Research on the Mendelsohn Maneuver

by Gittel Lebovic

Oh, T.H., Brumfield, K.A., Hoskin, T.L., Kasperbauer, J.L., & Basford, J.R. (2008). Dysphagia in inclusion body myositis. American Academy of Physical Medicine and Rehabilitation: 87:883–889. Available from Ebscohost database.

Objective: To evaluate the clinical features, treatment strategies, and outcome of dysphagia in patients with inclusion body myositis.

Design: Retrospective review of all 26 patients (20 women, 6 men, mean age of 72.2 yrs) with inclusion body myositis-associated dysphagia seen in 1997–2001.

Results: Twenty-four patients had a dysphagia evaluation. Cricopharyngeal muscle dysfunction was noted in all nine patients who had barium swallow studies. Eighteen patients underwent one or more interventional procedures: cricopharyngeal myotomy, pharyngoesophageal dilation, percutaneous endoscopic gastrostomy, and botulinum injection of the upper esophageal sphincter. Dysphagia tended to worsen with time. Symptomatic improvement was noted with cricopharyngeal myotomy and pharyngoesophageal dilation. The Mendelsohn maneuver seemed helpful in maintaining oral intake in the three patients in whom it was recommended. Thirteen patients died during follow-up at a mean age of 81 yrs. The cause of death was identified in eight and in all cases was because of the respiratory complications of aspiration.

Conclusions: Dysphagia is a progressive condition in patients with inclusion body myositis and often leads to death from aspiration pneumonia. Treatment targeting cricopharyngeal muscle dysfunction, such as the Mendelsohn maneuver, will benefit from further investigation.

In Summation

The Mendelsohn maneuver is a useful method in swallowing disorders with a neurological nature. This research was done on 62 patients with dysphagia associated with a diagnosis of an inflammatory myopathy. All the patients who were taught the Mendelsohn maneuver as their compensatory technique or exercise, reported to have no aspiration related illness, no reduced oral intake, or weight loss within those 5 years. Of all the strategies and swallowing maneuvers, the Mendelsohn maneuver was most successful at maintaining the patient’s oral intake. The Mendelsohn maneuver was recommended in only three patients and seemed beneficial in this small sample in maintaining oral intake. This maneuver is designed to prolong the UES opening during swallowing by voluntarily extending laryngeal elevation. In comparison with other swallowing maneuvers such as the supraglottic and supersupraglottic swallows, it is associated with increased pharyngeal peak contraction and contraction duration and significantly longer bolus transit time.The small number involved limits the assessment of the benefits of the Mendelsohn maneuver in this article. This approach may benefit from further investigation to determine the limited use of the approach (perhaps because of a lack of literature supporting its use in dysphagia of myopathic origin, the therapist’s comfort with the patient’s capacity to perform it successfully or a lack of clinical expertise in this uncommon condition). Further research on the Mendelsohn maneuver and its use in IBM patients with dysphagia is necessary and would be helpful in determining its assistance.

This article is relevant and helpful to SLPs who work with dysphagia patients, especially dysphagia with a neurological nature. It is helpful in swallowing treatment as noted above. Further and more comprehensive evidence and information on this maneuver, though, is severely lacking. Clinicians would profit immensely from additional data and statistics on what already seems to be a very advantageous technique in treatment for swallowing disorders.


Please see further information adapted from other sources below.

 

Reference 1

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders, 2nd edition, (pp. 221-222, 233). Austin: Pro-ed.

The Mendelsohn maneuver is fashioned to increase the extent and duration of laryngeal elevation, thus increasing the duration and width of cricopharyngeal opening. The overall coordingation of the swallow can also be improved by this maneuver. Logemann says that the clinician should provide the patient with instructions for the maneuver as follows: “Swallow your saliva several times and pay attention to your neck as you swallow. Tell me if you can feel that something (you Adam’s apple or voice box) lifts and lowers as you swallow. Now, this time, when you swallow and you feel soemthing lift as you swallow, don’t let your Adam’s apple drop. Hold it up with your muscles for several seconds.”

There are also alternative instructions, which are, “As you swallow, can you feel that everythign squeezes together in the middle of the swallow? When you feel this, swallow and hold the squeeze.” “Holding the squeeze” mean prolongating the moment when the larynx is most elevated, the tongue base is most retracted and in contact with the pharyngeal wall, and the airway is closed.



Reference 2

Lazarus, C. L. (1996, July 4). Mendelsohn maneuver. Dysphagia Resource Center. Message from http://dysphagia.com/maillist/1996-July/msg00051.html

It is important to realize that the instructions "swallow, hold, swallow again, drop larynx" are not really different from the instructions to "swallow, hold, drop larynx". The first set of instructions is using a double swallow, using the Mendelsohn maneuver. Patients with reduced laryngeal elevation often have pharyngeal residue, even with use of the maneuver, so an immediate second swallow using the Mendelsohn maneuver helps clear the pharyngeal residue. This double swallow type of Mendelsohn maneuver is not easy to perform, however, specifically if patients have pharyngeal swallow delays.  In addition, it is extremely tiring and exhausting.  However, it is often required to help clear pharyngeal remains, which could potentially be aspirated after the swallow.




Reference 3

Ogburn Yeager, A. (2006). The Mendelsohn maneuver for dysphagia. Retrieved July 31, 2006 from http://www.speechpathology.com/askexpert/display_question.asp?question_id=184 

The Mendelsohn maneuver is a swallowing maneuver which was designed to treat both reduced laryngeal excursion and limited cricopharyngeal opening. This maneuver is performed by having the patient hold the larynx up, either using the muscles of the neck or with the hand, during the swallow for an extended period of time. The premise behind this technique is that if the extent and duration of laryngeal elevation could be increased, there would be a reciprocal increase in the extent and duration of the cricopharyngeal opening. It is important to note that this technique is used only briefly while the patient’s swallow reflex returns to original state. This should not be viewed as permanent solution to dysphagia. Also, the clinician should seek medical clearance from the physician before attempting these techniques with patients as the individuals suffering from these types of problems often have multiple diagnoses.

In order to effectively use the Mendelsohn swallow maneuver, the patient must meet several requirements. First, the patient must have a sufficient amount of language ability to follow directions, which can be somewhat abstract. Therefore, a patient with severe language impairment would not be a good candidate. Second, patients must have intact cognitive abilities in that they must be able to understand what they are doing and why they are doing it. More importantly, these patients must have the ability to remember to do it each and every time they swallow, which can even be a problem for those individuals without memory impairment. Finally, patients who attempt this maneuver must be in good physical condition, as it requires increased muscular effort, which results in fatigue. These requirements can be viewed as limitations in many ways as patients who do not meet them cannot effectively use the maneuver.

In Ogburn Yeager’s clinical experience, which has mostly been in either long term or an acute care setting, the patients were either too debilitated medically or cognitively to use this maneuver. Therefore, these individuals were referred to an ENT for dilation of the cricopharyngeus, which offered a much more permanent and reliable solution to the problem. The outcomes from this procedure seemed to be positive overall with many patients returning to normal p.o. intake. For the patients who did learn this maneuver, most were younger, cognitively intact individuals who had experienced minor strokes or oropharyngeal cancer. However, even these patients had some difficulty learning exactly what to do and remembering to do it each time. Most required consistent cuing throughout the course of a meal. 

Therefore, swallowing maneuvers, specifically the Mendelsohn maneuver, can be used effectively treat different aspects of a patients swallow. However, these maneuvers can be difficult to teach due to abstract directions, difficult to follow due to memory limitations and difficult to consistently use due to the effects of fatigue


 

 Reference 4

Logemann, J.A. (2006). Medical and rehabilitative therapy of oral pharyngeal motor disorders. GI Motility online, doi:10.1038/gimo50.

 There are several directions that can achieve the Mendelsohn maneuver.

-The first thing is to ask patients to swallow several times and feel with their muscles (not their hand) the degree of lifting in their neck by their voice box.

-When patients can perceive that their voice box does lift during swallow, they are asked to swallow again, and as their voice box elevates, to grab it with muscles—not their hand—and to hold their larynx up for an extra few seconds.

-The effort of holding the larynx up generally increases the extent and duration of laryngeal elevation, thereby opening the upper esophageal sphincter longer and wider.

-Although this is generally an exercise, it can be utilized to improve upper esophageal sphincter opening during food swallows.

-A second set of directions for this maneuver involves asking patients to feel as they swallow to see if they can perceive that a squeeze occurs during swallow, which is the point at which the tongue base, pharyngeal wall, and larynx all come together. Patients can be instructed to "hold the squeeze" for several seconds. It is at that point that the larynx is most elevated and that elevation can be increased with effort.

 Reference 5      

Bailey, B.J., Johnson, J.T., & Newlands, S.D., (2006).  Head and neck surgery—Otolaryngology, 4th edition, (pp. 717, 718). Published by Lippincott Williams & Wilkins. 

 
The Mendelsohn maneuver is designed to increase the extent and duration of laryngeal elevation and anterior motion during the swallow, thereby increasing the width and duration of cricopharyngeal opening during the swallow. This maneuver can also improve the coordingation of the pharyngeal events occuring during the pharyngeal swallow. The patient is instructed to swallow normally, and in the middle of the swallow; when the larynx is felt to elevate, the patient is instructed to keep the larynx elevated for two seconds and then relax.


Reference 6

Trail, M., Protas, E.J., & Lai, E.C., (2008). Neurorehabilitation in Parkinson’s disease: An evidence-based treatment model, (pg. 289).  SLACK Incorporated.

An example of a compensatory strategy is the Mendelsohn manuever if there is reduced laryngeal elevation with decreased ability to protect the airway. The Mendelsohn maneuver teaches the patient to feel the larynx lift and hold it upward during the swallow. This maneuver is based on biomechanics for increasing width and duration of cricopharyngeal opening with laryngeal elavation.



In Conclusion

Although the Mendelsohn maneuver is valuable and beneficial, it is severely limited by a number of necessary conditions. It increases the extent and duration of laryngeal elevation and anterior motion during the swallow, thereby increasing the cricopharyngeal opening. Thus, this compensatory technique is used with patients that have pharyngeal swallow delays, reduced laryngeal elevation, and a decreased ability to protect the airway. It is also used to clear pharyngeal residue. In order to effectively use this method, the patient must meet several requirements. Firstly, the patient must be able to follow difficult directions, so the patient can’t be severely language impaired. In addition, the patient must have cognitive abilities because he must understand what he’s doing and why. Another vital prerequisite is that the patient must have the ability to remember to do the maneuver each time he swallows. Lastly, in order for the patient to endeavor this technique, he must have ample physical health. This maneuver results in extreme fatigue due to its requirement of increased muscular effort. Therefore, if a patient doesn’t meet all these restrictions, the maneuver can’t be used successfully.

According to most sources, the Mendelsohn maneuver is exhausting and complicated to perform, as the instructions are abstract. It is also difficult to follow in lieu of memory confines and not easy to use because of the consequence of weariness. However, it has been most successful to those who have experienced minor strokes, oropharyngeal cancer, or a mild neurological disease. It was especially effective in younger, cognitively stable people. For those patients who use the maneuver productively, it is definitely helpful in maintaining adequate nutrition and oral intake and preventing aspiration. All medical and professional authorities agree that further investigation and research on this seemingly valuable maneuver would assist dysphagia therapists and their patients immensely.

The directions for the Mendelsohn maneuver may vary slightly, but in actuality instruct the same thing. The guidelines are to tell the client to swallow several times and feel with their muscles the degree of lifting in their neck by the voice box. Then tell the client to swallow again and this time to hold the Adam’s apple up with his muscles for several seconds. In other words, holding the squeeze, which means to prolong the time when the larynx is most elevated and the airway is closed. This takes a lot of effort and can be exceedingly complex to pursue, but for those patients that find relief with this maneuver, there are wonderful benefits to be reaped. 
 


 

 

 

These pictures can be found at the following websites: www.healthmegamall.com www.nyee.edu/swallowing.html, and medgenmed.medscape.com.
 







 





 

 

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