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One Step Back and Two Steps Up and Forward: The Superior Movements of
Research Defining the Utility of the Mendelsohn Maneuver for Improving UES
Function
Article in Perspectives on Swallowing and Swallowing Disorders (Dysphagia) · February 2014
DOI: 10.1044/sasd23.1.5
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One Step Back and Two Steps Up and Forward: The Superior
Movements of Research Defining the Utility of the
Mendelsohn Maneuver for Improving UES Function
Gary H. McCullough
Department of Communication Sciences and Disorders, University of Central Arkansas
Conway, AR
Financial Disclosure: Gary McCullough is a Professor at the University of Central Arkansas.
Nonfinancial Disclosure: Gary McCullough has previously published in the subject area.
Abstract
The Mendelsohn maneuver has been used as both a compensatory strategy and a
rehabilitation exercise since it was first described in the mid-1980s. Its purpose has been
widely agreed upon: to improve hyolaryngeal movement and, consequently, opening of
the upper esophageal sphincter during deglutition. Reports of success with the maneuver
in isolation and as part of a larger regimen of treatments have been published. New
technologies and research are clarifying the ways in which the Mendelsohn maneuver, as
well as other treatments and strategies, impact swallowing musculature and bolus flow
and provide improved understanding of the impact of various exercise protocols.
Historical Perspective
The goals of swallowing therapy depend, minimally, upon the physiologic problem, the
patient’s functional abilities and desires, and the clinician’s knowledge and ability to administer
the treatment in a particular setting. Swallowing therapy can be focused more on compensating
for a particular physiologic problem or rehabilitating the swallow through exercises designed to
strengthen and/or improve coordination of the swallow (Huckabee & Pelletier, 1998). The origin
of compensatory strategies and rehabilitation exercises sometimes lies in the hands of chance.
Someone realizes he doesn’t cough when he tucks his chin or swallows more completely when he
turns his head. More often, however, such discoveries are the result of professionals considering
swallowing physiology and creating a methodology to improve muscle functioning for specific
aspects of swallowing. Clinical intuition and exploration lead to experimental application and
clinical case studies, which, if successful, breed methodological investigations on normal
physiology. Research then focuses on small cohorts of individuals with dysphagia and eventually,
clinical trials. Along the way technological advances, such as EMG, high resolution manometry,
and fMRI improve our understanding and compel us to take a couple steps back in order to make
a giant leap forward.
The Mendelsohn maneuver is an exemplary case in point. By name and definition, the
Mendelsohn is a maneuver “indicating to move (something or someone) in a careful and usually
skillful way.” Anyone who has attempted to perform a Mendelsohn maneuver can attest to this
definition. The Mendelsohn maneuver requires skillful execution. During the swallow, the
individual presses the tongue to the roof of the mouth and squeezes suprahyoid and pharyngeal
musculature. This action holds the hyolaryngeal complex in an elevated position for 2 or more
seconds. The maneuver requires effort as well as skill; but the effort, based on many years of
investigation, may be worth it in many cases.
Hyolaryngeal elevation is, of course, critical for successful opening of the upper
esophageal sphincter (UES) during the swallow. As vagal firing to the UES ceases, hyolaryngeal
elevation pulls superiorly and anteriorly on the cricoid cartilage, creating a traction force on the
cricopharyngeal muscle, the bulk muscle within the UES (see Figure 1). Pending properly
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coordinated and sufficient oral and upper pharyngeal swallowing function, this traction pulls
the cricopharyngeus and opens the UES to allow passage of the bolus into the esophagus. For
individuals with reduced hyolaryngeal elevation and residue building in the pyriform sinuses,
the Mendelsohn maneuver can improve UES opening by increasing hyolaryngeal elevation and,
consequently, UES opening (Mendesohn & McConnel, 1987).
Figure 1. Illustration of the Action of Longitudinal Pharyngeal Muscles and Suprahyoids on the
Hyolaryngeal Mechanism and Opening of the Upper Esophageal Sphincter (UES). Muscular
contractions pull the hyolaryngeal mechanism up and forward, stretching open the cricopharyngeal
which forms the bulk of the UES.
Source. Reproduced with permission from the International Journal of Radiation Oncology
(Pearson, Hindson, Langmore, & Zumwalt, 2012).
A Compensatory Strategy
Originally proposed as a compensatory strategy, the impact of the Mendelsohn maneuver
on swallowing physiology is immediate. Table 1 provides specific aspects of swallowing physiology
immediately impacted by the maneuver. Neuroimaging advances suggest neurologic, as well as
physical reasons for the success. Swallowing with a Mendelsohn maneuver appears to increase
cortical activation, particularly in the superior and middle frontal gyrus, angular gyrus, cingulate
gyrus, and inferior parietal lobe (Peck et al., 2010). The prolonged laryngeal response necessary
for the Mendelsohn, or perhaps the complex coordinated effort of respiration and deglutition,
also increases activity in the supplementary motor area compared to both normal and effortful
swallows.
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Table 1. Immediate Effects of Mendelsohn Maneuver on Swallowing Physiology
Physiologic Improvement
Authors
Increases superior/anterior hyoid movement &
Delays UES closure
Mendelsohn & McConnel, 1987; Kahrilas, Logemann,
Krugler, & Flanagan, 1991
Increases tongue base pressure & duration of
velopharyn closure
Decreases pre-opening pressure &
intraswallow pressure on UES
Increases post-swallow UES pressure
Hoffman et al., 2012
Increases mean diameter UES open
Regan, Walshe, Rommel, & McMahon, 2013
Increases maximum angle hyoid elevation
Wheeler-Hegeman, Rosenbek, & Sapienza, 2008
Whereas most data on the immediate effects of the Mendelsohn maneuver were derived
from normal participants, case studies and small case series do exist. Lazarus, Logemann and
Gibbons (1993) reported improved timing and coordination of the pharyngeal swallow with
reduction in aspiration in a patient with oropharyngeal cancer. Tongue base to pharyngeal wall
pressures and contact duration improved with the Mendelsohn maneuver in three patients with
head and neck cancer (Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002). It was also
reportedly helpful in maintaining or achieving oral intake as one of several compensatory
strategies and maneuvers in another report on neurologic patients (Neumann, Bartolome,
Buchholz, & Prosiegel, 1995).
The one problem with utilizing the Mendelsohn maneuver as a compensatory strategy
has likely occurred to anyone who has attempted twenty of them in a row. It’s tiring! Elderly
individuals with a dwindling dearth of functional motor units and dastardly decreased functional
reserve have less endurance. Adding a strenuous, not to mention complex, maneuver to every
swallow of a meal could readily lead to fatigue and potentially worse dysphagia. Thus, for some,
the maneuver may improve bolus passage through the pyriforms and into the esophagus. For
others the maneuver may help during a six to ten swallow videofluoroscopic swallow study
(VFSS) but lead to malnourishment and/or aspiration and pneumonia over time. Data have yet to
emerge examining this potential dilemma. Eventually, however, fatigue from repetitive use of the
maneuver led to consideration of the potential impact of the maneuver on muscle strength and
coordination. If the maneuver could immediately impact deglutition in both normal participants
and select patients, perhaps with repetition as an exercise it could provide more lasting effects.
A Rehabilitation Exercise
Employing surface electromyography (SEMG) to teach the complex act, the Mendelsohn
maneuver became one of several strategies targeted as an exercise to improve the strength and
coordination of swallowing in a number of investigations. Research (Bryant, 1991; Crary, 1995;
Crary, Carnaby, Groher, & Helseth, 2004; Huckabee & Cannito, 1999) indicates use of the
maneuver, along with strategies such as effortful swallows and oral bolus feeds, improve
swallowing physiology. Regimens of treatment included use of the maneuver repetitively twice per
day over a week-long period of time, along with other strategies and exercises. Patients formerly
eating nothing by mouth as a result of stroke and chronic dysphagia were weaning off tube feeds
and onto oral, and even regular, diets. Whereas these data were compelling for a partial role of
the Mendelsohn maneuver in rehabilitation, the lasting effects of the maneuver could not be
isolated and defined with such methodologies.
McCullough, et al. (2012) reported the first data on the effects of the Mendelsohn used
in isolation on patients. Eighteen stroke patients were enrolled and performed Mendelsohn
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maneuvers 30–40 times per session, twice per day over a 2-week period. Improvements in regular
swallows were observed from pre-treatment to post-treatment in duration of hyoid elevation and
hyoid anterior excursion, as well as UES opening, though changes in UES opening duration were
not statistically significant. In a subsequent report from the same data set (McCullough & Kim,
2013), distance of hyoid elevation in millimeters was also reported to significantly improve as
a result of the treatment. Anterior hyoid displacement and UES opening improved but not
significantly. Immediate improvements in timing and coordination reported by Lazarus et al.
(1993) were also observed for regular swallows after use of the Mendelsohn as an exercise
(McCullough & Kim, 2013). Improvement in coordination of events could have been the result of
the short, intense period of treatment employed in the investigation (McCullough et al., 2012,
2013). Use of the Mendelsohn over a prolonged work-rest mode could have yielded more
significant effects on muscle strength and associated durations and distance of movements, but
may or may not have had the same impact on swallowing coordination. Future research should
address this issue. Patients did continue to improve in week two of treatment, indicating that
10 sessions do not provide maximal benefit—at least in a contracted time frame.
At face value, researchers and clinicians alike may be tempted to forge ahead with such
data and commence the propitious use of Mendelsohn maneuvers for every sluggish hyoid east
and west of the Rio Grande, but the puzzling relationship between muscle physiology, extent and
duration of movement, and bolus flow is still missing a few pieces. Why did UES opening not
improve significantly? Small sample size could certainly be, and likely is, one reason; though
others potentially exist and require further exploration.
The plot thickens to a pudding consistency.
New Science and Emerging Clinical Knowledge
Researchers recently took a step back from advancing clinical application and utilized
new technology to investigate basic properties of muscles and physiology. Pearson, Langmore,
and Zumwalt (2011) examined cross sections from muscles of cadavers. Using a digital caliper,
direction and force of muscle contractions were calculated based on muscle attachment
sites. Muscle mass, angle, fiber length, and density were reported. Whereas the geniohyoid
demonstrated the greatest potential for impacting anterior hyoid displacement, the mylohyoid
demonstrated the greatest potential for impacting superior hyoid displacement. Longitudinal
pharyngeal muscles were also reported to have a significant impact (Pearson, Langmore, Yu, &
Zumwalt, 2012). These findings were substantiated by subsequent research (Pearson, Hindson,
Langmore, & Zumwalt, 2012) using muscle functioning magnetic resonance imaging (mfMRI).
A mean signal intensity muscle segmenting technique was employed to examine muscles slice
by slice through a semi-automated algorithm. Results indicated all suprahyoid muscles and
longitudinal pharyngeal muscles are active during swallowing. Moreover, all suprahyoids except
the thyrohyoid and anterior digastric demonstrated a significant effect size between pre- and
post-swallow measures. Comparisons of pre- and post-changes during Mendelsohn maneuver
swallows suggested the most significant effect for the mylohyoid muscle.
The answer to the burgeoning clinical application question regarding the limited, though
positive, improvement in UES opening from the Mendelsohn maneuver may lie in the muscle
structure, angle, and potential force of suprahyoid muscles. Use of the Mendelsohn maneuver
created the greatest physiologic change in the mylohyoid muscle (Pearson et al., 2011, 2012),
which is the primary muscle for hyolaryngeal elevation. Results of McCullough et al. (2012, 2013)
suggest duration and extent of hyolaryngeal elevation were more significantly improved than
duration and extent of anterior hyoid displacement. Combining the sleek basic science work of
Pearson and colleagues with the clinical application research of McCullough and colleagues,
among others outlined above, suggests the Mendelsohn has a greater impact on the mylohyoid
muscle, which more substantively affects hyoid elevation. Whereas extent and duration of
UES opening are obviously influenced by the maneuver, the overall impact on the UES during
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swallowing may not be as substantive as expected due to the greater change in mylohyoid activity
compared to geniohyoid activity. Thus, the Mendelsohn maneuver may be, and appears to be, a
useful part of an overall treatment regimen for reduced hyolaryngeal movement and decreased
UES opening. Future research should compare results of exercise with the Mendelsohn to other
exercises, such as the Shaker exercise and effortful swallow, and more carefully consider the
impact on the geniohyoid and resultant UES opening. Longitudinal pharyngeal muscles should
receive more attention in future studies utilizing as many current technologies as possible to
address the structural and physiologic changes resulting from all pharyngeal exercises.
Conclusion
Based on evidence to date, the Mendelsohn maneuver appears to be a useful maneuver
for immediately impacting hyolaryngeal elevation and UES opening and for creating a lasting
impact on the swallow when used as an exercise. Limitations of the exercise may exist due to the
relative impact on the mylohyoid muscle, more responsible for hyolaryngeal elevation than the
geniohyoid muscle, which demonstrates greater impact on anterior movement of the hyoid and
UES traction. Future research should target use of the maneuver as an exercise using work-rest
modes over a protracted period of time compared with use of other exercises, including the
Shaker exercise, to determine the most effective and efficient method of improving UES function.
Additional exploration of the role of longitudinal pharyngeal musculature seems warranted.
References
Bryant, M. (1991). Biofeedback in the treatment of a selected dysphagia patient. Dysphagia 6(3), 140–144.
Crary, M. A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem
stroke. Dysphagia 10(1), 6–18.
Crary, M. A., Carnaby, G. D., Groher, M. E., & Helseth, E. (2004). Functional benefits of dysphagia therapy
using adjunctive sEMG biofeedback. Dysphagia, 19(3), 160–164.
Hoffman, M. R., Mielens, J. D., Ciucci, M. R., Jones, C. A., Jiang, J. J., & McCulloch, T. M. (2012). Highresolution manometry of pharyngeal swallow pressure events associated with effortful swallow and the
Mendelsohn maneuver. Dysphagia, 27(3), 418–426.
Huckabee, M. L., & Cannito, M. P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem
dysphagia: A retrospective evaluation. Dysphagia, 14(2), 93–109.
Huckabee, M. L., & Pelletier, C. (1998). Management of adult neurogenic dysphagia. Cengage Learning:
Scottsdale, AZ.
Kahrilas, P. J., Logemann, J. A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper
esophageal sphincter opening during swallowing. American Journal of Physiology 260(3 Pt 1), G450–6.
Lazarus, C., Logemann, J. A., & Gibbons, P. (1993). Effects of maneuvers on swallowing function in a
dysphagic oral cancer patient. Head & Neck, 15(5), 419–424.
Lazarus, C., Logemann, J. A., Song, C. W., Rademaker, A. W., & Kahrilas, P. J. (2002). Effects of voluntary
maneuvers on tongue base function for swallowing. Folia Phoniatrica et Logopedica, 54(4), 171–176.
McCullough, G. H., Kamarunas, E., Mann, G. C., Schmidley, J. W., Robins, J. A., & Crary, M. A. (2012).
Effects of Mendelsohn maneuver on measures of swallowing duration post stroke. Topics in Stroke
Rehabilitation, 19(3), 234–243.
McCullough, G. H., & Kim, Y. (2013). Effects of the Mendelsohn maneuver on extent of hyoid movement and
UES opening post-stroke. Dysphagia, 28(4), 511–9.
Mendelsohn, M. S., & McConnell, F. M. (1987). Function in the pharyngoesophageal segment. Laryngoscope,
97(4), 483–489.
Neumann, S., Bartolome, G., Buchholz, D., & Prosiegel, M. (1995). Swallowing therapy of neurologic
patients: Correlation of outcome with pretreatment variables and therapeutic methods. Dysphagia, 10(1),
2–5.
9
Pearson, W. G., Jr., Hindson, D. F, Langmore, S. E., & Zumwalt, A. C. (2012). Evaluating swallowing
muscles essential for hyolaryngeal elevation by using muscle functional magnetic resonance imaging.
International Journal of Radiation Oncology, Biology, Physics, 85(3), 735–740.
Pearson, W. G., Jr., Langmore, S. E., Yu, L. B., & Zumwalt, A. C. (2012). Structural analysis of muscles
elevating the hyolaryngeal complex. Dysphagia, 27(4), 445–451.
Pearson, W. G., Jr., Langmore, S. E., & Zumwalt, A. C. (2011). Evaluating the structural properties of
suprahyoid muscles and their potential for moving the hyoid. Dysphagia, 26(4), 345–351.
Peck, K. K., Branski, R. C., Lazarus, C., Cody, V., Kraus, D., Haupage, S., . . . Kraus, D. H. (2010). Cortical
activation during swallowing rehabilitation maneuvers: A functional MRI study of healthy controls. The
Laryngoscope, 120(11), 2153–2159.
Regan, J., Walshe, M., Rommel, N., & McMahon, B. P. (2013). A new evaluation of the upper esophageal
sphincter using the functional lumen imaging probe: A preliminary report. Diseases of the Esophagus, 26,
117–123.
Wheeler-Hegland, K. M., Rosenbek, J. C., & Sapienza, C. M. (2008). Submental sEMG and hyoid movement
during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. Journal of Speech,
Language, and Hearing Research, 51(5), 1072–1087.
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