Dysphagia (2014) 29:603–609
DOI 10.1007/s00455-014-9551-8
ORIGINAL ARTICLE
Chin Tuck for Prevention of Aspiration: Effectiveness
and Appropriate Posture
Jong Yun Ra • Jung Keun Hyun • Kyung Rok Ko
Seong Jae Lee
Received: 9 January 2014 / Accepted: 16 June 2014 / Published online: 11 July 2014
Ó Springer Science+Business Media New York 2014
Abstract Chin tuck has been has been widely used to
prevent aspiration in the patients with dysphagia. This
study was performed to investigate the effectiveness and
the degree of optimal neck flexion of chin tuck. Ninety-
seven patients who showed aspiration in the videofluoro-
scopic swallow study (VFSS). Participants were grouped
into the effective (patients who showed effect with chin
tuck) and ineffective group (those who did not show effect
with chin tuck). VFSS was performed in neutral and chin
tuck position and findings were compared between the
groups. Severity of aspiration was assessed by the point
penetration-aspiration scale. Duration of dysphagic symp-
toms, history of tracheostomy, and other possible contrib-
uting factors were also compared. Neck flexion angle was
measured to find appropriate posture in which aspiration
was prevented with chin tuck. Aspiration was reduced or
eliminated in only 19 patients (19.6 %) with chin tuck.
Oral transit time, pharyngeal delayed time and pharyngeal
transit time were significantly shortened in both groups
(p \ 0.05), but the difference between the groups was not
significant. Female sex and absence of residue in pyriform
Electronic supplementary material The online version of this
article (doi:10.1007/s00455-014-9551-8) contains supplementary
material, which is available to authorized users.
J. Y. Ra
K. R. Ko
S. J. Lee (&)
Department of Rehabilitation Medicine, College of Medicine,
Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan-si,
Chungnam 330-714, Republic of Korea
e-mail: rmlee@dankook.ac.kr
J. K. Hyun
Department of Nanobiomedical Science and BK21 PLUS NBM
Global Research Center for Regenerative Medicine, Dankook
University, 119 Dandae-ro, Dongnam-gu, Cheonan-si,
Chungnam 330-714, Republic of Korea
•
sinus favored the effect of chin tuck (p \ 0.05). At least
17.5° of neck flexion was required to achieve an effect with
chin tuck. The effectiveness of chin tuck was less than
anticipated. Patients without residue in pyriform sinus were
more likely to benefit from chin tuck. Sufficient neck
flexion was important in chin tuck to prevent aspiration.
Keywords Deglutition
Deglutition disorders

Chin tuck
Videofluoroscopy
Posture
Introduction
Dysphagia is a common disorder and 300,000–600,000
individuals exhibit some form of dysphagia in the United
States annually [1]. It causes various complications such as
malnutrition, dehydration, pneumonia and asphyxia, which
are relevant to morbidity and mortality.
Among the compensatory treatment procedures that
control the flow of food and eliminate symptoms, chin tuck
(also known as chin down posture or neck flexion) is
widely used. Chin tuck has been used since the 1970’s
when some researchers recommended forward head tilting
at an angle of 45o in patients with dysphagia [2–4]. Patients
are instructed to tuck their chin towards their chest during
each swallow, which may lead to pushing of the tongue
base and epiglottis closer to the posterior pharyngeal wall;
the narrowed airway entrance has been presumed to
improve airway protection.[5].
Recently, a few studies raised suspicion about the true
effectiveness of chin tuck. Ashford et al. reviewed seven
studies about postural change techniques for dysphagic
patients, and found that chin tuck was effective in only
8–50 % [1]. In another study, on the patients with Par-
kinson’s disease and dementia, the chin tuck was less
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604 J. Y. Ra et al.: Chin Tuck for Prevention of Aspiration

effective than viscosity modification [6]. A videomano- Table 1 Etiology of dysphagia

metric study suggested that the chin tuck may weaken Etiology Total EFF group INEFF group
pharyngeal contraction.[7]. (n = 19) (n = 78)
Despite the common use of chin tuck in clinical practice,
Stroke 59 15 44
the neck position is still not standardized and the optimal
angle of chin tuck is still not clear. There has been only one Traumatic brain injury 10 2 8
study addressing neck flexion angle in chin neutral and Parkinson’s disease 4 0 4
chin-down posture in healthy subjects, but the swallowing Guillain–Barre syndrome 2 0 2
was not fully evaluated and an optimal neck flexion angle Vocal cord palsy 2 0 2
was not recommended [8]. To the author’s knowledge, the Hypoxic brain damage 2 0 2
relationship between neck angle and effect of chin tuck has Myasthenia gravis 1 0 1
never been studied. Additionally, no study has concerned Hypopharyngeal cancer 1 0 1
parameters that may affect the effectiveness of chin tuck Brain metastasis of lung cancer 1 0 1
method. Bacterial meningitis 1 0 1
The present study was undertaken in patients with dys- Unknown 14 2 12
phagia with the aims of identifying the factors affecting the Values are number of subjects
efficacy of chin tuck and to determine the optimal neck p-value = 0.974 by Fisher’s exact test
flexion angle in the chin tuck method.

Subjects and Methods

Subjects
The subjects were selected from the database of Dankook
Univeristy Hospital between April 2010 and July 2012.
Inclusion criteria were: [1] admittance to or consultation at
the Department of Rehabilitation Medicine due to dys-
phagia; [2] presence of penetration or aspiration confirmed
by videofluoroscopic swallow study (VFSS) and; [3] trial
of chin tuck trial during VFSS. The patients were excluded
if they [1] could not follow the instruction or had difficulty
in VFSS procedure due to cognitive impairment or aphasia;
[2] could not control the position of their head and neck;
[3] could not sit on a chair during VFSS; [4] did not
complete all the protocols of VFSS.
Of the 143 patients identified 46 were excluded. The
remaining 97 patients (56 males and 41 females;
67.1 ± 13.7 years-of-age) were included in the study. Causes
of dysphagia was stroke in 59 patients; traumatic brain injury
in 10; Parkinson’s disease in 4; Guillain–Barre syndrome in 2;
vocal cord paralysis in 2; hypoxic brain damage in 2; and one
case each of myasthenia gravis, hypopharyngeal cancer, brain
metastasis of lung cancer and bacterial meningitis each and 14
cases of unknown origin (Table 1).
Methods
VFSS Protocol
The VFSS protocol described by Logemann [9] was used
with minor modifications. Each patient was seated on a
chair that was placed on the ledge of a vertically tilted
fluoroscopic table. The patients were instructed to swallow
boluses of various consistencies while fluoroscopic video
images were taken in the lateral view and stored digitally at
a speed of 30 frames per second. However, only the results
of thin liquid swallowing were analyzed in this study
because they reflected the presence of aspiration most
sensitively. Water-soluble barium sulfate (Solotop powder
for suspensionÒ, Ta-joon Pharmacy, Seoul, Korea) was
diluted to 70 % and swallowed five times with amount of
5 ml in each swallowing. The patients were posed in the
chin tuck and swallowed the same volume of barium
solution five times more whenever any amount of pene-
tration or aspiration was evident in previous swallowing
attempts. When posed in the chin tuck, each patient was
instructed to flex their head as much as possible, with the
goal of the chin touching the chest. Recorded images were
reviewed frame-by-frame with Picture Motion Browser
2.0Ò video analyzing software (Sony Corporation, Tokyo,
Japan) by a physiatrist experienced in VFSS analysis.
VFSS Analyses
The swallowing processes in the oral and pharyngeal
phases were evaluated. In the oral phase, completeness of
lip closure, presence of oral residue and presence of pre-
mature bolus leakage were assessed and the oral transit
time (OTT–the time elapsed from backward movement of
bolus until the bolus head reaches the lower edge of the
mandible) was measured. In the pharyngeal phase, delay of
triggering of pharyngeal swallowing, height of laryngeal
elevation and presence of residue in the valleculae and

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J. Y. Ra et al.: Chin Tuck for Prevention of Aspiration 605

pyriformis sinus were assessed and the pharyngeal delayed
time (PDT: the time elapsed from arrival of the bolus at the
lower edge of the mandible until pharyngeal swallow is
triggered) and pharyngeal transit time (PTT: the time
elapsed from arrival of the bolus head at the lower edge of
the mandible until the bolus tail passes through the crico-
pharyngeal region) were measured [9]. Bolus head was
defined as the leading margin of bolus in the processing
direction in videofluoroscopy and bolus tail as the rear
margin in the same direction.
cervical lordosis was measured by a modification of a
previous technique in which the angle was measured
between two lines drawn along the posterior margin of
second and sixth cervical vertebrae (lordosis angle) [11].
Cervical flexion was defined as the difference of the lor-
dosis angle between neutral and the chin tuck position
(Fig. 1). The sum of AO flexion and cervical flexion cor-
responded to the total neck flexion angle (Table 3).
Grouping

Evaluation of Penetration and Aspiration To analyze the results, comparisons were made between
the patients displaying a significant decrease in penetration
Penetration and aspiration were measured semi-quantita- and aspiration (EFF group) and those who did not (INEFF
tively by the final version of an 8-point penetration-aspi- group). VFSS, change of 8PPAS score and the neck flexion
ration scale (8PPAS) (Table 2), [10]. It is a potentially angle were compared. The optimal neck flexion angle to
powerful outcome measure for clinical trials designed to achieve significant decrease in penetration and aspiration
investigate the efficacy of various swallowing treatments. was also investigated.
Reliability and validity have been reported as 96 and 95 %,
respectively. Scores of five swallowing were averaged with
the head positioned upright and in the chin tuck position. If
the score was decreased more than or equal to 1.0 in the
chin tuck position, it was assumed that penetration and
aspiration were decreased significantly.

Measurement of Neck Flexion Angle

It was assumed that the neck flexion consisted of flexion of

the axis-occipital (AO) joint and cervical spine. Still vid-
eofluoroscopic images were used to measure the angle
between the lower margin of the mandible and the anterior
surface of the second vertebral body (i.e., the chin angle).
AO flexion was defined as the difference of the chin angle
between neutral and the chin tuck position. The angle of

Table 2 Final version of an 8-point penetration-aspiration scale[10]

Point Degree of penetration and aspiration

1 Material does not enter the airway

2 Material enters the airway, remains above the vocal folds and
is ejected from the airway
3 Material enters the airway, remains above the vocal folds and
is not ejected from the airway
4 Material enters the airway, contacts above the vocal folds and
is ejected from the airway
5 Material enters the airway, contacts above the vocal folds and
is not ejected from the airway
6 Material passes below the vocal folds and is ejected into the
Fig. 1 Measurement of neck flexion angle. Angle a is the chin angle
larynx or out of the airway
defined as the angle between the lower margin of mandible and
7 Material passes below the vocal folds and is not ejected from anterior surface of second cervical vertebral body. Angle ß is the
the trachea despite effort lordosis angle defined as the angle between two lines drawn along the
8 Material passes below the vocal folds and no effort is made to posterior margin of second and sixth cervical vertebral body. a Angles
eject measured in the neutral position. b Angles measured in the chin tuck
position

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Table 3 Definition of the angles measured in VFSS Table 4 Comparisons of VFSS parameters
Angle Definition Parameters EFF group INEFF group pvalue*
(n = 19) (n = 78)
Chin angle The angle between the lower margin of mandible
and anterior surface of second vertebral body Sex Male 6 50 0.01
Lordosis angle The angle between two lines drawn along the Female 13 28
posterior margin of second and sixth cervical Age (years) 64.1 ± 17.7 67.8 ± 12.6 0.29*
vertebrae
Duration of 2.3 ± 3.1 4.2 ± 8.4 0.12*
AO (axis- The difference of chin angle between the neutral symptom
occipital) flexion and chin tuck position (months)
Cervical flexion The difference of lordosis angle between the Tracheostomy performed 4 8 0.20
neutral and chin tuck position
absent 15 70
Neck flexion angle The sum of AO flexion and cervical flexion
Lip closure Intact 18 71 0.60
Poor 1 7
Oral residue Exist 6 11 0.72
Statistical Analyses and Study Approval
None 13 67
Laryngeal Intact 18 69 0.42
Statistical analyses were performed using SPSS for Win-
elevation Reduced 1 9
dows version 12.0 (SPSS, Chicago, IL, USA). Categorical
parameters were compared by Chi square and Fisher’s Premature bolus present 6 11 0.07
leakage absent 13 67
exact test and numerical data between groups by inde-
pendent t-test. Within group changes were verified by Pharyngeal Intact 3 11 0.85
swallowing Delayed 16 67
paired t-test. To ascertain the optimal degree of neck trigger
flexion, a Receiver Operating Characteristic (ROC) curve Valleculae residue excessive 17 71 0.83
was used. Significance was accepted for p values \ 0.05. normal 2 7
The study protocol was approval by the Institutional Pyriformis sinus excessive 8 54 0.03
Review Board of Dankook University Hospital. residue normal 11 24
Values are mean ± standard deviation for age and duration of
symptom; otherwise, values are number of cases
Results
* p-values are calculated by independent t-test; otherwise, p-values
are calculated by Chi square test
Efficiency of the Chin Tuck Method

Only 19 of 97 subjects (19.6 %) presented a significant

Table 5 Comparisons of OTT, PDT and PTT
decrease (more than one scale) in 8PPAS scores with the
chin tuck method. Mean change of 8PPAS score was sig- Parameters EFF group INEFF p-value*
(n = 19) group (n = 78)
nificantly different between groups, being -3.3 ± 2.7 in
the EFF group and 0.9 ± 1.8 in the INEFF group OTT (neutral) 3.4 ± 2.9 2.7 ± 4.5 0.42
(p \ 0.001). No significant difference was observed in OTT (chin tuck) 1.8 ± 2.3 1.1 ± 1.2 0.07
crosstab analysis by etiology and effectiveness p-value  0.03 0.00
(Table 1).There were significantly more females in the EFF PDT (neutral) 1.8 ± 1.6 2.6 ± 4.7 0.24
group (p = 0.01) (Table 4). PDT (chin tuck) 1.1 ± 1.0 1.7 ± 2.4 0.09
p-value  0.03 0.04
Parameters of VFSS PTT (neutral) 2.7 ± 1.7 3.4 ± 4.8 0.34
PTT (chin tuck) 1.9 ± 1.0 2.4 ± 2.4 0.14
Presence of residue in the pyriformis sinus was signifi- p-value  0.01 0.04
cantly more frequent in the INEFF group (p = 0.03)
OTT Oral transit time, PDT Pharyngeal delayed time, PTT Pharyngeal
(Table 3). Other parameters did not differ significantly
transit time
between the groups. OTT, PDT and PTT were significantly
Values are mean ± standard deviation
shortened with the chin tuck protocol within both groups
* p-value by independent t-test (between the groups)
(p \ 0.05), but they did not differ significantly between the  
p-value by paired t-test (within each group)
groups (Table 5).

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J. Y. Ra et al.: Chin Tuck for Prevention of Aspiration 607

Neck Flexion Angle

The data of measured angles are summarized in Table 6.

The cervical spine in the neutral position was more lordotic
in the EFF group (18.2 ± 13.8°) compared to the INEFF
group (10.1 ± 10.6°) (p = 0.02). The chin angle at neutral
and chin tuck and lordosis angle at chin tuck position were
not statistically different between the groups. Cervical
spine of female patients was significantly more lordotic
(15.2 ± 12.7° in females vs 9.1 ± 10.1° in males at neutral
position, 4.0 ± 11.3° in females vs 0.1 ± 8.9° in males at
chin tuck) (p \ 0.05). Significantly larger values in the
EFF groups were apparent for AO flexion (12.4 ± 10.1 in
EFF group vs 7.6 ± 7.8 in INEFF group), cervical flexion
(14.7 ± 11.1 in EFF group vs 8.9 ± 7.4 in INEFF group)
and total neck flexion (27.1 ± 16.4° in the EFF group vs
16.5 ± 11.8° in the INEFF group) (p \ 0.05).

Optimal Neck Flexion Angle

To ascertain the optimal neck flexion angle for effective Fig. 2 Determination of optimal neck flexion angle. Receiver
chin tuck, a ROC curve was drawn (Fig. 2). Each point Operating Characteristics curve demonstrates the performance of
neck flexion angle in relation to sensitivity and specificity
represented specificity and sensitivity values when total
neck flexion angles were used as the cut-off point. The area
under the curve was 0.711, which was statistically signif- and pharyngolaryngeal change was evaluated only by
icant (p = 0.005). The circled point on Fig. 2 shows that simple X-ray images. In another study using still images of
the cut-off point of the neck flexion angle was 17.5° VFSS, chin tuck narrowed the airway entrance distance,
(sensitivity = 0.737, specificity = 0.654). widened the epiglottic distance and shortened pharyngeal
swallow delay [12]. In the present study, we reviewed the
VFSS images and tried to evaluate the effect of chin tuck as
Discussion objectively as possible, focusing on the neck flexion angle.
The efficacy of the chin tuck is still controversial. The
Previous studies concerning chin tuck mostly focused on efficacy of the chin tuck has been reported to be ranged from
physiological changes. One study reported that chin tuck 8 to 50 % [1]. In a previous study, chin tuck reduced aspi-
narrows the laryngeal entrance and may improve airway ration in only 8 % of the patients with Parkinson’s disease
protection [5]. But, the subjects were only healthy people [13]. However, some of the patients had no dysphagia at all,
and chin tuck was combined with supraglottic swallow
Table 6 Between the groups comparison of angles measured in technique. In the present study, only 19.6 % of the subjects
VFSS benefited from the chin tuck method. It is still not certain that
Parameters EFF group INEFF group p-value the chin tuck is highly effective in prevention of aspiration.
(n = 19) (n = 78) We tried to evaluate the effect of chin tuck as objec-
tively as possible. Most prior studies assessed the presence
Neutral
and severity of the penetration and aspiration qualitatively
Chin angle (°) 73.4 ± 10.4 74.3 ± 9.2 0.74
[6, 12–14]. In the present study, the severity of penetration
Lordosis angle (°) 18.2 ± 13.8 10.1 ± 10.6 0.02*
and aspiration was assessed by an 8PPAS score developed
Chin tuck
to provide quantification of penetration and aspiration
Chin angle (°) 61.1 ± 13.4 66.7 ± 12.3 0.10
events with high reliability [10]. The scale is easy to use
Lordosis angle (°) 3.4 ± 11.9 1.2 ± 9.7 0.46
and suitable for evaluating the aspiration found in VFSS
AO flexion (°) 12.4 ± 10.1 7.6 ± 7.8 0.02* although it is mainly focused on depth and incorporates not
Cervical flexion (°) 14.7 ± 11.1 8.9 ± 7.4 0.04* only aspiration, but clearance of aspirated material. It
Neck flexion angle (°) 27.1 ± 16.4 16.5 ± 11.8 0.01* might be rather arbitrary to assume that score change of
Values are mean ± standard deviation one or more was indicative of a significant improve in
* p-value by independent t-test aspiration or penetration. The rationale for the assumption

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608
was that each scale in 8PPAS was designed to imply a
significant change of depth and protection of aspiration.
The results show that the effective group had more lor-
dotic cervical spine in the neutral position. The effective
group also showed more neck flexion than the ineffective
group. We assume that the more lordotic spine may afford
more room for flexion that will affect the efficacy of the chin
tuck method. In the present study, the neck flexion angle was
defined as a sum of cervical flexion and atlanto-occiptial
flexion. It was greater in the effective group, suggesting that
sufficient neck flexion may be required to gain benefit from
the chin tuck method. The optimal neck flexion angle in the
chin tuck has never been studied to our knowledge. Using
ROC curve analysis, we found that the optimal angle of neck
flexion was 17.5° with relatively good sensitivity (0.737) and
specificity (0.654). Nevertheless, the significance of our
results is limited because the effect of different neck flexion
angles has not been compared within subjects. Well-
designed prospective study comparing the effect of neck
flexion within subjects will be required.
Although we investigated many parameters of VFSS,
only female sex and absence of residue in pyriformis sinus
were associated with the effect of chin tuck. It is unclear
why the female patients outnumbered the males in the
effective group. The gender difference might be coinci-
dental or the difference of cervical lordosis may affected
the results because cervical spines of the female patients
were significantly more lordotic (15.2 ± 12.7° in females
vs 9.1 ± 10.1° in males, p = 0.01) (Table 6). The signif-
icance of cervical lordosis has been mentioned above. A
previous study reported that the patients without benefit
from the chin tuck posture have tendency to aspirate
material from the pyriformis sinus rather than from the
valleculae.[12] Likewise, absence of residue in pyriformis
sinus favored the efficacy of chin tuck in the present study.
We speculate that the chin tuck may not be able to prevent
aspiration from the pyriformis sinus.
It is notable that the penetration and aspiration were
aggravated with chin tuck in 20 patients, as indicated by
increased 8PPAS scores. We could not identify the factors
related to increased penetration and aspiration. Clinicians
must be cautious about the possibility of aggravation by the
chin tuck method.
Study Limitations
The present study has several limitations. This study was
retrospective and compared degree of neck flexion between
two groups. This study investigated only the immediate
effect of chin tuck without training. Cervical lordosis was
measured between the C2 and C6 vertebrae; this was
inevitable because C7 vertebrae are barely visible in still
images of VFSS in which X-ray beam has a different angle
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J. Y. Ra et al.: Chin Tuck for Prevention of Aspiration
from usual cervical spine radiographs. Angle measurement
between C2 and C7 might be more precise[11], but the
errors from this modification must be negligible.
Conclusions
The study demonstrates that the chin tuck was effective in
only 19.6 % of the patients with aspiration. Chin tuck
might be less effective in those who have excessive residue
in the pyriformis sinus. Sufficient neck flexion is important
and the minimum neck flexion (sum of of cervical and
atlanto-occipital flexion) of 17.5° is required to acquire a
benefit from the chin tuck method.
Acknowledgment The present research was conducted by the
research fund of Dankook University in 2013.
Conflict of interest The authors declare that there is no conflict of
interest.
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