Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties

Residual velopharyngeal insufficiency after palatal repair varies from 10 to 20 percent in most centers. Secondary velopharyngeal surgery to correct residual velopharyngeal insufficiency in patients with cleft palate is a topic frequently discussed in the medical literature. Several authors have reported that varying the operative approach according to the findings of videonasopharyngoscopy and multiview videofluoroscopy significantly improved the success of velopharyngeal surgery. This article compares two surgical techniques for correcting residual velopharyngeal insufficiency, namely pharyngeal flap and sphincter pharyngoplasty. Both techniques were carefully planned according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. Fifty patients with cleft palate and residual velopharyngeal insufficiency were randomly divided into two groups: 25 in group 1 and 25 in group 2. Patients in group 1 were operated on by using a customized pharyngeal flap according to the findings of videonasopharyngoscopy and multiview videofluoroscopy in each case. Those in group 2 received a sphincter pharyngoplasty also customized according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients in both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after the individualized velopharyngeal surgery was not significantly different between the patient groups (12 percent versus 16 percent; p > 0.05). It seems that customized pharyngeal flaps and sphincter pharyngoplasties performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy are safe and reliable procedures for treating residual velopharyngeal insufficiency in cleft palate patients.     

An electromyographic study of elbow motion during postexercise muscle soreness

Postexercise muscle soreness was induced in the elbow flexors of human volunteer subjects through the use of a regimen of eccentric contractions. Physical examination before and 48 h after the exercise included measurements of range of elbow motion at the elbow and of arm diameter. Electromyographic (EMG) observations, utilizing fine wire electrodes introduced into each of the elbow flexors, were carried out before and 48 h after the exercise. These observations included resting EMG levels, EMG activity under various isometric loads, and activity during active and passive extensions. The soreness induced was accompanied by a reduction in resting elbow angle while the subjects stood with arms relaxed at their sides, decreased range of both flexion and extension of the elbow, and swelling of the arm. EMG measurements showed no increase in EMG activity as the sore arms were extended passively at the elbow, indicating that the extra resistance to extension associated with the soreness was not a result of stretch receptor-induced activity in the flexors. The results rule out the possibility that neuromuscular activity is responsible for the restriction of motion and are consistent with the idea that edematous changes within the perimuscular connective tissue alter the elastic behavior of the muscles and cause restriction of motion.     

Quadriceps and hamstring isokinetic strength and electromyographic activity measured at different ranges of motion: a reproducibility study.

Isokinetic strength measurements of the quadriceps and hamstring that are commonly conducted using a 90 degrees range of motion (RoM) may involve some risk to specific knee patient groups. Testing these muscles at a much shorter RoM may reduce the risk but in order to render this method clinically acceptable the reproducibility of the derived test findings has to be established. Therefore the main objective of this study was to assess the reproducibility of isokinetic peak torque and normalized EMG scores of these muscles based on 90 degrees (0-90 degrees flexion, LR) and three successive short RoMs: 0-30 degrees (SR1), 30-60 degrees (SR2) and 60-90 degrees (SR3). Eight healthy subjects were tested three times with a 2 week between-session interval. All tests were performed on the dominant limb and consisted of maximal concentric and eccentric exertions. The velocities applied were 90 degrees /s for LR and 30 degrees /s for each of the SRs. Findings indicated no between-session improvement in strength. Based on the coefficient of variation the measurement error for all isokinetic strength scores remained stable throughout the testing sessions ranging 0.6-13.9% with the absolute majority of instances less than 10%. The reproducibility of the EMG scores was poorer ranging 1.5-25% and 0.5-19% for the quadriceps and hamstring, respectively. It is concluded that testing of knee muscles at short (30 degrees ) RoMs does not compromise the reproducibility of the strength or EMG scores derived from the commonly used RoM of 90 degrees . However, whereas strength was reproducible to within the accepted clinical standards, the corresponding EMG scores were characterized by a wider error band.     

Velopharyngeal incompetence: a guide for clinical evaluation

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.     

Abnormal electromyographic activity of the urethral sphincter,voiding dysfunction,and polycystic ovaries: a new syndrome?

A potential association between abnormal electromyographic activity--that is, decelerating bursts and complex repetitive discharges--of the urethral sphincter and difficulty in voiding was examined in 57 women with urinary retention. Abnormal electromyographic activity was found in 33. Ultrasonography of the ovaries in 22 of the 33 women showed that 14 had polycystic ovaries. Of the other eight women, two had had oophorectomies, one had shrunken ovaries and ovarian failure, and one had previously undergone oophorectomy and the other ovary could not be seen; in one neither ovary could be seen, and three had ovaries of normal appearance, although two of these women were taking the contraceptive pill. Thirteen of the group had endocrine symptoms and signs characteristic of the polycystic ovary syndrome. Videocystometrography in 17 of the women who were examined by ultrasonography showed low flow rates and high residual volumes of urine after micturition in 12 women who could void, the other five having chronic urinary retention. A speculative hypothesis for the observed association of impaired voiding, abnormal electromyographic activity of the urinary sphincter, and polycystic ovaries is advanced, based on the relative progesterone deficiency that characterises the polycystic ovary syndrome. Progesterone stabilises membranes, and its depletion might permit ephaptic transmission of impulses between muscle fibres in the muscle of the urethral sphincter, giving rise to the abnormal electromyographic activity. This may impair relaxation of the sphincter, resulting in low flow rates of urine, incomplete emptying of the bladder, and, finally, urinary retention.     

Increased diaphragmatic strength and tolerance to fatigue after bilateral lung transplantation: an electromyographic study.

We evaluated the diaphragmatic function of seven patients with severe chronic respiratory failure before and after a bilateral lung transplantation (BLT), with follow-up at one year of pulmonary function tests, maximal inspiratory mouth pressure (MIP) and surface diaphragmatic electromyogram (Edi). The patients were asked to sustain target inspiratory pressures at -15, -30, and -50 cmH(2)O. We measured the endurance time (Tlim) to sustain inspiratory efforts and the power spectrum density function of Edi at each inspiratory maneuver. The Edi power spectra was analysed in terms of median frequency (MF), total power (TP) and energies in high-and low-frequency bands (EL and EH). Before BLT, a defect of the diaphragmatic function was evident: MIP was 62+/-7% of the predicted value and the Tlim measured at each inspiratory effort was very short ( 13+/-1 s, 10+/-1 s and 8+/-1 s at pressures of -15, -30, and -50 cmH(2)O, respectively). One month after BLT, the Tlim began to increase at all target inspiratory pressures and at 6 months MIP recovered to normal values. One month after BLT, there was a significant decrease in TP measured at the beginning of each inspiratory efforts and also an increase in the concomitant MF value. BLT markedly accentuated the maximal variations of TP, MF and low-frequency Edi energy. Some hypotheses are raised to explain this dramatic improvement in diaphragmatic function after BLT.     

Seeing invisible motion: a human FMRI study

A common view about visual consciousness is that it could arise when and where activity reaches some higher level of processing along the cortical hierarchy. Reports showing that activity in striate cortex can be dissociated from awareness , whereas the latter modulates activity in higher areas , point in this direction. In the specific case of visual motion, a central, "perceptual" role has been assigned to area V5: several human and monkey studies have shown V5 activity to correlate with the motion percept. Here we show that activity in this and other higher cortical areas can be also dissociated from perception and follow the physical stimulus instead. The motion information in a peripheral grating modulated fMRI responses, despite being invisible to human volunteers: under crowding conditions , areas V3A, V5, and parietal cortex still showed increased activity when the grating was moving compared to when it was flickering. We conclude that stimulus-specific activation of higher cortical areas does not necessarily result in awareness of the underlying stimulus.     

The effect of lunate position on range of motion after a four-corner arthrodesis: a biomechanical simulation study

A four-corner arthrodesis of the wrist is a salvage procedure for the treatment of specific wrist disorders, to achieve a movable, stable and pain free joint. However, a partial arthrodesis limits the postoperative range of motion (ROM). The goal of this study is to understand the mechanism of the reduction of the ROM and to evaluate the effect of the orientation of the lunate in the four-corner arthrodesis on the range of motion by using a biomechanical model, containing articular contacts and ligaments. Multi-body models of a normal wrist and a four-corner arthrodesis wrist with different orientation of the lunate were used for simulations of flexion-extension motion (FEM) and radial-ulnar deviation motion (RUD). The ROM of the postoperative wrist was reduced from 145° to 82° of the total arc of FEM and from 73° to 41.5° of the total arc of RUD. The model simulations show that the range of motion reduction is caused by overtension of the extrinsic wrist ligaments. Different positioning of the lunate changes the balance between the contact forces and ligament forces in the wrist. This explains the effect on the postoperative range of motion. The 20° flexed lunate did not give any gain in the extension motion of the wrist, caused joint luxation in flexion and limitation in RUD. The 30° extended lunate caused overtension of the extrinsic ligaments attached to the lunate. The ROM in this case is dramatically reduced. The model simulations suggest that the neutral position of the lunate seems to be most favorable for mobility of the wrist after a four-corner arthrodesis procedure.     

The flexor function of the m. pronator teres in man: a quantitative electromyographic study

The muscle pronator teres was studied by surface electromyography during elbow flexion in a horizontal plane. The forearm was in semi-pronation and movement was performed at various velocities. A quantitative comparison was made between pronator teres activity and two main elbow flexors, biceps brachii and brachioradialis. The mean timing of the onset of activity was constant: biceps brachii was activated first followed by pronator teres and brachioradialis, and the lower the velocity of flexion, the earlier was the onset of biceps brachii activity. There was a linear relationship between the integrated EMG from each muscle and the work done. However, this relationship was less exact for pronator teres and brachioradialis at low values of work, a finding which opens questions about the generality of this relationship and about the "muscle equivalent" concept. Pronator teres appears to participate in elbow flexion besides its role in pronation. Despite similar anatomical peculiarities, pronator teres does not behave in the same way as anconaeus or popliteus and, above all, it is not the sole muscle active in slow movement. Thus, all the stocky muscles lying close to an articulation do not behave in the same way.     

Respiratory function of intercostal muscles in supine dog: an electromyographic study

It is traditionally considered that the difference in orientation of the muscle fibers makes the external intercostals elevate the ribs and the internal interosseous intercostals lower the ribs during breathing. This traditional view, however, has recently been challenged by the observation that the external and internal interosseous intercostals, when contracting alone in a single interspace, have a similar effect on the ribs into which they insert. This view has also been challenged by the observation that the external and internal intercostals in a given interspace often change their length in the same direction during breathing. In an attempt to clarify the respiratory function of these muscles, we studied eight supine lightly anesthetized dogs during quiet breathing and during static inspiratory efforts. In each animal electromyographic (EMG) recordings from the external and internal interosseous intercostals were obtained in all interspaces from the second to the eighth, and selective denervations were systematically performed to ensure with complete certainty the origin of the recorded EMG activities. The external intercostals were only activated in phase with inspiration, whereas the internal interosseous intercostals were only activated in phase with expiration. These phasic EMG activities, however, were generally small in magnitude, and the muscles were often silent. Indeed, activation of the externals was always confined to the upper portion of the rib cage, whereas activation of the internals was limited to the lower portion of the rib cage. Internal intercostal activation always occurred sequentially along a caudocephalic gradient. These observations are thus compatible with the traditional view of intercostal muscle action.(ABSTRACT TRUNCATED AT 250 WORDS)     

Visual stability and the motion aftereffect: a psychophysical study revealing spatial updating

Eye movements create an ever-changing image of the world on the retina. In particular, frequent saccades call for a compensatory mechanism to transform the changing visual information into a stable percept. To this end, the brain presumably uses internal copies of motor commands. Electrophysiological recordings of visual neurons in the primate lateral intraparietal cortex, the frontal eye fields, and the superior colliculus suggest that the receptive fields (RFs) of special neurons shift towards their post-saccadic positions before the onset of a saccade. However, the perceptual consequences of these shifts remain controversial. We wanted to test in humans whether a remapping of motion adaptation occurs in visual perception.The motion aftereffect (MAE) occurs after viewing of a moving stimulus as an apparent movement to the opposite direction. We designed a saccade paradigm suitable for revealing pre-saccadic remapping of the MAE. Indeed, a transfer of motion adaptation from pre-saccadic to post-saccadic position could be observed when subjects prepared saccades. In the remapping condition, the strength of the MAE was comparable to the effect measured in a control condition (33±7% vs. 27±4%). Contrary, after a saccade or without saccade planning, the MAE was weak or absent when adaptation and test stimulus were located at different retinal locations, i.e. the effect was clearly retinotopic. Regarding visual cognition, our study reveals for the first time predictive remapping of the MAE but no spatiotopic transfer across saccades. Since the cortical sites involved in motion adaptation in primates are most likely the primary visual cortex and the middle temporal area (MT/V5) corresponding to human MT, our results suggest that pre-saccadic remapping extends to these areas, which have been associated with strict retinotopy and therefore with classical RF organization. The pre-saccadic transfer of visual features demonstrated here may be a crucial determinant for a stable percept despite saccades.     

A cineradiographic and electromyographic study of mastication in Tenrec ecaudatus

Regular chewing was studied in the specialized Malagasy insectivore Tenrec ecaudatus with the aid of precisely correlated electromyography of the main adductors, digastrics, and two hyoid muscles and cineradiography for which metallic markers were placed in the mandibles, tongue, and hyoid bone. During the power stroke the body of the mandible moves dorsally and medially. The medially directed component of movement at this time is greatly increased by simultaneous rotation of the mandible about its longitudinal axis. The highly mobile symphysis, spherical dentary condyle, loss of superficial masseter muscle and zygoma, and the simplified zalamnodont molars all appear to be related to the large amount of mandibular rotation that occurs during occlusion. The balancing side lateral pterygoid muscle (inferior head) apparently shifts the working side mandible laterally during the last part of opening and the first part of closing. The working side temporalis and the superficial masseter muscle are both responsible for the shift back to the midline. The temporalis is usually active to the same extent on the working and balancing sides during the power stroke. The level of activity (amplitude) of the temporalis and duration of the power stroke increase with harder foods. Whenever soft foods are chewed, the superficial masseter is only active on the working side; whenever foods of increasing hardness are chewed, its level of activity on the balancing side increases to approach that of the working side. Mandibular rotation is greatly reduced when hard foods are chewed.     

A comparison of visual and mathematical detection of the electromyographic threshold during incremental pedaling exercise: a pilot study

During exhaustive incremental pedaling exercises, root mean square or amplitude of integrated electromyographic values exhibits a nonlinear increase, i.e., the so-called electromyographic threshold (EMG(Th)). As proposed by various authors, this EMG(Th) could be used as a complementary indicator of the aerobic-anaerobic transition in physiological evaluations. However, most of these studies used visual detection for the EMG(Th) and to date no previous study has shown the reliability of this type of EMG(Th) detection. We aimed to compare a visual and a mathematical method for EMG(Th) detection in each of 8 lower limb muscles during incremental cycling exercise. Our results showed an overestimation in the number of cases in which EMG(Th) was detected when using visual inspection (n = 45) compared with the mathematical method (n = 32). However, no significant differences were observed between the 2 methods concerning the power output at which EMG(Th) occurred. These results suggest that EMG(Th) should be mathematically detected. In this context, coaches can easily perform such measurements in order to evaluate the impact of their training programs on the neuromuscular adaptations of their athletes. For example, an automatic mathematical detection of EMG(Th) could be performed during a pedaling exercise in order to detect neuromuscular fatigue. Furthermore, this index could be used during test or training sessions performed either in a lab or in ecological situations. Moreover, the use of EMG(Th) to predict ventilatory threshold occurrence could be an interesting tool for trainers who cannot use the very expensive devices needed to analyze respiratory gas exchanges.     

An electromyographic study of serratus anterior in atelines and Alouatta: Implications for hominoid evolution

The serratus anterior pars caudalis muscle of nonhuman primates displays anatomical differences among genera that can be attributed to differences in the mechanical demands placed on these genera by their diverse locomotor: behaviors. In primates that engage extensively in climbing and suspensory behaviors, the caudal digitations of this fan-shaped muscle are aligned more nearly parallel to the long axis of the trunk. In order to clarify the selective factors promoting such a morphological change, we have conducted a telemetered electromyographic study of the caudal and middle digitations of the serratus anterior pars caudalis. During voluntary elevation of the forelimb, only the middle, more obliquely disposed digitations are powerfully recruited. The caudal digitations are either inactive or function just to initiate scapular rotation. During locomotion, the middle digitations act in the swing (recovery) phase, whereas the caudal digitations are predominatly active in the support (propulsive)These Pashe findings suggest that the caudal digitations are important in propelling the trunk past the scapula during locomotion. Evolution of a fiber orientation more parallel to the long axis of the trunk is suggested to have occurred in broad chested primates for the purpose of facilitating locomotor behaviors requiring caudal scapular retraction for propulsion, but which would be deleteriously affected if such retraction were linked to simultaneous ventral displacement of the shoulder girdle. In its current state, the human serratus anterior seems clearly adapted for arm-raising functions and indicates descent from a small ape with a thoracic shape similar to atelines.     

Tissue Doppler imaging of carotid plaque wall motion: a pilot study

Background

Studies suggest the physical and mechanical properties of vessel walls and plaque may be of clinical value in the diagnosis and treatment of cardiovascular atherosclerotic disease. The purpose of this pilot study was to investigate the potential clinical application of ultrasound Tissue Doppler Imaging (TDI) of Arterial Wall Motion (AWM) and to quantify simple wall motion indices in normal and diseased carotid arteries.

Methods

224 normal and diseased carotid arteries (0–100% stenoses) were imaged in 126 patients (age 25–88 years, mean 68 ± 11). Longitudinal sections of the carotid bifurcation were imaged using a Philips HDI5000 scanner and L12-5 probe under optimized TDI settings. Temporal and spatial AWMs were analyzed to evaluate the vessel wall displacements and spatial gradients at peak systole averaged over 5 cardiac cycles.

Results

AWM data were successfully extracted in 91% of cases. Within the carotid bifurcation/plaque region, the maximum wall dilation at peak systole ranged from -100 to 750 microns, mean 335 ± 138 microns. Maximum wall dilation spatial gradients ranged 0–0.49, mean 0.14 ± 0.08. The AWM parameters showed a wide variation and had poor correlation with stenoses severity. Case studies illustrated a variety of pertinent qualitative and quantitative wall motion features related to the biophysics of arterial disease.

Conclusion

Our clinical experience, using a challenging but realistic imaging protocol, suggests the use of simple quantitative AWM measures may have limitations due to high variability. Despite this, pertinent features of AWM in normal and diseased arteries demonstrate the potential clinical benefit of the biomechanical information provided by TDI.     

Susceptibility to motion sickness in fish: a parabolic aircraft flight study

Juvenile swordtail fish and larval cichlids were subjected to parabolic aircraft flights (PAFs) and individually observed. After the PAFs, inner ear otoliths and sensory epithelia were examined on the light microscopical level. Otolith asymmetry (differences in otolith size between the left and the right side) was especially pronounced in those fish, who exhibited a kinetotic behaviour (e.g., spinning movements) during microgravity. This speaks in favour of a theoretical concept according to which susceptibility to space motion sickness in humans may be based on asymmetric inner ear stones. The cell density of sensory epithelia was lower in kinetotic animals as compared to normally swimming fish. Thus, asymmetric otoliths can cause kinetosis in fish during PAFs, but susceptibility to kinetosis may also be based on an aberrative inner ear morphology.     

Deglutitive upper esophageal sphincter relaxation: a study of 75 volunteer subjects using solid-state high-resolution manometry

This study aimed to use a novel high-resolution manometry (HRM) system to establish normative values for deglutitive upper esophageal sphincter (UES) relaxation. Seventy-five asymptomatic controls were studied. A solid-state HRM assembly with 36 circumferential sensors spaced 1 cm apart was positioned to record from the hypopharynx to the stomach. Subjects performed ten 5-ml water swallows and one each of 1-, 10-, and 20-ml volume swallows. Pressure profiles across the UES were analyzed using customized computational algorithms that measured 1) the relaxation interval (RI), 2) the median intrabolus pressure (mIBP) during the RI, and 3) the deglutitive sphincter resistance (DSR) defined as mIBP/RI. The automated analysis succeeded in confirming bolus volume modulation of both the RI and the mIBP with the mean RI ranging from 0.32 to 0.50 s and mIBP ranging from 5.93 to 13.80 mmHg for 1- and 20-ml swallows, respectively. DSR was relatively independent of bolus volume. Peak pharyngeal contraction during the return to the resting state postswallow was almost 300 mmHg, again independent of bolus volume. We performed a detailed analysis of deglutitive UES relaxation with a novel HRM system and customized software. The enhanced spatial resolution of HRM allows for the accurate, automated assessment of UES relaxation and intrabolus pressure characteristics, in both cases confirming the volume-dependent effects and absolute values of these parameters previously demonstrated by detailed analysis of concurrent manometry/fluoroscopy data. Normative values were established to aid in future clinical and investigative studies.