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Chin-Down Posture Effect on Aspiration in

Dysphagic Patients

Article in Archives of Physical Medicine and Rehabilitation August 1993

DOI: 10.1016/0003-9993(93)90035-9 Source: PubMed

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 736

Chin-Down Posture Effect on Aspiration in Dysphagic Patients

Therese K. Shanahan, MA, Jeri A. Logemann, PhD, Alfred W. Rademaker, PhD, Barbara Roa Pauloski, PhD,
Peter J. Kahrilas, MD

ABSTRACT. Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ. Chin-down posture effect on
aspiration in dysphagic patients. Arch Phys Med Rehabil 1993;74:736-9.
l Use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in some
dysphagic patients. This study measured four pharyngeal dimensions in 30 neurologically impaired patients who aspi-
rated before the swallow because of a delay in triggering the pharyngeal swallow, I5 for whom the posture eliminated
aspiration and 15 who aspirated despite the chin-down position. Patients who did not benefit from the posture were
significantly younger and aspirated material from the pyriform sinus rather than the valleculae when the pharyngeal
swallow was triggered. Changes in pharyngeal dimensions with the chin down were not significantly different for both
patient groups, except for epiglottic angle, which increased significantly more in the group who continued to aspirate.
Changes in pharyngeal dimensions with chin-neutral versus chin-down differed somewhat from those reported in a
previous publication. Possible reasons for these differences are discussed.
G 1993 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation

Chin lowering is a postural technique frequently used as METHODS

compensatory treatment to eliminate aspiration that results Subjects consisted of two groups of 15 patients each, con-
from a delayed pharyngeal swallow or reduced airway clo- secutively referred for videofluoroscopic evaluation of oro-
sure in order to improve the safety and efficiency of the pharyngeal dysphagia. who met the study entry criteria: ( 1)
swallow in dysphagic patients with these disorders.-4 Ob- dysphagia as the result of neurologic damage without any
servations of videofluorographic studies of dysphagic pa- anatomic abnormality: and (2) aspiration because of a de-
tients using the chin-down posture led clinicians to believe layed pharyngeal swallow, observed during a modified bar-
that the effectiveness of this posture in eliminating aspira- ium swallow on a liquid swallow of measured amount ( 1,3,
tion resulted from enlargement of the vallecular space with 5 or 1OmL) while the chin was in a neutral upright posi-
the chin down and a posterior shift of the epiglottis to a tion..3 Delayed pharyngeal swallow was defined as the pha-
more protective position over the airway.3 A recent study ryngeal swallow beginning after the bolus head passes the
that measured changes in pharyngeal dimensions with the point where the ramus of the mandible crosses the tongue
chin up and down revealed no uniform enlargement in the base. Subsequently, each patient swallowed the same mea-
valleculae (though some individual subjects exhibited this sured amount of liquid as had been aspirated with the chin
change), but did reveal a significant narrowing of the laryn- upright, while maintaining the chin in a maximally lowered
geal entrance and posterior shift of the epiglottis. thus in- position. Subjects who could not achieve and maintain
creasing airway protection. both a chin-neutral and a chin-down position because of
Unfortunately, not all patients who aspirate because of a reduced ability to carry out instructions or reduced cervical
delayed pharyngeal swallow or reduced airway closure ben- range of motion, who were under 18 years of age, who had
efit from the chin down posture. This present research was surgically altered pharyngeal anatomy, or who had a tra-
designed to identify those variables that influence success or cheostomy tube were excluded from the study. Aspiration
failure of the chin-lowering posture in eliminating aspira- was eliminated with the chin down for the 15 patients in
tion in patients with a delayed pharyngeal swallow, and to Group 1, whereas the 15 patients in Group 2 continued to
determine whether patients for whom the posture success- aspirate despite the chin-down posture. The protocol was
fully eliminated aspiration differed significantly from those approved by the Institutional Review Board.
for whom the posture fails to eliminate aspiration. Group 1 consisted of 10 males and five females. ages 55
to 87, with a mean age of 74.3 years. Group 2 included five
From the Department ofCommunication Sciences and Disorders (Ms. Shannhan. males and 10 females, ages 30 to 84, with a mean age of 6 I. 1
Drs. Logemann. Radrmaher. Pauloski. Kahrilas). Cancer Center (Dr. Rademaker).
Department of Medicine (Dr. Kahrilas). Northwestern Llniversity Medical School,
years. Neurologic diagnosis of the patients in each group
Evanston. IL. and time since onset of their neurologic damage when the
Submitted for publication March 75. 1992. Accepted in revised form Septcmhcr2. videofluorographic study was performed are presented in
I)92
This research was funded hy R01 NS2855.01.
Table 1.
No commercial party havingadirect or indirect interest in thesuhject matter ofthis Fluorographic swallow data were recorded on i inch vid-
article has or will confer a benefit upon the authors or upon any organization with
eotape using a Sony 5800 videocassette recorder coupled
which the authors are associated.
Reprint requests to Jerl A. Logemann, PhD. Northwestern Umversity. 2299 Sheri- to a Thalner Electronicsb video counter timer that num-
dan Road. Evanston, IL 6020X. bered each frame to facilitate slow motion and frame-by-
El 1993 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
frame analysis of swallows. Each patient was seated and
0003-9993/93/7407-0154$3.00/O viewed laterally, with the radiographic image revealing the

Arch Phys Med Rehabil Vol74, July 1993

 EFFECTS OF CHIN-DOWN POSTURE, Shanahan 737

Table 1: Neurologic Diagnosis for the 15 Subjects in Each of the Two Groups and the Mean Time
Between Diagnosis and th4 Videofluorographic Study

Group I Group 2
.- ____ .__
Neurologir Number of Mean Time Post Diagnosis Number of Mean Iime Post Diagnosis
Diagnosis Patients When VFG Completed Patients When VFC Completed

l.efr cortical CV 4 75 days 25 days

Right cortical CVA 21 days 6 days
Multiple CVA 14 days I8 days
Motor neuron disrate 6 months 9 months
Closed head injuq 22 days 68
7 days
Multiple sclerosis Unknown years
Dementia Unknown Linknown
Depression Unknown Llnknown

4bhreviations: VFG, videofluorographic: CVA.

oral cavity and pharynx. A lcm round disc was taped to the from the most anterior poini of the arytenoid carti-
midline of the neck to serve as a ruler to compensate for lage to the anterior wall of the laryngeal vestibule.
radiographic magnification. Two swallows were analyzed All distances were corrected for fluoroscopic magnihca-
per subject: one with the chin in the neutral upright posi- tion using the ruler included in the videofluoroscopic
tion. and one with the chin tucked. image. All videoprints were replicated and each parameter
Slow motion and frame-by-frame analyses of the two was remeasured, with only the mean values of the repli-
swallows were performed to determine the duration of the cated measures used in statistical analyses. Group means
pharyngeal swallow delay, calculated as the time difference were then calculated for each measure. Statistical signifi-
between the moment at which the bolus passed the inferior cance of 11 variables measured on chin-neutral swallows
border of the ramus of the mandible and the onset of laryn- for the two groups was tested to determine if patients in
geal elevation. Clinical judgments were made regarding: (1) group 2 who aspirated using the chin tuck were distinguish-
percent of the bolus aspirated, (2) percent of the bolus lo- able from patients in group 1 who did not aspirate using the
cated in the pyriform sinus region, (3) percent of the bolus chin tuck. Statistical significance of gender, liquid volume
reaching the valleculae, and (4) percent of the bolus remain- on which aspiration occurred. and source of aspiration (ie.
ing in the oral cavity at the onset of laryngeal elevation for from valleculae or from the pyriform sinus region) was as-
chin-down swallows, and (5) source of the aspirated mate- sessed using the Fishers exact test. All other analyses were
rial (ie, the valleculae versus the pyriform sinus region). All performed using unpaired l-tests. Statistical significance
judgments were reported twice by the same examiner, and was defined by two tailed p values of at most .05.
10% of the judgments were repeated by a second examiner. The effect of the postural change from chin up to chin
lntraobserver variability on all observations was no more down was examined by comparing the differences in chin
than .07 seconds on temporal measures of delay, 4% for all up/chin down measures between the two patient groups.
angles, mm on all distances, and 5% on all percentages.
lnterobserver variability was no more than .06 seconds on
temporal measures of delay. 5% for all angles, 3mm on all
distances. and 5%)on all percentages.
A single video field of each subject with the chin in neu-
tral and in lowered position was selected at the end of a
swallow when structures had returned to rest and no bolus
was present that might change tongue base position. The
selected video field was transferred from videotape to a Mit-
subishi video copy-processor P604 to produce video prints.
From each of the two video prints per subject, two angles
and two distances were measured as shown in the figure:
(1) postural angle: the angle formed by the inferior
border of the mandible and the posterior pharyngeal
wall (ie, the degree of chin tilt);
(2) epiglottic angle: the angle formed by the posterior
surface of the epiglottis and the anterior wall of the
laryngeal vestibule:
Arytenoid
(3) epiglottic distance: the distance in millimeters from
the most posterior point of the epiglottis to the poste- Cartilage
rior pharyngeal wall; Angles and pharyngeal distances measured from video prints of
(4) airway entrance distance: the distance in millimeters each subject with the chin upright and chin tucked.

Arch Phys Med Aehabil Vol74, July 1993

 738 EFFECTS OF CHIN-DOWN POSTURE, Shanahan

Finally, the chin up/chin down measures for the 30 subjects Table 3: Mean f SEM for Pharyngeal Dimensions and
in this study were compared with those of the previous Duration of Swallow Delay for the Two Groups of Subjects
study.5 Using the Chin-Down and Chin-Neutral Positions

Group 1 Group 2
RESULTS Did not aspirate Aspirated
There was no significant difference in the bolus volume Variables w/chin down w/chin down P
on which aspiration occurred for the two patient groups
Postural angle:
with the chin in neutral position. Table 2 presents the mean Difference (degrees) -13.5 k 1.6 --9.2 + 3.4 .26
differences between the two groups of subjects (those who % Difference -14.6 k I.7 -8.3 * 3.4 .I I
did not continue to aspirate with chin down [Group l] and Epiglottic angle:
those who did [Group 21) on the 10 variables studied with Difference (degrees) -0.4 + 5.5 18.0 + 5.9 .03*
the chin in neutral position. Subjects in Group 2 were signif- 1;Difference I.3 t 4.7 14.7 * 4.5 .05*
Epiglottic distance:
icantly younger than subjects in Group I. Group 2 subjects Difference (mm) 3.7 k 1.8 2.7 * I.5 .66
also had a significantly higher incidence of aspiration of % Difference I I 1.3i 64.6 154.6 f 121.0 .75
material from the pyriform sinus (rather than from the val- Airway entrance distance:
leculae) on swallows with the chin upright. There was no Difference (mm) 1.8 k 3.0 -2.7 k 0.8 .I7
% Difference 42.4 + 54.5 -31.0 k 7.8 .I9
statistically significant difference in the gender, duration of Duration of pharyngeal
the pharyngeal swallow delay, percent of the bolus aspi- swallow delay:
rated, postural angle, or in any of the pharyngeal dimen- Difference (set) -0.3 _t 0. I -0.3 + 0.2 .65
sions with the chin upright. Thus, with the exception of age % Difference -4.4 + 68.1 161.2 k 129.1 .28
and bolus location, the two groups of subjects were compa-
Negative values indicate a mean decrease from chin neutral to chin low-
rable before the chin-down posture was used. ered position. Positive values indicatea mean increase from chin neutral to
Table 3 presents the results of the second analysis, the chin lowered position.
comparison of pharyngeal measures with the chin up and * p 5 .05.
chin down in the two groups of subjects. The postural angle,
epiglottic distance, and airway entrance distance changed
similarly in the two groups of subjects. The epiglottic angle tic angle, and epiglottic position. As expected, the postural
was significantly increased from chin-neutral to chin-low- angle significantly decreased with the chin tucked. The
ered position in Group 2 subjects (those for whom the chin- epiglottic angle increased significantly and the epiglottic
down posture was ineffective). This measure remained es- distance to the posterior pharyngeal wall increased signifi-
sentially unchanged in Group 1 (subjects who benefited cantly with the chin lowered. The airway entrance became
from the chin-down posture). smaller, but not significantly so.
As shown in table 4, three of the four pharyngeal mea- Change in pharyngeal dimensions with chin upright and
sures changed significantly from the chin upright to the chin lowered were compared to the findings of an earlier
chin lowered for the 30 patients in this study, whereas the study (table 4). Both the present study and the earlier study
pharynx was at rest after a swallow: postural angle, epiglot- found a significant decrease in the postural angle with the
chin lowered and a significant increase in the epiglottic an-
gle. Each study also found that epiglottic distance changed
Table 2: Mean f SEM or Percent for Age, Gender, Four significantly: however, the earlier study indicated that it de-
Swallow Measures/Observations, the Postural Angle and creased. while the present study found epiglottic distance to
Three Pharyngeal Distance/Angle Measures in the Two the pharyngeal wall increased. The two studies differed re-
Groups of Subjects With the Chin in Neutral Position
garding the significance of the airway entrance measure.
Group I Group 2 The previous study indicated a significant decrease with
Did not Aspirate Aspirated chin lowered, however, the current study, a decrease was
Variable w/Chin Down w/Chin Down p observed but was not statistically significant.
Age 74.3 k 2.3 61.1 + 4.8 .02*
Gender (female) 5/15 (339,) IO/15 (67%) .I4 DISCUSSION
Pharnyngeal swallow delay This study revealed that patients who aspirated despite
(set) 0.63 f 0.32 1.08f 0.27 .29
Percent of bolus in pyriform
using the chin tuck correctly aspirated material from the
sinus (at onset of pyriform sinus more often than did those for whom the
laryngeal elevation) 16.1 k 5.8 33.5 k 8.3 .I0 chin-tucked posture was effective.
Percent of bolus aspirated 3.6 + 0.9 3.0 I!zI.3 .72 This significant difference in amount of bolus in the pyri-
Source of aspirated material:
form sinus during the pharyngeal swallow delay probably
Pyriform sinus 4/ I5 (27%) IO/15 (67%) .04*
Valleculae I l/l5 (73%) 7115 (47%) .26 explains why aspiration persists despite the chin tuck. At
Postural angle (degree) 92.1 * 2.5 95.2 t 4.8 .56 the onset of the swallow, the larynx and pharynx elevate
Epiglottic angle (degree) 134.7 k 4.8 134.4 -t 3.9 .97 dramatically (approximately 2cm, or f of their length at
Epiglottic distance (mm) 7.7 + 0.9 7.8 + I.? .95 rest).6 thus severely shortening and narrowing the pyriform
Airway entrance distance
(mm) 5.7 t 0.8 6.9 - 0.9 .30
sinuses and causing some of their contents to spill into the
airway. The results of this study indicate that if clinicians
* 1 I .05. observe bolus entering the pyriform sinus during the pha-

Arch Phys Med Rehabil Vol74, July 1993

 EFFECTS OF CHIN-DOWN POSTURE, Shanahan 739

Table 4: Comparison of Mean f SEM Changes in Pharyngeal Dimension With Chin-up/Chin-Down Posture in the 30 Subjects
in This Study and in the Previous Study*

Previous Study Current Study

(n = 30) (n 30)

Chin Chin Chin Chin

Neutral Down P Neutral Down P

Postural angle ( 1 89.1 * 1.5 14.6 i- 3.0 <.oooI 93.7 + 7.7 x2.3 :t 2.4 1.001
Epigtottic angle Ci)) 151.6? 1.6 156.9 -+ 1.7 .007 134.5 t- 3.0 I-13.3 .+ 3.3 .05
Epigtottic distance (mm) 11.5 + 1.2 8.1 + I.1 <.ooo I 7.X i 0.7 I I.0 + 1.2 .Ol
decrease increase
Anway entrance distance (mm) 13.8 & 1.3 7.8 + 0.9 ,000 I 6.3 -t 0.6 5.x :f I.5 .77
__- -
* Ekherg.4

ryngeal swallow delay, the chances that the chin tuck will rior shift of the anterior pharyngeal wall in the two studies.
eliminate aspiration are reduced. In the previous study, both the airway entrance distance
The angles and pharyngeal dimensions changed similarly and the epiglottic distance significantly decreased, indicat-
in the two groups of 15 subjects in this study except for the ing posterior pressure on the anterior phaTngea1 wall with
epiglottic angle, which had a significantly larger increase in the chin down. In the present study, the eplglottic distance
the group who continued to aspirate on swallows with chin increased significantly and the airway entrance distance de-
lowered (Group 2). The increase in the epiglottic angle creased, but only slightly and not significantly, perhaps in-
should reflect increased airway protection because it occurs dicating less direct posterior pressure on the anterior pha-
as the chin pushes the anterior laryngeal wall more posteri- ryngeal wall in subjects in the present study.
orly. Theoretically, the airway entrance should also be Effects of the chin tuck (down) posture are clearly not
narrowed. Although the airway entrance was narrowed uniform in their effects on pharyngeal dimensions or on
slightly in the Group 2 patients who aspirated despite the swallow physiology in dysphagic subjects. Results of this
chin tuck, the bolus was already too low in the pharynx to study emphasize the importance of the relationship be-
be affected by this change. The significantly younger age of tween bolus location and this postures effectiveness. Re-
the subjects in Group 2 may have contributed to the differ- sults also indicate that effects of this posture must be docu-
ence in epiglottic angle between Groups 1 and 2. With age. mented videofluoroscopically in each patient to assure that
the larynx continues to descend in the neck. Thus, when aspiration is actually eliminated.
the younger subjects in Group 2 tucked the chin down, they References
may have exerted more direct posterior pressure on the thy- I. Horner J. Massey E. Riski J, Lathrop D. Chase K. Aspiration following
roid notch, thus more directly compressing the anterior tra- stroke: clinical correlates and outcome. Neurology t988;38: 1359-62.
cheal wall posteriorly than the subjects in Group 1. 2. Logemann J. Treatment for aspiration related to dysphagia: an over-
view. Dysphagia 1986: I :34-8.
Pharyngeal measures that changed significantly with
_3 Logemann J. Evaluation and treatment of swallowing disorders. San
chin-down posture for all 30 subjects included epiglottic Diego: College Hilt, 1983.
angle and postural angle. The increase in epiglottic angle 4. Ekberg 0. Posture of the head and pharyngeat swallowing. Acta Radio1
and decrease in postural angle were consistent with the find- Diagnos 19X6:27:269-74.
ings of an earlier study.5 The airway entrance measure gen- 5. Welch M. Logemann J. Rademaker A. Kahritas P. Changes in pharyn-
geal dimensions effected by chin tuck. Arch Phys Med Rehab (in press).
erally decreased with the chin tucked: however, the de- 6. Kahrilas PJ. Logemann JA, Lin S. Ergun GA. Pharyngeal clearance
crease was significant only in the previous study. The during swallow: a combined manometric and videofluoroscopic study.
epiglottic distance also changed significantly in both stud- Gastroenterotogy 1992; 103: 128-36.
ies; however, it increased in the present study, rather than Wind J. On the phylogeny and the ontogeny of rhe human larynx.
Groningen. Netherlands: Walters-NoordhsoH: I970.
decreased (as reported in the previous study). This differ-
ence in the direction of change of the epiglottic distance Suppliers
may relate to the different conditions of the two studies. Sony VO-5X00 VCR. Columbia Audio-Visual, I7iJl 2nd Street. High-
The present study examined the pharynx as it recovered land Park, IL 60035.
Thatner Electronic Laboratories. Incorporated. 135 Jackson Road.
from a swallow. The previous study examined video prints Ann Arbor. Ml 48 103.
of postures unrelated to actual swallows. Another explana- Mitsubishi P604 Video Copy Processor. Midwest Visual Equipment
tion may lie in the apparent difference in the degree ofposte- Company. Incorporated. 6500 North Hamtin. Chicago, Il. 60645.

Arch Phys Med Rehabil Vol74, July 1993

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