The Masako manoeuvre, also known as the tongue-hold or tongue-retaining swallow, is a rehabilitation exercise targeting the posterior pharyngeal wall and tongue base. Unlike compensatory manoeuvres used during meals, it is primarily an exercise performed dry (without food or liquid) to strengthen pharyngeal constrictor function over time.

Background

Named after Fujiu and Logemann’s 1996 paper describing the technique (conducted partly in collaboration with Japanese colleagues, hence the eponym), the Masako manoeuvre was developed in response to a clinical problem: the posterior pharyngeal wall often contracts insufficiently to contact the tongue base during the swallow, leaving residue in the valleculae and increasing aspiration risk. Directly strengthening pharyngeal wall contraction is difficult, as the constrictor muscles are not under easy voluntary control. The Masako manoeuvre offers an indirect approach.

Mechanism of Action

During a normal swallow, the tongue base retracts to contact the posterior pharyngeal wall, and the pharyngeal constrictors simultaneously contract forward to meet the tongue base — a pincer-like motion that generates the pressure wave driving the food bolus through the pharynx into the oesophagus.

When the patient holds the tongue tip gently between their anterior teeth and swallows, the tongue cannot retract normally. This forces the posterior pharyngeal wall to compensate by contracting further forward than usual to maintain bolus propulsion. Over repeated practice, this increased demand is thought to strengthen the pharyngeal constrictor muscles through physiological overload — the same principle used in resistance training.

Biomechanical support for this mechanism was provided by Fujiu and Logemann (1996), who used videofluoroscopy to show significantly increased posterior pharyngeal wall motion during tongue-hold swallows compared to normal swallows.

Evidence Base

• Fujiu and Logemann (1996): Original study demonstrating posterior pharyngeal wall augmentation on fluoroscopy in healthy volunteers. This paper established the biomechanical rationale.
• Umezaki et al. (1998): Confirmed pharyngeal wall motion increase in patients with dysphagia secondary to oral-pharyngeal cancer resection.
• Doeltgen et al. (2009) used manometry to show that practising the Masako manoeuvre over six weeks increased pharyngeal pressure in dysphagic patients.
• Van Daele et al. (2005): Surface EMG study showing increased submental and suprahyoid muscle activity during tongue-hold swallows, suggesting secondary benefit to hyolaryngeal elevation.
• A Cochrane review on swallowing exercises by Speyer (2013) included the Masako manoeuvre among exercises with some evidence for benefit on physiological outcomes, noting methodological limitations in the literature.

The evidence is stronger for physiological outcome measures (pharyngeal wall motion, manometry pressure) than for functional outcomes (penetration-aspiration scale, diet level changes), reflecting a need for further pragmatic RCTs.

Patient Selection Criteria

Appropriate for patients who:

• Show reduced posterior pharyngeal wall motion on VFSS or FEES, with vallecular residue as a prominent finding
• Have received treatment for oral or oropharyngeal cancer, particularly where pharyngeal reconstruction was performed
• Present with presbyphagia and reduced pharyngeal pressure generation
• Are cognitively intact and motivated for an exercise programme (typically three to five sessions per day, five days per week for six to twelve weeks)
• Can gently protrude and hold the tongue between the front teeth without discomfort

Contraindications and Precautions

• Anterior dentition problems: Patients with dentures, crowns, or significant periodontal disease may not be able to hold the tongue between teeth comfortably. Modify the technique (hold tongue at lip line rather than between teeth) and document the adaptation.
• Tongue resection or reconstruction: The technique must be adapted and confirmed feasible by the SLT on a case-by-case basis; partial glossectomy patients may find tongue protrusion limited.
• Active oral mucositis: Common in patients undergoing chemotherapy or radiotherapy — defer until mucositis resolves.
• Severe cognitive impairment: The exercise requires consistent unsupervised home practice; patients who cannot follow through should have caregiver involvement.
• This is an exercise, not a meal strategy: The Masako manoeuvre should NOT be used routinely during meals, as the tongue-hold position reduces bolus control and can paradoxically increase aspiration. It is exclusively for exercise sets.

Protocol

A standard Masako manoeuvre programme:

Preparation: Sit upright, relaxed. Ensure adequate saliva (sip water beforehand if mouth is dry).

The manoeuvre:

1. Gently protrude the tongue and hold the tip lightly between the front teeth (upper and lower incisors). Do not bite down hard.
2. Swallow your saliva while keeping the tongue in this position.
3. Release and rest for three to five seconds.
4. Repeat.

Dosage: 10 repetitions per set, 3–5 sets per day, five to seven days per week. Continue for six to twelve weeks, then reassess with instrumental evaluation.

Progression: Once posterior pharyngeal wall motion normalises on reassessment, transition to functional swallowing tasks and consider whether the exercise should continue as maintenance.

Home practice record: Provide patients with a simple tally sheet to track daily repetitions. Compliance directly correlates with outcomes.

Combining with Other Techniques

The Masako manoeuvre is commonly used alongside:

• Shaker (head-lift) exercise: Targets suprahyoid and anterior neck muscles; different muscle group from Masako.
• Effortful swallow: Also targets pharyngeal pressure generation and complements Masako training.
• EMST: Targets expiratory and suprahyoid muscles; can be combined for comprehensive pharyngeal rehabilitation.

In a structured programme, mixing exercises prevents monotony and targets multiple dysphagia mechanisms simultaneously.

HK and Regional Context

In Hong Kong public hospital SLT departments, the Masako manoeuvre is most often prescribed in oncology follow-up clinics and post-radiation dysphagia programmes. At institutions such as Queen Mary Hospital and the Prince of Wales Hospital, it is part of standard post-treatment rehabilitation protocols for head and neck cancer.

The technique can be taught in Cantonese using simple language: “把舌頭尖輕輕夾住上下門牙，然後吞口水。” Family members can monitor home exercise compliance, which is particularly helpful in Chinese family caregiving culture.

Patients undergoing radiotherapy for nasopharyngeal carcinoma (NPC) — a cancer with elevated prevalence in Hong Kong and southern China compared to Western populations — represent a significant patient group who may benefit from this manoeuvre as part of prophylactic or rehabilitative swallowing therapy.

Outcome Monitoring

Reassess with VFSS or FEES at six and twelve weeks. Look for:

• Increased posterior pharyngeal wall excursion during swallow
• Reduction in vallecular residue
• Improved overall pharyngeal clearance

If no response at twelve weeks, review patient compliance, reconsider diagnosis (structural vs. neuromuscular cause), and evaluate alternative or adjunctive treatments.