Response of genioglossus muscle activity to nasal airway occlusion in normal sleeping adults

To determine the combined effect of increased subatmospheric upper airway pressure and withdrawal of phasic volume feedback from the lung on genioglossus muscle activity, the response of this muscle to intermittent nasal airway occlusion was studied in 12 normal adult males during sleep. Nasal occlusion at end expiration was achieved by inflating balloon-tipped catheters located within the portals of a nose mask. No seal was placed over the mouth. During nose breathing in non-rapid-eye-movement (NREM) sleep, nasal airway occlusion resulted in multiple respiratory efforts before arousal. Mouth breathing was not initiated until arousal. Phasic inspiratory genioglossus activity was present in eight subjects during NREM sleep. In these subjects, comparison of peak genioglossus inspiratory activity on the first three occluded efforts to the value just before occlusion showed an increase of 4.7, 16.1, and 28.0%, respectively. The relative increases in peak genioglossus activity were very similar to respective increases in peak diaphragm activity. Arousal was associated with a large burst in genioglossus activity. During airway occlusion in rapid-eye-movement (REM) sleep, mouth breathing could occur without a change in sleep state. In general, genioglossus responses to airway occlusion in REM sleep were similar in pattern to those in NREM sleep. A relatively small reflex activation of upper airway muscles associated with a sudden increase in subatmospheric pressure in the potentially collapsible segment of the upper airway may help compromise upper airway patency during sleep.     

Fluctuation in timing of upper airway and chest wall inspiratory muscle activity in obstructive sleep apnea

An imbalance in the amplitude of electrical activity of the upper airway and chest wall inspiratory muscles is associated with both collapse and reopening of the upper airway in obstructive sleep apnea (OSA). The purpose of this study was to examine whether timing of the phasic activity of these inspiratory muscles also was associated with changes in upper airway caliber in OSA. We hypothesized that activation of upper airway muscle phasic electrical activity before activation of the chest wall pump muscles would help preserve upper airway patency. In contrast, we anticipated that the reversal of this pattern with delayed activation of upper airway inspiratory muscles would be associated with upper airway narrowing or collapse. Therefore the timing and amplitude of midline transmandibular and costal margin moving time average (MTA) electromyogram (EMG) signals were analyzed from 58 apnea cycles in stage 2 sleep in six OSA patients. In 86% of the postapnea breaths analyzed the upper airway MTA peak activity preceded the chest wall peak activity. In 86% of the obstructed respiratory efforts the upper airway MTA peak activity followed the chest wall peak activity. The onset of phasic electrical activity followed this same pattern. During inspiratory efforts when phasic inspiratory EMG amplitude did not change from preapnea to apnea, the timing changes noted above occurred. Even within breaths the relative timing of the upper airway and chest wall electrical activities was closely associated with changes in the pressure-flow relationship. We conclude that the relative timing of inspiratory activity of the upper airway and chest wall inspiratory muscles fluctuates during sleep in OSA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional significance of the coupling between head and jaw movements

When humans open or close the jaw they also move the head. Unintentionally, it rotates backwards when the jaw opens and returns upon jaw closure. We hypothesized that this mutual movement coupling is related to the muscles in the floor of the mouth. A biomechanical model was applied to comprehend the functional significance of this movement coupling. As the jaw opened the jaw opening muscles shortened and became less forceful. Meanwhile they had to stretch the jaw closing muscles. The simulations showed that a simultaneous head extension facilitated jaw opening. A possible functional significance for the coupling between head and jaw movements is that it can extend jaw gape. Head extension can contribute to a wider jaw gape by on the one hand a reduced shortening of the jaw opening muscles and on the other hand by a reorientation of these muscles so that they obtain a more favorable position for jaw opening.     

Activation of masseter muscles with inspiratory resistance loading

Closure of the jaw exerts traction on muscles that insert on the hyoid bone and that may stabilize or expand the pharyngeal airway. We postulated that the masseter muscles, which close the jaw, would be activated when the patency of the pharyngeal airway is threatened. We therefore measured electromyographic activation of the masseters during inspiratory resistance loading and compared it with activation of chin muscles and alae nasi in 10 normal subjects. We observed no masseter activation during quiet unloaded breathing, but as pharyngeal pressure became lower there was a significant increase in masseter activation in all subjects. The change in masseter activation relative to pharyngeal pressure was similar to that of chin muscles and alae nasi. Activation of the masseter preceded the fall in pharyngeal pressure as also occurred in the chin muscles and alae nasi. We conclude that the masseters are activated by inspiratory resistance loading and have respiratory activity similar to pharyngeal airway muscles.     

Respiratory-related activity of upper airway muscles in anesthetized rabbit

The electromyographic activity of the glossal, suprahyoid, infrahyoid, and pharyngeal muscles was examined during spontaneous respiration in rabbits anesthetized with ketamine hydrochloride. This activity was then correlated with phases of the respiratory cycle. Our findings indicate that the overwhelming majority of the muscles comprising these groups show activity that increased during inspiration and returns to the background level during expiration and the end-expiratory pause. The exceptions are the inferior pharyngeal constrictor muscle, which demonstrates increased activity during expiration and the end-expiratory pause, and the stylohyoid major and digastric muscles, whose activity was not modulated with respiration. In general, the results obtained under ketamine anesthesia are in agreement with the studies on a more limited number of muscles in humans during sleep or in animal studies utilizing light anesthesia. Furthermore, the use of ketamine avoids the central suppressant effects produced by barbituate anesthesia. It has been argued that the upper airway muscles are rhythmically active during respiration to maintain the patency of the upper airway. Both the number of muscles that are rhythmically active and their strict correlation with specific phases of the respiratory cycle suggest that the forces exerted on the upper airway are complex and that peak tension is generated during inspiration. Further studies are required to evaluate the effects of ketamine anesthesia on these upper airway muscles before this rabbit model can be utilized to examine respiratory disorders of the upper airway.     

Respiratory-related recruitment of the masseter: response to hypercapnia and loading

To test the hypothesis that a muscle that closes the jaw, the masseter, can be recruited by ventilatory stimuli, we studied the electromyographic activation of the masseter and genioglossus in seven normal awake males who were exposed in random order to progressive hyperoxic hypercapnia, inspiratory threshold loading (-40 cmH2O), and combined hypercapnia and loading. With hypercapnia, the masseter was generally recruited after the genioglossus had been activated. Once recruited, activation of both muscles increased linearly with increasing CO2. Combined hypercapnia and loading produced more activation than either stimulus alone. These data indicate that the masseter is activated by ventilatory stimuli that activate the genioglossus. Earlier recruitment of the genioglossus suggests that activation of the masseter serves to stabilize the mandible and allow the genioglossus to function as a more efficient dilator of the upper airway.     

Effects of negative upper airway pressure on pattern of breathing in sleeping infants

Negative upper airway (UAW) pressure inhibits diaphragm inspiratory activity in animals, but there is no direct evidence of this reflex in humans. Also, little is known regarding reflex latency or effects of varying time of stimulation during the breathing cycle. We studied effects of UAW negative pressure on inspiratory airflow and respiratory timing in seven tracheostomized infants during quiet sleep with a face mask and syringe used to produce UAW suction without changing lower airway pressure. Suction trials lasted 2-3 s. During UAW suction, mean and peak inspiratory airflow as well as tidal volume was markedly reduced (16-68%) regardless of whether stimulation occurred in inspiration or expiration. Reflex latency was 42 +/- 3 ms. When suction was applied during inspiration or late expiration, the inspiration and the following expiration were shortened. In contrast, suction applied during midexpiration prolonged expiration and tended to prolong inspiration. The changes in flow, tidal volume, and timing indicate a marked inhibitory effect of UAW suction on thoracic inspiratory muscles. Such a reflex mechanism may function in preventing pharyngeal collapse by inspiratory suction pressure.     

Genioglossus activity available via non-arousal mechanisms vs. that required for opening the airway in obstructive apnea patients

It is generally believed that reflex recruitment of pharyngeal dilator muscles is insufficient to open the airway of obstructive apnea (OSA) patients once it is closed and, therefore, that arousal is required. Yet arousal promotes recurrence of obstruction. There is no information about how much dilator [genioglossus (GG)] activation is required to open the airway (GG Opening Threshold) or about the capacity of reflex mechanisms to increase dilator activity before/without arousal (Non-Arousal Activation). The relationship between these two variables is important for ventilatory stability. We measured both variables in 32 OSA patients (apnea-hypopnea index 74 ± 42 events/h). GG activity was monitored while patients were on optimal continuous positive airway pressure (CPAP). Zopiclone was administered to delay arousal. Maximum GG activity (GG(MAX)) and airway closing pressure (P(CRIT)) were measured. During stable sleep CPAP was decreased to 1 cmH(2)O to induce obstructive events and the dial-downs were maintained until the airway opened with or without arousal. GG activity at the instant of opening (GG Opening Threshold) was measured. GG Opening Threshold averaged only 10.4 ± 9.5% GG(Max) and did not correlate with P(CRIT) (r = 0.04). Twenty-six patients had >3 openings without arousal, indicating that Non-Arousal Activation can exceed GG Opening Threshold in the majority of patients. GG activity reached before arousal in Arousal-Associated Openings was only 5.4 ± 4.6% GG(MAX) below GG Opening Threshold. We conclude that in most patients GG activity required to open the airway is modest and can be reached by non-arousal mechanisms. Arousals occur in most cases just before non-arousal mechanisms manage to increase activity above GG Opening Threshold. Measures to reduce GG Opening Threshold even slightly may help stabilize breathing in many patients.     

Effects of Neuromuscular Electrical Stimulation on the Masticatory Muscles and Physiologic Sleep Variables in Adults with Cerebral Palsy: A Novel Therapeutic Approach

Cerebral palsy (CP) is a term employed to define a group of non-progressive neuromotor disorders caused by damage to the immature or developing brain, with consequent limitations regarding movement and posture. CP may impair orapharygeal muscle tone, leading to a compromised chewing function and to sleep disorders (such as obstructive sleep apnea). Thirteen adults with CP underwent bilateral masseter and temporalis neuromuscular electrical stimulation (NMES) therapy. The effects on the masticatory muscles and sleep variables were evaluated using electromyography (EMG) and polysomnography (PSG), respectively, prior and after 2 months of NMES. EMG consisted of 3 tests in different positions: rest, mouth opening and maximum clenching effort (MCE). EMG values in the rest position were 100% higher than values recorded prior to therapy for all muscles analyzed (p < 0.05); mean mouth opening increased from 38.0 ± 8.0 to 44.0 ± 10.0 cm (p = 0.03). A significant difference in MCE was found only for the right masseter. PSG revealed an improved in the AHI from 7.2±7.0/h to 2.3±1.5/h (p < 0.05); total sleep time improved from 185 min to 250 min (p = 0.04) and minimun SaO2 improved from 83.6 ± 3.0 to 86.4 ± 4.0 (p = 0.04). NMES performed over a two-month period led to improvements in the electrical activity of the masticatory muscles at rest, mouth opening, isometric contraction and sleep variables, including the elimination of obstructive sleep apnea events in patients with CP.

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ReBEC RBR994XFS http://www.ensaiosclinicos.gov.br     

The orientation of the force of the jaw muscles and the length of the mandible in mammals

Ungulates generally have large masseter and pterygoid muscles and a necessarily large angular process provides attachment surface on the mandible. The temporalis muscle tends to be small. It has been suggested that this is an adaptation for enhanced control of the lower jaw and reduction of forces at the jaw joint. I suggest an additional reason: because of the geometry of the jaw, the length of that segment of the lower jaw that spans the distance from the jaw joint to the most posterior tooth is significantly reduced when the masseler and pterygoid are the dominant muscles; this region is necessarily much longer when the temporalis is large.     

Influence of upper airway negative pressure reflex on response to airway occlusion in sleeping infants

Artificially produced upper airway suction inhibits the diaphragm in animals and infants; however, the effects of spontaneously generated suction in humans are unknown. We studied nine tracheostomized infants because separation of the upper from the lower airway allowed us to channel suction created by an occluded inspiratory effort to both upper and lower airways (upper + lower airway occlusions) or to the lower airway only (lower airway occlusion). The tracheostomy airway was briefly occluded at end expiration during quiet sleep. In upper + lower airway occlusions, peak airway pressure of the first occluded breath was less negative and rate of pressure decrease slower than that of lower airway occlusions, indicating that upper airway suction inhibits thoracic inspiratory muscles. The threshold for this response was less than or equal to 4 cmH2O suction pressure. The effect on inspiratory time was variable. A decrease in slope of the inspiratory pressure waveform occurring at approximately 0.12 s after inspiration onset was more marked in upper + lower airway occlusions. We conclude that infants have an upper airway reflex response to inspiratory pressure that alters not only the peak and slope but also the shape of the inspiratory pressure waveform.     

Respiratory function of hyoid muscles and hyoid arch

The position of the hyoid arch suggests that it supports soft tissue surrounding the upper airway (UA) and can act to maintain UA patency. We also suspected that muscles inserting on the hyoid arch might show respiratory patterns of activity that could be affected by respiratory stimuli. To test these possibilities, we moved the hyoid arch ventrally in six anesthetized dogs either by traction on it or by stimulation of hyoid muscles. UA resistance was decreased 73 +/- (SE) 6% and 72 +/- 6% by traction and stimulation during expiration and 57 +/- 15% and 52 +/- 8% during inspiration. Moving averages of the geniohyoid (GH) and thyrohyoid (TH) obtained in six other dogs breathing 100% O2 showed phasic respiratory activity while the sternohyoid (SH) showed phasic respiratory activity in only two of these animals and no activity in four. With progressive hypercapnia, GH and TH increased as did SH when activity was already present. Airway occlusion at end expiration augmented and prolonged inspiratory activity in the hyoid muscles but did not elicit SH activity if not already present. Occlusion at end inspiration suppressed phasic activity in hyoid muscles for as long as in the diaphragm. After vagotomy activity increased and became almost exclusively inspiratory. Activity appeared in SH when not previously present. Duration and amplitude of hyoid muscle activity were increased with negative UA pressure and augmented breaths. We conclude that the hyoid arch and muscles can strongly affect UA flow resistance. Hyoid muscles show responses to chemical, vagal, and negative pressure stimuli similar to other UA muscles.     

Airway resistance and respiratory muscle function in snorers during NREM sleep

The effect of non-rapid-eye-movement (NREM) sleep on total pulmonary resistance (RL) and respiratory muscle function was determined in four snorers and four nonsnorers. RL at peak flow increased progressively from wakefulness through the stages of NREM sleep in all snorers (3.7 +/- 0.4 vs. 13.0 +/- 4.0 cmH2O X 0.1(-1) X s) and nonsnorers (4.8 +/- 0.4 vs. 7.5 +/- 1.1 cmH2O X 1(-1) X s). Snorers developed inspiratory flow limitation and progressive increase in RL within a breath. The increased RL placed an increased resistive load on the inspiratory muscles, increasing the pressure-time product for the diaphragm between wakefulness and NREM sleep. Tidal volume and minute ventilation decreased in all subjects. The three snorers who showed the greatest increase in within-breath RL demonstrated an increase in the contribution of the lateral rib cage to tidal volume, a contraction of the abdominal muscles during a substantial part of expiration, and an abrupt relaxation of abdominal muscles at the onset of inspiration. We concluded that the magnitude of increase in RL leads to dynamic compression of the upper airway during inspiration, marked distortion of the rib cage, recruitment of the intercostal muscles, and an increased contribution of expiratory muscles to inspiration. This increased RL acts as an internal resistive load that probably contributes to hypoventilation and CO2 retention in NREM sleep.     

Medial pterygoid muscle activity during the closing and compressive phases of human mastication

The lack of specific data correlating activity in the human medial pterygoid muscle with displacement of the jaw during mastication, and the hint of possible differences in function between certain mammalian species, prompted a study of unilateral mastication in six adult subjects. Muscle activity in the medial pterygoid, masseter, and anterior temporal muscles was recorded simultaneously with three-dimensional movement of an incisor point on the mandible. Signals from muscles and displacement transducer were sampled by a disc-based computer system programmed to analyze data averaged over 30 chewing cycles on each side and in some instances over 30 open-close and clench cycles. Patterns of medial pterygoid activity were consistent for the group as a whole, demonstrating activation of both muscles early in the closing cycle with strong ipsilateral muscle activity before and throughout the intercuspal phase of mastication. By contrast contralateral activity ceased during the crushing phase of the cycle, reappearing in some subjects just before the end of intercuspation. Medial pterygoid activity mirrored masseter and anterior temporal activity only during certain phases of the closing cycle, suggesting that these muscles should be considered as being selectively coactivated with, rather than synergists of, the major elevators of the jaw. The muscles were active during horizontal components of movement of the incisor teeth in chewing, but were inactive during the open-close and clench task despite vigorous contraction of the masseter muscles. Overall, the observations complement previous reports of medial pterygoid muscle activity in humans. They also confirm, for these muscles at least, a general similarity between man and the little brown bat, a relationship hitherto suspected but unsubstantiated.     

Influences of NREM sleep on the activity of tonic vs. inspiratory phasic muscles in normal men.

Studies of sleep influences on human pharyngeal and other respiratory muscles suggest that the activity of these muscles may be affected by non-rapid-eye-movement (NREM) sleep in a nonuniform manner. This variable sleep response may relate to the pattern of activation of the muscle (inspiratory phasic vs. tonic) and peripheral events occurring in the airway. Furthermore, the ability of these muscles to respond to respiratory stimuli during NREM sleep may also differ. To systematically investigate the effect of NREM sleep on respiratory muscle activity, we studied two tonic muscles [tensor palatini (TP), masseter (M)] and two inspiratory phasic ones [genioglossus (GG), diaphragm (D)], also measuring the response of these muscles to inspiratory resistive loading (12 cmH2O.l-1.s) during wakefulness and NREM sleep. Seven normal male subjects were studied on a single night with intramuscular electrodes placed in the TP and GG and surface electrodes placed over the D and M. Sleep stage, inspiratory airflow, and moving time average electromyograph (EMG) of the above four muscles were continuously recorded. The EMG of both tonic muscles fell significantly (P less than 0.05) during NREM sleep [TP awake, 4.3 +/- 0.05 (SE) arbitrary units, stage 2, 1.1 +/- 0.2; stage 3/4, 1.0 +/- 0.2. Masseter awake, 4.8 +/- 0.6; stage 2, 3.3 +/- 0.5; stage 3/4, 3.1 +/- 0.5]. On the other hand, the peak phasic EMG of both inspiratory phasic muscles (GG and D) was well maintained.(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of pharyngeal airway stability in normal and micrognathic infants

A current hypothesis for obstructive sleep apnea states that 1) negative airway pressure during inspiration can collapse the pharyngeal airway, and 2) neural control of pharyngeal airway-dilating muscles is important in preventing this collapse. To test this hypothesis we performed nasal mask occlusions to increase negative pharyngeal airway pressures during inspiration in eight normal and five micrognathic infants. Both groups developed midinspiratory pharyngeal obstruction, but obstruction was more frequent in micrognathic infants and varied in some infants with sleep state. The airway usually reopened with the subsequent expiration. The occasional failure to reopen was presumably due to pharyngeal wall adhesion. If airway obstruction occurred in sequential breaths during multiple-breath nasal mask occlusions in normal infants, there was a breath-by-breath change in the airway pressure associated with airway closure (airway closing pressure); the airway closing pressure became progressively more negative. Micrognathic infants showed less ability to improve the airway closing pressure, but this ability increased with age. These findings suggest that nasal mask occlusion can test the competence of the neuromuscular mechanisms that maintain pharyngeal airway patency in infants. Micrognathic infants had spontaneous midinspiratory pharyngeal airway obstructions during snoring. Their episodes of obstructive apnea began with midinspiratory pharyngeal obstruction similar to that seen during snoring and nasal mask occlusions. These findings imply a similar pathophysiology for snoring, spontaneous airway obstruction, and obstruction during snoring.     

Simultaneous total correction of temporomandibular ankylosis and facial asymmetry

Ankylosis of the temporomandibular joint not only prevents mouth opening and chewing, but also affects the growth and position of the mandible. This produces progressive facial distortion with devastating psychosocial effects compounding the already difficult problem of not being able to open the mouth. Over the past 6 years, 18 patients in Canada and Taiwan were treated by excision of a large block of bone at the ankylosis and repositioning of the jaw, with the addition of osteotomies as necessary to produce a symmetrical face with good occlusion. Bilateral cases were treated at one operation in a similar way. The temporomandibular joint and absent ramus were constructed with a costochondral graft taken from the opposite chest. Some patients were treated with intermaxillary fixation for 8 weeks, while others had no fixation, but there was no difference in the effectiveness of correction of the ankylosis.     

Jaw muscles in older overdenture patients

Objective: To determine, using computer tomography (CT), whether the retention of a small number of teeth in the older adult used to support overdentures could affect the cross‐sectional area (CSA) and X‐ray density of two jaw closing muscles. Design: Cross‐sectional study of a group of older patients subdivided into dentate, edentulous and those wearing overdentures supported by two to five teeth. Subjects: The sample consisted of 24 subjects aged 55–68 years. Outcome measures: CSA and X‐ray density of two jaw closing muscles, masseter and medial pterygoid were measured and evaluated using CT. Results: There were no significant differences between left and right jaw muscles, but the CSA of the masseter muscles were significantly larger than the medial pterygoid muscles. The CSA of the masseter and medial pterygoid muscles was significantly smaller in edentulous subjects compared with dentate subjects but no significant difference was observed between subjects wearing overdentures and those with a natural dentition. No significant differences were observed with the X‐ray density between different muscles or dental states. Conclusion: The retention of a small number of teeth in the older adult used to support overdentures appears to sustain the CSA of two jaw closing muscles and therefore could enhance these patients’ masticatory ability compared with those who were edentulous.     

Coactivation of jaw muscles: recruitment order and level as a function of bite force direction and magnitude

The aim of this study was to obtain insight into the coactivation behaviour of the jaw muscles under various a priori defined static loading conditions of the mandible. As the masticatory system is mechanically redundant, an infinite number of recruitment patterns is theoretically possible to produce a certain bite force. Using a three-component force transducer and a feedback method, subjects could be instructed to produce a bite force of specific direction and magnitude under simultaneous registration of the EMG activity of anterior and posterior temporal, masseter and digastric muscles on each side. Forces were measured at the second premolars. Vertical, anterior, posterior, lateral and medial force directions were examined; in each direction force levels between 50 N and maximal voluntary force were produced. The results show that for all muscles the bite force-EMG relationship obeys a straight-line fit for forces exceeding 50 N. The relationship varies with bite force direction, except in the case of the digastric muscles. Variation is small for the anterior temporal and large for the posterior temporal and masseter muscles. The relative activation of muscles for a particular force in a particular direction in unique, despite the redundancy.     

Changes of respiratory input impedance during breathing in humans.

Changes of total respiratory resistance (Rrs) and reactance (Xrs) were studied between 8 and 32 Hz at five moments during the respiratory cycle in healthy adults (group A) and children (group B) and in patients with chronic obstructive lung disease (group C) and with upper airway obstruction (group D). Two forced oscillation techniques were used: the conventional one and the head generator, with the oscillations applied at the mouth and around the head of the subject, respectively. Both techniques yielded similar results. Rrs is lowest during the transition from inspiration to expiration and highest in the course of expiration, except in group D. Mean Xrs is highest at the transitions from inspiration to expiration or vice versa and lowest during expiration, except in group D. In groups C and D, the increases of Rrs are accompanied by a more pronounced negative frequency dependence of Rrs. The variations of Rrs and Xrs appear to be markedly flow dependent and may be a consequence of the interaction of breathing with oscillatory flows.