration
occurring and being eliminated.3-7
Although manometric methods are much more rare, re-
searchers8,9 have used them to measure the changes in pressure
of the pharynx cavity and upper esophageal sphincter. We are
aware of no studies that describe the effects that different head
and neck positions have on swallowing, as determined by
electrophysiologic investigations. Piecemeal deglutition and
dysphagia limit, which express the presence of dysphagia or
the difficulty in swallowing, have been defined and used pre-
viously10 in various neurologic disorders. In the present study,
we attempted to quantify by electrophysiologic studies the
effects of head position on swallow in healthy subjects and
dysphagic patients.
METHODS
Participants
Twenty-four healthy volunteers (10 men, 14 women; age
range, 20 – 65yr; mean, 40.4yr) without complaint of dysphagia
or other oropharyngeal problems were included in the present
study. Three authors (AK, NK, AYO) also served as volun-
teers.
All 51 patients (37 men, 14 women; age range, 14 –78yr;
mean, 56.3yr) were inpatients being treated at the neurologic
department of the university hospital. Exclusion criteria in-
cluded diabetes mellitus, alcoholism, dementia, or any other
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
of 42 dysphagic patients who had no clinical evidence of
laterality in pharyngolaryngeal function; these patients were
divided into 2 subgroups: (1) all the patients with bilateral
symptoms (n ⫽ 42), regardless of their ability to perform
various head and neck positions, and (2) the 16 patients able to
perform all head and neck positions systematically. The inves-
tigators and data analysis were not blinded. Informed consent
was obtained from all patients and the study was approved by
the local ethics committee.
Arch Phys Med Rehabil Vol 82, September 2001
1256 EFFECT OF HEAD/NECK POSITIONS ON SWALLOWING, Ertekin

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

 EFFECT OF HEAD/NECK POSITIONS ON SWALLOWING, Ertekin 1257

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

1258 EFFECT OF HEAD/NECK POSITIONS ON SWALLOWING, Ertekin

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

 EFFECT OF HEAD/NECK POSITIONS ON SWALLOWING, Ertekin 1259

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
dysphagia limit, whereas head rotation to the nonparetic side
resulted in deterioration or no efficacy in 55% of the subjects.
Group 2: Patients with bilateral oropharyngeal symptoms
(n ⴝ 42). The first subgroup consisted of 42 patients, some of
whom could not perform all of the head postures. All the head
positions were, however, applied systematically to the 16 pa-
tients in the second subgroup. Table 4 shows the mean dys-
phagia limits obtained from the patients in the first subgroup. A
very significant increase in dysphagia limit ( p ⬍ .01) was
obtained with the chin-tuck position, and a decrease in dyspha-
gia limit ( p ⬍ .01) occurred with the chin-up position. No
significant change was obtained with head rotation ( p ⬎ .05).
Similarly, the chin-tuck posture improved the dysphagia
limit significantly ( p ⬍ .05) while the chin-up posture de-
creased ( p ⬍ .01) the dysphagia limit in the patients who could
perform all the maneuvers (table 5). Figure 5 shows the dys-
phagia limits obtained in chin-up and chin-tuck position for the
2 subgroups. In chin-tuck position, the improvement was in the
range of 40% to 50%. In chin-up position, the deterioration was
in the range of 50% to 55%.
In figure 6, the improvement in dysphagia limit of a dysph-
agic patient is shown. Even aspiration was eliminated (fig 6A,
B) when the chin-tuck position was adopted. This patient’s
findings were typical of those for all patients with bilateral
symptoms.
Dysphagia limit did not increase in chin-tuck position in the
case of severe dysphagia, where the dysphagia limit was be-
tween 1 and 3mL, and in patients whom the dysphagia limit
was normal (20mL). In patients with dysphagia limits between
5 and 15mL, significant improvement was obtained in chin-
tuck position, while deterioration occurred in chin-up position.
DISCUSSION
In the present study, healthy adults did not experience piece-
meal deglutition or aspiration when they held their heads in 90°
neutral position and swallowed different volumes of water, includ-
ing 20mL of water as 1 bolus. This finding is in accordance with
other studies.10,15 Head extension, however, performed during
chin-up position caused physiologic dysphagia. Double swallow
occurred in 50% of the healthy subjects attempting to swallow
various volumes of water less than 20mL. The chin-up posture is
not usually performed in studies because it might endanger the
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

1260 EFFECT OF HEAD/NECK POSITIONS ON SWALLOWING, Ertekin
Ekberg7 proved that closure of the laryngeal vestibule is
defective in subjects swallowing with the neck extended. Cas-
tell et al8 showed that head extension produces mechanical
widening of the laryngeal vestibule and narrowing of vallecu-
lae, in addition to the significant decrease in upper esophageal
sphincter relaxation. The development of piecemeal deglutition
with 20mL of water in 50% of unimpaired controls confirms
the belief that head extension should not be assessed during
swallowing procedures.
The chin-tuck posture has been widely used in neurogenic
patients with dysphagia, especially in individuals in whom
delays in triggering the reflex pharyngeal swallow were ob-
served.1,16 The chin-tuck position widens the vallecular space
to prevent the bolus from entering the airway, narrows the
airway entrance, pushes the tongue base backward toward the
pharyngeal wall, and puts the epiglottis in a more protective
position.17
It has also been suggested that there is no change manomet-
rically8 and no decrease in pharyngeal contraction pressure18 in
chin-tuck position. Recent videofluoroscopic and manometric
data may explain the increase in dysphagia limit that occurs
with chin-tuck posture and which supports the facilitated swal-
lowing that occurred in the present patient group under the
chin-tuck condition.4-8,16,18 But in 3 of the healthy controls, the
dysphagia limit decreased. This finding might also be related to
the decrease in pharyngeal contraction pressure as shown by
manometric studies by Bulow et al18 and may explain individ-
ual differences observed in the chin-tuck posture.
In videofluoroscopic studies,6 elimination of aspiration was
seen in 77% of patients in different head positions such as chin
tuck and head rotation. In the present study, we found facili-
tation of swallowing by means of head and neck positions in
almost 55% of the patients (see figs 5, 6; tables 4, 5). In patients
with unilateral lower cranial dysfunction and pharyngeal pa-
ralysis, 67% improvement occurred when the head was rotated
to the paretic side (see fig 4; table 3). These electromyographic
findings are similar to the results obtained with videofluoro-
scopic studies. In videofluoroscopic studies, 65% improvement
was found in patients with Wallenberg syndrome when the
head was rotated to the paretic side.3 Rotating the head to the
paretic side can direct the flow of a bolus down a potentially
more sensate and stronger side of the pharynx.3 The rotation
reduces the size of the pharyngeal cavities on that side of the
pharynx, promoting more efficient swallowing. Head rotation
apparently also facilitates opening of the upper esophageal
sphincter by posturally providing external pull to the sphinc-
ter.9 The thyroid cartilage also applies pressure toward the
paralytic plica glottis and helps them to close.3
It is interesting that 4 of our patients with unilateral pharyn-
geal paresis had an increase in their dysphagia limit when the
head was rotated to the nonparetic side. The observer might
have missed minimal head anteflexion during the patients head
rotation.
CONCLUSION
The objective improvement in dysphagia limit and facilita-
tion of swallowing in patients with bilateral symptoms found
by electrophysiologic studies seems to be less than the average
values obtained with videofluoroscopic studies. This difference
may be attributable to methods and methodologic sensitivity.
Our electrophysiologic methods led us to conclude that pos-
tural techniques did not facilitate swallowing, at least in se-
Arch Phys Med Rehabil Vol 82, September 2001
verely dysphagic patients with dysphagia limits between 1 and
3mL.10,13 Similar observations have also been reported with
videofluoroscopic studies.6
Our present study was conducted in a typical electromyography
laboratory to evaluate neurogenic dysphagia objectively. Al-
though the sensitivity is less than that of the videofluoroscopic
methods, this simple and noninvasive electrophysiologic method
for describing dysphagia limit may have a place in the evaluation
of persons with dysphagia and may reveal how the dysphagia is
affected by various head and neck positions.
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3. Logemann JA, Kahrilas PJ, Kobara M, Vakil NB. The benefit of
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Supplier
a. Medelec Mystro MS-20e; Oxford Instruments Plc, Old Station Way,
Eynsham, Witney, Oxfordshire, OX8 1TL, England.