Toynbee maneuver

Anatomy of the right middle ear. The Eustachian tube extends from the middle-ear cavity toward the nasopharynx.

The Toynbee maneuver (also Toynbee manoeuvre) is a technique in which a person swallows while the nostrils are occluded, usually with the mouth closed. The maneuver produces pressure changes in the nasopharynx and, when the Eustachian tube opens during swallowing, may cause a measurable change in middle ear pressure.

The maneuver is named after the English otologist Joseph Toynbee, who in 1853 described an experiment in which the mouth and nose were closed while saliva was swallowed. The maneuver is used in tests of Eustachian-tube function and is also one of several techniques used in attempts to equalize middle-ear pressure.

History

The first page of the published abstract of Toynbee's 1853 paper, containing his closed-mouth and closed-nose swallowing experiment.

Joseph Toynbee investigated the anatomy and function of the Eustachian tube during the development of nineteenth-century otology. His paper On the Muscles which open the Eustachian Tube was received by the Royal Society on 2 February 1853 and read at a meeting on 17 February.

The Royal Society archive retains the original 33-page manuscript as reference AP/35/5. The Society did not publish the paper in full, but published a two-page abstract in volume 6 of the Abstracts of the Papers Communicated to the Royal Society of London.

In the published abstract, Toynbee described swallowing saliva while the mouth and nose were closed and reported a sensation of fullness or distension in the ears. He interpreted this as evidence that swallowing opened the Eustachian tubes and allowed compressed pharyngeal air to enter the tympanic cavities. He also cited the practice of swallowing during descent in a diving bell, reasoning that opening of the Eustachian tubes allowed pressure in the middle ear to equilibrate with the increasing external pressure.

A contemporary version of the paper appeared in the Philadelphia journal The Medical Examiner in April 1853.

Later otological literature associated the closed-nose swallowing maneuver with Toynbee's name. A historical review by Feldmann describes Toynbee's conclusion that the Eustachian tube is normally closed, opens during swallowing, and that swallowing with the nostrils closed changes middle-ear pressure.

Toynbee's original explanation treated the pressure change as predominantly positive. Subsequent studies have produced differing descriptions of the pressure generated by the maneuver, and direct simultaneous nasopharyngeal and tympanometric measurements demonstrate that both positive and negative pressure phases can occur.

Physiology

The Eustachian tube connects the middle-ear cavity with the nasopharynx. In normal physiology it is closed for much of the time and opens transiently during activities including swallowing, permitting ventilation and pressure regulation of the middle ear.

Occluding the nostrils during swallowing alters the pressure changes generated in the nasopharynx. The resulting pressure sequence is not simply negative or positive. In a study using nasopharyngeal catheters together with repeated tympanometry, researchers recorded individual nasopharyngeal pressure patterns ranging from maxima of approximately +450 mm H₂O to minima of −320 mm H₂O. When the Eustachian tube opens during the maneuver, part of these pressure changes may be transmitted to the middle ear. The associated nasopharyngeal and middle-ear pressure changes have been called the Toynbee phenomenon.

The direction and magnitude of the resulting middle-ear pressure change vary between individuals and according to the timing of Eustachian-tube opening relative to the nasopharyngeal pressure cycle. Consequently, descriptions of the Toynbee maneuver as invariably producing either positive or negative middle-ear pressure are oversimplifications.

Clinical use

The Toynbee maneuver can be incorporated into tests intended to detect Eustachian-tube opening. For example, middle-ear pressure can be measured before and after the maneuver by tympanometry, while other test systems can detect tube opening by changes in sound transmission or acoustic impedance.

A detectable pressure change after a Toynbee maneuver can provide evidence that the Eustachian tube has opened, but the maneuver is not considered a sufficiently sensitive or specific test to diagnose Eustachian tube dysfunction on its own. An international consensus statement on Eustachian-tube dysfunction concluded that the ability to auto-inflate the middle ear using either the Valsalva maneuver or Toynbee maneuver does not have adequate sensitivity or specificity for diagnosis.

Results also depend on how Eustachian-tube opening is measured and on the exact maneuver performed. In a study of 75 healthy ears, Smith and colleagues found substantial differences in detected opening rates between different test–maneuver combinations; Toynbee and ordinary swallowing maneuvers also differed according to whether swallowing was performed with or without water.

A subsequent diagnostic-accuracy study found that combining objective tests of Eustachian-tube opening was more informative than relying on individual symptoms or a single test, and proposed a diagnostic pathway incorporating tests such as tympanometry, sonotubometry and tubomanometry.

For baro-challenge-induced Eustachian-tube dysfunction, a 2018 systematic review found that no single Eustachian-tube function test could be recommended for routine clinical use and suggested that combinations of objective tests were more promising.

Pressure equalization

The Toynbee maneuver is also used as a voluntary middle-ear pressure-equalization technique. Evidence for its effectiveness as an isolated equalization maneuver is limited. In a prospective study of 60 healthy ears under normal atmospheric conditions, both the Toynbee and Valsalva maneuvers produced successful middle-ear pressure equalization in 51.7% of ears, with no statistically significant difference between the two techniques. Because the experiment was performed under physiological rather than changing ambient-pressure conditions, the result does not directly establish effectiveness during diving, aviation or other barometric challenges.

See also

• Ear clearing
• Eustachian tube
• Eustachian tube dysfunction
• Valsalva maneuver
• Frenzel maneuver
• Barotrauma
• Voluntary Tubal Opening

Further reading

• Alsayegh, Raihanah; Silver, Jennifer; Agnihotram, Raman; Gurberg, Joshua (2024). "When Can Children Perform Valsalva and Toynbee Maneuvers? An Exploratory Study". Otology & Neurotology. 45 (4): 415–418. doi:10.1097/MAO.0000000000004146. PMID 38437819.

• Kruthika, Suresh; Govindaraju, Jeevan; Shetty, Hemanth N. (2025). "Comparative Evaluation of Wet and Dry Swallowing in Assessing Eustachian Tube Function in Tympanic Membrane Perforation". International Archives of Otorhinolaryngology. 29 (4): 001–006. doi:10.1055/s-0045-1811253. PMC 12530902. PMID 41113755.