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Japanese Journal of Comprehensive Rehabilitation Science (2020)

Original Article

Effect of tongue-hold swallow on pharyngeal cavity: kinematic
analysis using 320-row area detector CT
Keiko Aihara, SLHT, MS,1 Yoko Inamoto, SLHT, PhD,2 Yoichiro Aoyagi, MD, PhD,3Seiko Shibata, MD, DMSc,3 Hitoshi Kagaya, MD, DMSc,3 Yuriko Sato, SLHT, MS,1
Masanao Kobayashi, Rt, PhD,4 Eiichi Saitoh, MD, DMSc3
Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan
Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan3
Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
4
Faculty of Radiology, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan1
2

ABSTRACT
Aihara K, Inamoto Y, Aoyagi Y, Shibata S, Kagaya H,
Sato Y, Kobayashi M, Saitoh E. Effect of tongue-holdswallow on pharyngeal cavity: kinematic analysis
using 320-row area detector CT. Jpn J Compr Rehabil
Sci 2020; 11: 35-42.
Purpose: This study analyzed the effect of the tonguehold swallow (THS) on the pharyngeal cavity during
swallowing three-dimensionally using 320-row area
detector computed tomography (320-ADCT). We
hypothesized a greater decrease in pharyngeal volume
with the THS than with the saliva swallow (SS); thatis, the pharyngeal cavity would be more constrictedwith the THS.
Methods: The THS and SS were examined using 320ADCT in six speech language pathologists (22‐29 yearsold). Pharyngeal volume, hyolaryngeal displacement,
and cross-sectional area of the upper esophageal
sphincter (UES) were measured frame-by-frame andcompared between the two swallows.
Results: Although some participants showed smaller
pharyngeal volume with the THS than hypothesized,
others showed larger pharyngeal volume. With the
THS, the hyoid bone was positioned significantly
higher at swallow onset, the hyoid and larynx weresignificantly higher at maximum superior displacement,
and the cross-sectional area of the UES was significantly
larger.
Correspondence: Keiko Aihara, SLHT, MS
Department of Rehabilitation, Fujita Health University
Hospital, 1‐98 Dengakugakubo, Kutsukake, Toyoake,
Aichi 470‐1192, Japan.
E-mail: keiko-a@fujita-hu.ac.jp
Accepted: October 18, 2019.
Declaration of Conflicting Interests: The author(s) declared
no potential conflicts of Interest with research, authorship,
and/or publication of this article.
©Kaifukuki Rehabilitation Ward Association 2020
doi.org/10.11336/jjcrs.11.35

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Discussion: No constant effect of the THS onpharyngeal volume was found. The THS may influencehyolaryngeal elevation and UES opening. Further
study is necessary to consider the methodology of the
THS, such as tongue protrusion length.
Key words: tongue-hold swallow, 320-row area detector
CT, dysphagia
Introduction
The tongue-hold swallow (THS) is one of theindirect swallowing exercises reported by Fujiu &Logemann [1] and involves swallowing saliva while
holding the anterior part of the tongue between theupper and lower teeth. They proposed that the increasein pharyngeal wall bulging compensates for the
reduced tongue base retraction during the swallow,
which in turn may strengthen pharyngeal constriction[1, 2]. Because there are few indirect exercises tostrengthen pharyngeal constriction, the THS has been
widely used in swallowing rehabilitation. However, noconsistent findings have been reported to date for thephysiologic effect of THS exercise and there iscurrently insufficient evidence to establish the THS asa technique for strengthening pharyngeal constriction.
The conflicting findings of several studies that haveanalyzed pharyngeal pressure with the THS do notsupport the hypothesis that the THS increases pharyngeal
constriction. Lazarus et al. performed manometry andvideofluoroscopy (VF) in three patients with head andneck cancer and reported that the THS increased themagnitude and duration of pharyngeal pressure. They
concluded that the THS was effective for pharyngeal
constriction [3]. Umeki et al. used high-resolution
manometry (HRM) and found that the THS tended toincrease both nasopharyngeal and oropharyngealpressure but not significantly [4]. On the other hand,
Doeltgen et al. found with HRM that the THS decreased
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both oropharyngeal and hypopharyngeal pressure [5, 6].
Also using HRM, Hammer et al. found no difference inpharyngeal pressure between the regular saliva swallow(SS) and the THS [7].
Since Fujiu & Logemann first reported kinematic
analysis using VF, few studies have reported the effectof the THS on structural movements during swallowing.
This may be due to limitations of the method foranalyzing the THS. Because the muscles targeted by the
THS are the pharyngeal constriction muscles surrounding
the pharyngeal cavity, not only the posterior pharyngeal
wall, but also the lateral pharyngeal wall is affected bypharyngeal constriction. However, VF allows for only
two-dimensional evaluation of the pharyngeal cavity
and not three-dimensional (3D) kinematic analysis of
the effect on the pharyngeal cavity.
The recently-developed 320-row area detector
computed tomography (320-ADCT) enables 3D
kinematic analysis during swallowing and quantitative
measurement of structural movements [8‐10]. It
allows 3D analysis of the pharyngeal cavity andcalculation of the pharyngeal constriction ratio by
measuring the volume of the pharyngeal cavity.
Therefore, it should be possible to clarify the kinematiceffect of the THS by conducting a 3D quantitative
analysis of the pharyngeal cavity by 320-ADCT.
In this study, we used 320-ADCT to determine thekinematic effect of the THS on the pharyngeal cavity
by measuring the change in pharyngeal volume,
distance of hyolaryngeal elevation, cross-sectional
area of the upper esophageal sphincter (UES), and its
opening duration. We hypothesized that the volume ofthe pharyngeal cavity would decrease more with the
THS than with the regular SS; that is, pharyngeal
volume would be smaller with the THS than with theregular SS.
Methods
1. Participants
Six speech language pathologists who were able toperform the THS as instructed (all female; 22‐29 years
old) were recruited for this study. They had no historyof dysphagia, were following a regular diet, and wereindependent in daily living. All provided informed
consent to participate in the study following
comprehensive explanation of the study’s purpose andprocedure. This study was approved by the institutional
review board at our university (HM16-135).
2. Procedure
2.1 CT imaging
A 320-ADCT scanner (Aquilion ONE vision; Canon
Medical Systems, Otawara, Japan) was used for
imaging. The gantry was tilted 30° and the customized
offset-sliding CT chair (eMedical Tokyo, Chuo-ku,
Japan; Tomei Brace, Seto, Japan) was positioned on
the opposite side of the CT table. The participants

were first seated on the chair, the reclining angle of thechair was adjusted to 45°, and then the scanningstructures were positioned to the right of the scannerby sliding the chair posteriorly. The participants started
one SS and then one THS upon the examiner’s verbal
cues, and one scan was performed for each swallow.
The THS instruction was “Protrude your tongue
between your front teeth. Hold it in place by gently
biting down on the anterior part of the tongue andswallow while maintaining this posture,” which
follows that described in the “Summary of Swallowing
Exercises” published in 2014 by the Japanese Society
of Dysphagia Rehabilitation.
The scanning parameters were scanning range 160
mm from the skull base to the upper esophagus,
scanning duration 2.2‐3.3 s for each swallow using
8‐12 rotations of the gantry (0.275 s/1 rotation of thegantry), tube voltage 120 kV and current 40 mA.
The radiation dose was DLP 219.3 mGy and theeffective dose was 1.08 mSv per swallow, which was
equivalent to 1‐5 min of videofluoroscopy [11]. To
minimize the radiation dose, the scanning duration
was adjusted for each participant according toswallowing duration, which was measured beforehand.
2.2 Image reconstruction
To generate the images, a half reconstruction
technique was used and 22‐33 image phases werecreated at 0.10-s intervals over 2.2‐3.3 s (10 frames/s).
Multiplanar reconstruction images and 3D-CT images
were created using the 320-ADCT software. The aircolumn surface was depicted with a window level of<300 HU, and the hyoid bone and cranial bones weredepicted with a window level of >450 HU [12].
2.3 Measurement of pharyngeal volume
The air space of the pharyngeal cavity was viewed
on 3D-CT images and its volume was measured using
the scanner software.
The borders of the pharyngeal cavity were defined
as follows: 1) superior–axial through the anterior nasal
spine and posterior nasal spine (PNS) parallel to theinfraorbital line, then diagonally from the PNS to theanterior arch of the atlas; 2) anterior–coronal from thePNS perpendicular to the superior plane; and 3)
inferior–axial through the superior surface of the true
vocal cords, inferior edge of the pyriform sinus, andabove the pharyngoesophageal segment (Figure 1). As
a reference time for swallow onset, time 0 was definedas the onset of rapid anterosuperior movement of thehyoid bone and the volume of the pharyngeal cavity
was measured at every frame. The change inpharyngeal volume throughout the swallow and two
integral volumes were compared between the SS andthe THS: 1) from −0.3 to 0 s (swallow onset) and 2)
from 0 s (swallow onset) to the time of minimum
pharyngeal volume.

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Figure 1. Method of measuring pharyngeal volume.
3D-CT images were used for measurement.
Left and right orbitomeatal base lines were adjusted in parallel, and upper, anterior, and lower borders
were defined.
Upper border: Superior-axial through the anterior nasal spine and posterior nasal spine (PNS) parallelto the infraorbital line, then diagonally from the PNS to the anterior arch of the atlas.
Anterior border: Anterior-coronal from the PNS perpendicular to the superior plane.
Lower border: Inferior-axial through the superior surface of the true vocal cords, inferior edge of thepyriform sinus, and above the pharyngoesophageal segment.
Right graph shows the change of pharyngeal volume measured at every frame using the calculation
software of the workstation. X axis is time and Y axis is volume.
SS, Saliva swallow; THS, Tongue-hold swallow.
2.4 Measurement of hyoid and laryngeal displacement
An x-y coordinate system was used for measurement.
The origin (0, 0) is the anterior-superior corner of the
fourth cervical vertebra (C4), the y-axis lies in the plane
made by the anterior-inferior corner of the second
cervical vertebra and anterior-superior corner of C4, andthe x-axis lies in the plane perpendicular to the y-axis
and crosses the origin. The hyoid bone and larynx weretracked frame-by-frame during swallowing. The
anterior-superior corner of the symphysis was set as theanatomical landmark for the hyoid bone, while thecenter of the laryngeal prominence was set as thelandmark for the larynx. Maximum anterior displacement
for both the hyoid and larynx was calculated as thedifference from the starting position to the most anterior
position. Maximum superior displacement wascalculated as the difference from the starting position to
the most superior position.
 easurement of duration of UES opening and
2.5 M
cross-sectional area of UES
The UES was identified on axial sections at thelevel of the lower aspect of the thyroid cartilage,
parallel to the true vocal cords. The cross-sectional
area of the UES was measured frame-by-frame during
UES opening using the calculation software of theworkstation. Among the calculated areas, themaximum cross-sectional area was identified.

Results
1. Volume of pharyngeal cavity
Pharyngeal volume in both the THS and SS
decreased rapidly immediately after swallow onset,
but there were differences between participants (Figure2). Participants 1 and 2 showed smaller pharyngeal
volume with the THS than with the SS from before theonset of hyoid anterosuperior movement andthroughout swallowing. Participants 3, 4, and 5
showed greater laryngopharyngeal volume with the
THS than with the SS before swallow onset andthroughout swallowing. Participant 6 showed larger
pharyngeal volume before swallowing but an earlier
decrease in pharyngeal volume with the THS thanwith the SS.
There were also differences between participants in
the integrated volume from −0.3 s to swallow onset andfrom swallow onset to minimum pharyngeal volume(Figures 3, 4). Some showed decreased pharyngeal
volume with the THS, whereas others showed anincrease. When comparing the shape of the pharyngeal
cavity at the onset of anterosuperior movement of the
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3. Statistical analysis
Wilcoxon’s signed-rank test was used for comparing
hyolaryngeal displacement, duration of UES opening,and cross-sectional area between the SS and THS.
Statistical significance was set at p<0.05. SPSS ver.
22.0 was used for analysis.

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Figure 2. Pharyngeal volume change for six subjects.
Upper: Subjects who showed smaller pharyngeal volume with THS than with SS from before swallow
onset and throughout swallowing.
Middle: Subjects who showed greater pharyngeal volume with THS and with SS before swallow onset
and throughout swallowing.
Lower: Subject who showed another pattern.
SS, Saliva swallow; THS, Tongue-hold swallow.

Figure 3. Integral volumes from −0.3 to 0 s (swallow
onset).
SS, Saliva swallow; THS, Tongue-hold swallow.

Figure 4. Integral volumes from 0 (swallow onset) to
the time of minimum pharyngeal volume.
SS, Saliva swallow; THS, Tongue-hold swallow.

hyoid (Figure 5), the anteroposterior diameter was
shorter in some participants and longer in others.
Similarly, some participants showed a shorter lateraldiameter, whereas others showed a longer lateraldiameter. Similar to volume, anteroposterior and lateral
distances varied between participants. These results do
not support our hypothesis that pharyngeal volume issmaller with the THS than with the SS.

2. Hyolaryngeal displacement (Table 1)
At swallow onset, there was no significant differencein the forward position of the hyoid between the two
swallows, but the hyoid was positioned significantly
higher with the THS than with the SS (p=0.001); thehyoid was located 29.3±2.5 mm forward and 17.7±5.7mm upward from the anterosuperior corner of C4 with
the THS vs 30.4±1.5 mm forward and 14.1±6.1 mm
upward with the SS. There was also no significant

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Figure 5. 3D-CT images of pharyngeal cavity for six subjects.
Arrows show the pharyngeal parts of which SS and THS look different.
In subject 1, the pharyngeal cavity seemed larger in the lateral view (lateral antero-posterior distance),
however, it seemed smaller in the posterior view (smaller lateral distance).
SS, Saliva swallow; THS, Tongue-hold swallow.
Table 1. Hyoid and larynx movement.

ForwardHyoid
UpwardForwardLarynxUpwardSwallow onset
Maximum anterior position
Maximum anterior displacement
Swallow onset
Maximum superior position
Maximum superior displacement
Swallow onset
Maximum anterior position
Maximum anterior displacement
Swallow onset
Maximum superior position
Maximum superior displacement

difference in maximum anterior position between thetwo swallows, but the maximum superior position was
significantly higher with the THS (p=0.001; maximum
anterior location 41.8±1.1 mm with the THS vs41.6±0.7 mm with the SS; maximum superior location
20.4±7.6 mm with the THS vs 17.1±6.5 mm with theSS). Neither anterior nor superior displacement
differed between the swallows (anterior displacement:
12.3±2.6 mm with the THS vs 11.3±1.7 mm with theSS; superior displacement: 3.6±3.5 mm with the THS
vs 3.7±2.6 mm with the SS).
The larynx at swallow onset was located forward
and upward from the anterosuperior corner of C4 at

THS
29.3±2.541.8±1.1
12.3±2.6
17.7±5.7
20.4±7.6
3.6±3.525.4±3.1
29.5±2.7
4.1±1.8
20.5±5.635.1±5.0
14.6±3.6

p-Value
0.25
0.60
0.23
<0.01*<0.01*
0.60
0.25
0.46
0.22
0.11
0.04*
0.02*

25.4±3.1 mm and 20.5±5.6 mm, respectively, with the
THS and at 26.6±2.3 mm and 19.7±4.0 mm,
respectively, with the SS. There was no significant
difference in maximum anterior location of the larynx
between the two swallows, but it was locatedsignificantly higher at the maximum position with the
THS than with the SS (p=0.04; maximum anterior
location: 29.5±2.7 mm with the THS vs 29.1±2.2 mm
with the SS; maximum superior location: 35.1±5.0
mm with the THS vs 32.1±5.1 mm with the SS).
Superior displacement of the larynx was significantly
larger with the THS than with the SS (p=0.02; 14.6±3.6mm vs 12.4±2.6 mm, respectively). However, there
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SS
30.4±1.541.6±0.7
11.3±1.7
14.1±6.1
17.1±6.5
3.7±2.6
26.6±2.3
29.1±2.2
2.5±0.8
19.7±4.0
32.1±5.1
12.4±2.6

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Aihara K et al.: Effect of tongue-hold swallow on pharyngeal cavity

Figure 6. Duration of UES opening and maximum cross-sectional area of UES.
(a) Duration of UES opening; (b) maximum cross-sectional area of UES.
SS, Saliva swallow; THS, Tongue-hold swallow.
*
p-Value by Wilcoxon’s test (p<0.05).
was no significant difference in anterior displacementof the larynx between the two swallows (4.1±1.8 mm
vs 2.5±0.8 mm, respectively).
3. UES opening duration and cross-sectional areaof UES (Figure 6)
Although UES opening tended to be longer with the
THS than with the SS, the difference was not significant(p=0.15; 0.36±0.10 s vs 0.30±0.06 s, respectively). The
maximum cross-sectional area of the UES wassignificantly larger with the THS than with the SS(p=0.03; 28.4±12.8 mm2 vs 20.8±8.9 mm2, respectively).
Discussion
In this study, we analyzed the kinematic effect of the
THS on the pharyngeal cavity by measuring pharyngeal
volume, hyolaryngeal movement, and UES opening
duration and cross-sectional area using 320-ADCT.
1. Pharyngeal volume change
The pharyngeal cavity is surrounded by the base of
the tongue and the pharyngeal wall. Tongue baseretraction and pharyngeal constriction during
swallowing exert a force that transports the bolus into
the esophagus. The THS may reduce tongue baseretraction by anchoring the protruded tongue and tocompensate for this, the anterior posterior pharyngeal
wall bulges.
We hypothesized that pharyngeal volume would
decrease as the pharyngeal posterior wall approaches
the base of the tongue during the THS, and it is thisdecreased volume that contributes to pharyngeal
constriction. We confirmed our hypothesis in a few
participants whose pharyngeal volume decreased with
the THS compared with the SS, but pharyngeal volume
unexpectedly increased in some participants.
Therefore, we are unable to conclude that thepharyngeal cavity is more constricted with the THS
than with the SS. However, the differences weobserved in pharyngeal volume and pattern of volume
change between the THS and SS indicate that theeffect on the pharyngeal cavity with the THS may bedifferent from that with the SS.
Fujiu reported that although anterior bulging of theposterior pharyngeal wall tended to increase with the
THS, between-subject variability was evident [13].
The results of studies investigating pharyngealpressure using HRM have also been inconsistent, withsome researchers reporting an increase in pharyngealpressure, others reporting no pressure change, and yetothers reporting a decrease in pressure [3‐7]. Suchdiscrepancies may be due to between-subject
variability in effects on the pharynx, as seen in ourstudy.
One possible explanation for the individual
differences we observed in pharyngeal volumeconcerns the THS instruction given: “Protrude yourtongue between your front teeth. Hold it in place by
gently biting down on the anterior part of the tongue
and swallow while maintaining this posture.” This
may not have been sufficient to limit tongue baseretraction because the instruction was not specificenough. As a result, some of our participants did notshow changes in the posterior pharyngeal wall anddecreased pharyngeal volume. In support of thisnotion, Fujiwara et al. found, using a tongue pressure
sensor, that tongue protrusion length influenced
increases or decreases in tongue pressure with the
THS. Thus, adjustment of tongue protrusion length is
an important component of the THS [14]. The THS
limits tongue motion due to protrusion and promotes
compensational movement of the posterior pharyngeal
wall. For greater protrusions, the tongue is positioned
more anteriorly, which triggers anterior movement of
the posterior pharyngeal wall and results in larger

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momentum. This therefore suggests that adjusting
tongue protrusion length is critical to accurately
understanding the effect of the THS on pharyngeal
volume.
2. Hyolaryngeal movement and cross-sectional areaof UES
The hyoid bone was located significantly higher atswallow onset and its maximum elevation position
was significantly higher with the THS than with the
SS. Laryngeal superior displacement was alsosignificantly larger with the THS. These results can beinterpreted to have occurred because of hyoid superior
excursion accompanying tongue protrusion. Moreover,by holding the tongue between the incisors, the hyoidbone may be anchored more strongly, which might
facilitate greater laryngeal elevation and thus result inincreased superior displacement of the larynx. This
increased superior displacement could also explain thesignificant increase in the cross-sectional area of the
UES with the THS.
Oh et al. compared hyolaryngeal elevation after 4
weeks of training between a THS practice group and anormal swallow practice group. They found nodifference in hyolaryngeal elevation between the twogroups and concluded that the THS does not affecthyolaryngeal elevation during swallowing [15]. In ourstudy, however, comparison of the kinematics between
the THS and SS suggested that the THS may facilitate
the superior movement of the hyolarynx because thehyoid and larynx were positioned more superiorly
with the THS than with the SS. We also found thatwhen the cross-sectional area of the UES was larger,
hyolaryngeal elevation was increased with the THS.
To the best of our knowledge, no studies have yetreported the effect of the THS on UES opening. Ourfindings that not only pharyngeal constriction, but also
hyolaryngeal elevation and UES opening change with
the THS may be important in clinical practice. Further
study is needed to analyze the effect of the THS on
hyolaryngeal elevation and UES opening by adjusting
tongue protrusion length.
There were some limitations in this study. First, ourprotocol was limited to one SS scan and one THS scanfor each participant in order to minimize the potential
risk associated with radiation exposure. All participants
were speech language pathologists who wereknowledgeable about the THS and were familiar withits methodology, and thus variability was expected tobe small between trials. In future, however, it will benecessary to minimize variability between trials by
ensuring that participants practice the THS sufficiently
before scanning. The second limitation was the 45°
reclining posture during scanning, which was the only
position technically feasible with 320-ADCT.
Generally, the reclining posture, which changes theangle of the trunk, is used to facilitate bolus transport
to the pharynx. The effect of posture is an importantconsideration during swallowing. Because food is not
used with the THS, the influence of the reclining
posture on the results was probably low. However, wecannot eliminate the possibility that gravity may havealtered the positional relation of swallowing structures.
In future, tongue protrusion length should be adjusted
and the effect of the THS on pharyngeal volume change,
hyolaryngeal movement, and UES opening should be
addressed to clarify whether the THS is effective forstrengthening pharyngeal constriction and to determine
the optimal THS methodology. Moreover, the effect of
the THS in patients with dysphagia needs to be analyzed
in order to comprehensively understand its feasibility inthis population.
Conclusion
We analyzed the effect of the THS on swallowing
kinematics. Pharyngeal volume differed with the THS
compared with the regular SS. This suggests that the
THS influenced the pharyngeal cavity in some way,
but we could not identify a clear trend. To clarify theeffect of the THS on the pharyngeal cavity, more
specific THS instruction is recommended. Our study
also revealed the potential effect of the THS on
hyolaryngeal elevation and UES opening.
Acknowledgments
We would like to acknowledge the SLHT at Fujita
Health University Hospital.

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