Table 2.
Technique | Execution (rationale) | Indication | Limitations in geriatric patients |
---|---|---|---|
Maneuvers | |||
Supraglottic swallow | Breath hold, double swallow, forceful expiration (closes vocal folds before and during swallow) | Reduced/late vocal fold closure | Problematic in patients with cardiovascular disease |
Supersupraglottic swallow | Effortful breath hold, swallow, cough, swallow (closes vocal folds before and during swallow) | Reduced/late vocal fold closure | Problematic in patients with cardiovascular disease |
Effortful swallow | Effortful tongue action (increases posterior motion of tongue base) | Poor posterior tongue base motion | May cause fatigue of swallowing |
Mendelsohn maneuver | Prolong hyoid excursion guided by manual palpation (prolongs upper esophageal sphincter opening) | Poor pharyngeal clearance and laryngeal movement | May cause fatigue of swallowing |
Postural adjustments | |||
Head tilt | Head tilt posteriorly at swallow initiation (gravity clears oral cavity) | Poor tongue control | Increases aspiration risk in most older subjects |
Head tilt laterally to unaffected side (directs bolus down stronger side) | Unilateral pharyngeal weakness | May have limitations in patients with cervical spine disease | |
Chin tuck | Chin down (displaces tongue base and epiglottis posteriorly) | Delayed pharyngeal swallow response | May have limitations in patients with cervical spine disease |
Head rotation | Rotate head to affected side (isolates damaged side from bolus path) | Unilateral pharyngeal weakness | May have limitations in patients with cervical spine disease |
Facilitatory techniques | |||
Thermal stimulation | Cold tactile stimulation to anterior faucial pillar | Delayed/absent swallow response | Poor evidence, especially in stroke patients |
Gustatory stimulation | Sour or spicy bolus, capsaicin (facilitates swallow response) | Reduced oral sensitivity, delayed/absent swallow response | Promising approach |
Strengthening exercises | |||
Shaker exercise | Repeated head lifting while lying (strengthening of neck and laryngeal muscles) | Enhanced opening of the upper esophageal sphincter | May have limitations in patients with cervical spine disease; the suggested intensity may not be feasible for geriatric patients |
Notes: Adapted from Gastroenterology, Volume 116/Edition 2, Cook IJ, Kahrilas PJ, AGA technical review on management of oropharyngeal dysphagia, Pages 455–478, Copyright 1999, with permission from Elsevier.112