These are strategies used to help people who have swallowing disorders swallow their food without negative consequences. The term compensatory, in this case, means that these strategies are not treatment or therapy; if these are the solution to a long term problem, they will have to be used every time you swallow. As such, they are ideally used only in the short term, although unfortunately many people will end up using one or more of these strategies indefinitely.

These are presented here for informational purposes; if you or someone you are caring for has nerve damage to the larynx and pharynx (and if you have a swallowing disorder, you probably do) you may not know if you are aspirating, and you may not be able to judge the efficacy of these strategies on your own. You will never have enough information to be certain that one of these strategies will work for you. In order to figure out what will work, you need to actually see the swallow from the inside; this means using video fluoroscopy with a modified barium swallow or a video endoscope threaded through the nasal cavity and down the back of the throat. However, if you have a swallowing disorder there is nothing wrong with trying to find a more comfortable and efficient way to get your food down. If you try the methods below, please be careful, and I strongly encourage you to see a SLP or other professional. And beware of any professional who prescribes a 'positional' or 'muscular' strategy without looking at your swallow using the methods listed above. Some strategies, particularly the 'chin tuck' are so useful that they are sometimes suggested without checking to see that they actually work in a given case; this can be a mistake, and you should question it.

Some words you should know: aspiration means food or other material going down your windpipe and into your lungs. Bolus is the technical term for the wad of food you are chewing, or liquid that you are swallowing. Residue means any food that is left over in the pharynx after you swallow. The pharynx is the area between the back of your tongue and the back of your throat, with the nasal cavity above and your larynx and esophagus below. The larynx is the top of your windpipe; it contains your vocal cords and your false vocal cords. Your False vocal cords are just flaps of tissue that close tight above your vocal cords to protect the windpipe. The esophagus is the pipe going down to your stomach. It has a sphincter at the top, the Upper Esophageal Sphincter, or UES. And finally, the epiglottis is the 'trap door' that folds down over your windpipe when you swallow.

The Normal Swallow

You need to know what a normal swallow looks like in order to understand how the compensatory strategies work. Don't worry, I'll keep it quick and simple.

Normally you chew your food and use your tongue to move it to the back of your mouth; once there (specifically at the faucial pillars), the swallow reflex is triggered. Before you actually swallow, your soft palate will elevate to close off your nasal cavity. Importantly, before you swallow the 'trap door' of your epiglottis is standing open, up straight. If any food falls down over the back of your tongue it will get caught behind the epiglottis, keeping it from falling down your windpipe.

When you swallow your pharynx shortens; your vocal cords and your false vocal cords shut tightly; the epiglottis closes down over the larynx (note that you now have three layers of protection over your airway); the UES both relaxes and is pulled open; and the food is pushed down by the tongue and moved through the pharynx by a waving motion and contraction of the muscles. If things go right, all the food will go down to the stomach in one fell swoop.

The Abnormal Swallow

Any of these steps can go wrong. Everybody has laughed and had food go up their nose, inhaled at the wrong time and aspirated some food, has had some food spill down their throat before they were ready (usually to be caught safely behind the epiglottis), or had to swallow more than once to get something down properly. If any of these things happen regularly it can be a serious problem; food falling down too early or remaining behind after the swallow can enter the airway, causing aspiration and aspiration pneumonia (your body can reabsorb most food and liquids that spill into the lungs, but when bacteria from the mouth repeatedly enter the lungs, eventually they'll start an infection). Difficulty swallowing can also cause pain, malnutrition and dehydration due to the difficulty of eating, and social awkwardness.

These problems are most often due to neurological damage (for example, a stroke), cancer, or the after effects of an operation. However there are many other possible causes, any any type of nerve damage, particularity to the vagus nerve, can cause problems in the swallow reflex, leading to aspiration and difficulty swallowing.

Behavioral strategies

These are by far the safest strategies to try, and are generally both the easiest and the 'least weird', in that they can easily be used when eating dinner with friends and family without anyone noticing that you are working on your swallow. They are very simple, but unfortunately that makes them easy to forget. These are generally the first line of defense for anyone who has a swallowing problem, and are good advice for the rest of us too.

Take small bites and sips: Your grandmother was right, small bites are safer. This is especially true with liquids, which tend to make a run for your windpipe and may be able to get to the back of your mouth before you are ready to swallow, but it is good advice for any type of food. Smaller bites are easier to move into position for swallowing, are less likely to leave residue in the mouth and throat, and are easier to clear if they do get into the windpipe.

Alternate bites and sips: Most of us tend to eat a bit and then take a swallow or two of drink. It's actually safer to alternate one bite, one sip. The liquid helps to clear out food residue that might fall into the windpipe, and breaking up your consumption of liquids discourages you from taking large gulps or multiple sips when you do drink.

Avoid slurping and drinking through straws: Both of these tend to deliver liquids at high velocity to the back of the tongue. If you have a delayed swallow reflex, this liquid is likely to start down your throat before you are ready for it. Straws should only be used when there is a good reason, i.e., if you are unable to hold a cup. Slurping is even worse that using a straw; at least the straw is somewhat targeted in its delivery of liquid.

Postural strategies

Sitting up: Your swallowing apparatus works best when you are sitting upright. This keeps food from falling back into your throat before you are ready for it, and allows the pouch behind the epiglottis to hold the maximum amount of 'spilled' food. Even if you are bedridden, it is well worth the effort of sitting up during eating. This will also allow gravity to help pull and keep that food down in the stomach, so if you are prone to reflux, you may also wish to remain sitting up for 30 minutes or so after you finish eating.

Lying down or Side lying: Most of the strategies that are commonly used involve doing something with the head or throat, but simply lying down will solve some problems. Both of these postures reduce the effect of gravity on the bolus; in the case of people who have a delayed swallow reflex, simply slowing the passage of the bolus through the oral cavity and the pharynx may be enough to prevent aspiration. Side-lying is used specifically when one side of the pharynx is weaker than the other (usually due to stroke); lying with the stronger side down makes the bolus fall to the side with the muscle strength to swallow it effectively.

The downside: Lying down when eating can often lead to acid reflux and problems with esophageal functioning. If you are prone to aspirating food, you are also prone to aspirating reflux. Stomach acid in the lungs is worse than food in the lungs, so this can be a major problem. These strategies also inhibit social eating more than many of the other strategies.

Chin tuck: AKA 'head flexion', the chin tuck is both simple and effective. The chin is brought down towards the chest ('looking down'), as far as is comfortable. This will narrow the oropharynx (the part of the pharynx directly behind the oral cavity), preventing food from spilling over the back of the tongue before the swallow reflex is triggered. It also pulls the base of the tongue forwards, widening the space between the tongue and the epiglottis, allowing it to hold more spilled material. This is one of the more effective ways of protecting the airway. This is very useful for patients who have food entering the pharynx before the swallow is triggered, and is very easy to experiment with; if you have a patient in front of the x-ray machine for an evaluation anyway, you can test its effectiveness in a matter of seconds.

The downside: This maneuver will weaken the strength of the muscle contractions of the larynx, and may reduce the opening of the UES. Thus, while the airway is well protected before the swallow, there may be more residue remaining after the swallow. Also, this is not a good action for someone with a spinal injury to try.

Head extension: Extension of the neck means raising the chin, or looking up. This is used for patients whose jaw or tongue are too weak to move the bolus backwards towards the throat. By raising the chin you allow gravity to help pull the food down -- very simple.

The downside: This is a bad maneuver for patients with swallowing problems other than that of moving the food back. It reduces airway protection and reduces UES opening, meaning aspiration is more likely and food going down towards the stomach is less likely.

Head rotation: Simply turning the head to the left or to the right can help if you have weakness on only one side. Common practice is to turn the head towards the weak side, narrowing the pharynx on that side and encouraging the bolus to keep to the other side. It also pulls the UES open, allowing the food to enter the esophagus more easily, decreasing food residue in the pharynx.

The downside: If you have unilateral neck weakness, it can be tiring to turn your head towards the weak side. You also have to worry about residue in the weak side of the pharynx, although this isn't exactly a downside, as without the head turn you would have even more residue.

Muscular strategies

Supraglottic and Super supraglottic swallows: These are useful strategies for people with airway protection problems, although they are a bit laborious to use through an entire meal. In the supraglottic swallow a person inhales, holds their breath, swallows, and then coughs to clear food residue from the larynx. This is used when it is common for food residue to be left in the pharynx, and the goal is simply to clear food residue away from the airway. The super supraglottic swallow differs in that one uses extra effort to hold one's breath. Without this extra effort about 33% of adults will not completely close the airway.

The downside: None actually. Aside from the obvious fact that deliberately holding one's breath and coughing for every single swallow is tiresome, I am aware of no problems with this maneuver. It should be noted that the natural instinct is to inhale after swallowing, so this swallow will take careful concentration until one is used to it.

The Mendelsohn Maneuver: This is a hard one to describe, so bear with me. The simple description is that you are holding the swallow for longer than you normally would. But to do it correctly you are measuring a specific landmark: hold your hand up to your throat, your fingers perpendicular to your neck, and swallow. You should feel a bony bump that moves up about a finger's width, and then back down. Now do it again, but hold that bump up at the top of its path for as long as you can (hold it by tensing your neck muscles, not with your fingers!). While the throat is in this state the epiglottis is closed, protecting the airway, and in some individuals the UES is open for longer periods of time. This maneuver may actually be used as therapy, rather than just as a compensatory strategy.

The downside: It is hard to teach, and tiring to do. It also may interrupt respiration for even longer than the supraglottic swallow, and so may be a problem for people with respiratory problems.

The Effortful swallow: AKA a 'hard swallow' or a 'forceful swallow'. Another hard one to describe; in this one you are simply "swallowing really hard". You are putting more muscle behind your swallow. The best way I can describe it is as if you were swallowing air for a burp -- just as you have to swallow a little harder to push the air down, you swallow a little harder to get the food down. This improves the seal above your airway and helps push the food down, resulting in less residue.

The downside: Different studies have found slightly different effects from this maneuver, making it somewhat uncertain. By and large, however, it does prove useful in many cases. Another problem is that it is hard to tell if the patient is actually 'swallowing hard'; even the Mendelsohn Maneuver can be easily observed by a trained professional, but there is no easy way to monitor the effortful swallow (although you can use a manometer).

These strategies listed above are by and large the only compensatory strategies that you are likely to come across. While there are other things your SLP may have you try, they tend to be therapeutic rather than compensatory. If you come across any others, I'd like to hear about them.

A few ending notes:

I would like to add two points for those of you who actually have to deal with a swallowing problem, especially if you are caring for someone else.

1. One of the biggest risks of swallowing disorders is that of aspiration pneumonia. The best thing you can do if aspiration is suspected is to maintain good oral hygiene. Brush teeth often, especially before eating, because you want the bad bacteria out of there before you aspirate it.

2. If you are caring for someone else who has a swallowing problem, be aware that studies have found overwhelmingly that individuals who feed themselves do better than those that are fed by someone else. Even a patient that is fed by some one guiding their hand to their mouth and helping them tip the food off the spoon will do better than if they are not part of the feeding process at all. This may be because the action of lifting food to your mouth activates a mental script that will cue the upcoming swallow reflex; it may be for some other reason entirely. Whatever the reason it's good information, use it if you can.

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