Intranasal electromyography in evaluation of the nasal valve

OBJECTIVES: The present study was performed to investigate the best way of using surface electromyography (sEMG) in evaluation of muscle involvement in nasal valve function. The function of the nasal muscles in nasal valve movements has not been investigated sufficiently and in the present study we tried to improve the way of testing these muscles introducing the intranasal placement of surface EMG electrodes. METHODS: Skin surface electromyography (EMG) and intranasal electrode EMG investigation of nasal muscles was performed in two groups (n = 30 for each Group) of healthy subjects: (1) subjects with extremely effective coordination of nasal muscles and (2) those with extremely poor coordination of nasal muscles. Functions of the nasal muscles were assessed by EMG in response to breathing and voluntary nasal movements. RESULTS: In both Groups, during normal breathing all the tested muscles were not active. During forced nasal inspiration in Group 1 the transverse nasalis, anomalous nasi, alar nasalis and dilator naris anterior were active. In Group 2 during forced nasal inspiration these muscles remained inactive. During rhythmic widening of the nostril, the tested nasal muscles were active in subjects of Group 1 and significantly less active in Group 2 (p = 0.0024). In both Groups the amplitude of muscle activity, recorded from intranasal electrodes was significantly higher that the amplitude recorded from the skin electrodes (p < 0.05). During the tests with two intranasal electrodes, the insignificant difference was detected in amplitude between left and right nostrils in majority of subjects (Group 1 p = 0.15; Group 2 p = 0.1). CONCLUSION: We conclude that in human population the ability to operate nasal muscles is varying from person to person, i.e. the nasal muscles can be either inactive ("relatively rudimentary") or active. This fact should be taken into account before any surgical intervention is planned. The subjects with active nasal muscles can control the function of their nasal valve. The intranasal surface EMG is a more direct and precise EMG method for nasal valve evaluation in comparison to skin surface EMG testing.     

Dilator naris activity in relation to obstructive sleep apnea

We evaluated the activity of dilator nasalis+ EMG (Electro-Myo-Graphy) and submental EMG during sleep in three patients with obstructive sleep apnea syndrome. Both EMG activities involved periodic changes which proved to be correlated with each other (r = 0.85). Apnea and hypopnea episodes always occurred at the nadir of these periodic changes. The activity of dilator nasalis+ EMG, as well as submental EMG, at the nadir of these periodic changes was significantly lower during REM (Rapid Eye Movement) sleep than non-REM sleep and also significantly lower during severe airway obstruction accompanied by paradoxical movements of thorax and abdomen. The correlation of this EMG activity with SaO2 or the duration of obstructive apnea was more remarkable in submental EMG than dilator nasalis+ EMG in the observed patients.     

Surface recordings of respiratory muscle activity during speech: some preliminary findings

Bipolar electromyographic (EMG) recordings were made from six chest wall and nasal sites with disk electrodes attached to the skin. Electrode locations were based on previous studies of nonspeech breathing and were designed to sample the activity of both primary and accessory respiratory muscles. EMG activity was sampled while subjects performed a series of speech and nonspeech tasks. The results revealed that surface electrodes could sample the activity of respiratory muscles during speech and other ventilatory tasks, particularly during the expiratory phases of the breathing cycle.     

Electromyography of the infrahyoid muscles - part 1: normal findings]

BACKGROUND: The infrahyoid muscles (IHM) are very useful as a neurovascular myofascial flap in plastic reconstructive surgery of the upper aerodigestive tract, especially for restoration of the muscular component in larger tongue defects. As a base for further postoperative investigations on the function of transferred IHM this first part of the study describes the physiological function and the electromyographical features of the IHM. METHODS: In 17 patients with cancer of the upper aerodigestive tract the sternohyoid and sternothyroid muscles and in additionally eight patients the upper part of the omohyoid muscle were studied electromyographically. Muscular activity was recorded at various movements and maximal voluntary innervation. In ten healthy volunteers the motor unit potentials (MUP) during light voluntary innervation of these muscles were studied. RESULTS: In both muscles we found the steadist and strongest muscular activity at isometric head bending and yaw opening, in the omohyoid muscle also at head rotation. At swallowing and breathing in (2/3) of the cases muscular activity could be recorded. Amplitudes and electromyographic charge pattern in comparison were diminished. Phonation und tongue movements showed no noticable muscular activity. Analysis of the MUP in 10 healthy volunteers showed a mean amplitude of 274 +/- 59 microV and a mean duration of 8.5 +/- 0.6 ms. CONCLUSIONS: The presented study demonstrates that EMG of the IHM are recorded best while head bending, yaw opening and head rotation. Since there is no interchange of nerve fibres between the hypoglossal nerve and the cervical ansa it should be possible to differentiate between original tongue muscles and transferred muscles in electromyographic studies of myofascial flaps after tongue reconstruction.     

周期性呼吸与稳态呼吸状态下正常鼻腔气流的数值模拟比较

目的 比较周期性呼吸状态与稳态呼吸状态下正常鼻腔气流的流场特点.方法 根据正常成人鼻腔的CT扫描,利用计算流体力学软件Fluent建立正常的鼻腔模型,模拟周期性呼吸下鼻腔的气流状况,选取其中某些时刻(呼气加速区第15.600秒、呼气减速区第16.495秒)的气流状态与相同流量下稳态呼气状态下的气流状态进行比较.结果 周期性呼吸时第15.600秒与入口流量为697.25ml/s稳态呼气情况下鼻腔气流参数如下:两种呼吸状态下,左鼻腔主要通道气流的平均速度、最大速度和压强相近,各鼻窦内气流的平均速度相近;气流分布均以总鼻道和中鼻道为主,两者分别占气流总流量的50%和30%以上;两种呼吸状态下,下鼻道和总鼻道下部的气流流线均以直线为主,中鼻道、上鼻道和总鼻道中上部的气流流线呈抛物线形.周期性呼吸第16.495秒(距离交界点0.005 s)时鼻腔气流平均速度为0.0706 m/s,气流在鼻咽和鼻阈等宽阔区域形成大范围的涡旋运动;而入口流量为7.62 ml/s稳态呼气时左鼻腔气流的平均速度为0.0415 m/s,鼻腔气体的流动与高流量时相似.结论 在相同流量时,除在呼气和吸气交界点附近外,周期性呼吸和稳态呼吸状态下鼻腔气流流动的各参数相似.     

Biofeedback training of nasal muscles using internal and external surface electromyography of the nose

BACKGROUND: The purpose of this paper is to describe the outcome of biofeedback training of nasal muscles in cases of nasal valve stenosis and collapse. The present study was performed to investigate the best way of using surface electromyography (sEMG) in biofeedback training of muscles involved in nasal valve function. In the present study, we present the way of biofeedback training of these muscles introducing the intranasal placement of sEMG electrodes and a home exercise program. METHODS: A nonrandomized pilot study of patients presenting with symptoms of obstructed nasal breathing was conducted. All selected patients (n = 15) demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Follow-up ranged from 9 to 12 months. Treatment included surface and intranasal EMG biofeedback-assisted specific strategies for nasal muscle education and a home exercise program of specific nasal movements. RESULTS: All patients exhibited variable subjective improvement. In 86.66% (n = 13), the improvement was proved objectively and there was no need for operation. In 13.33% (n = 2), an endonasal operation was recommended. CONCLUSION: Relieve of obstructed nasal breathing after nasal valve stenosis and/or collapse can be achieved with biofeedback training of nasal muscles and a home exercise program as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention.     

A functional anatomic study of the relationship of the nasal cartilages and muscles to the nasal valve area

The functioning of the nasal valve area is largely determined by the stability and the mobility of the lateral nasal wall. To gain insight into the kinematics of the lateral nasal wall, we studied the functional anatomy of the nasal muscles and the intercartilaginous and osseous-cartilaginous junctions. We performed gross and microscopic nasal dissection and serial sectioning in 15 human cadaveric noses. In addition, two noses were used for three-dimensional reconstruction of the nasal cartilages. We conclude that the lateral nasal wall can be seen as made up of three parts. At the level of the osseous-cartilaginous chain of bone, lateral nasal cartilage, and lateral crus, the lateral nasal wall is relatively stable, limited mobility being allowed by translation and rotation in the intercartilaginous joint and a coupled distortion of the cartilages. At the level of the hinge area the lateral nasal wall is supported by one or more accessory cartilages, embedded in soft tissue, and therefore much more compliant. The alar part of the nasalis muscle, which originates from the maxilla and inserts on these cartilages, may dilate the valve area by drawing this hinge area laterally. The third and most compliant part of the lateral nasal wall is the part that is not supported by cartilage, the ala. The dilatator naris muscle largely occupies the ala and is attached to the lateral crus; it opens the vestibule and nostril. The third nasal muscle that influences the lateral nasal wall is the transverse part of the nasalis muscle. It overlies the nose but is not attached to it. This muscle stabilizes the lateral nasal wall, in particular, the lateral nasal cartilage, the intercartilaginous junction, and the hinge area, by moving the nasal skin.     

Reproducibility and variability of speech muscle activity in athetoid dysarthria of cerebral palsy

Athetoid dysarthria is thought to result from involuntary movements which are variable and irregular in nature. In this study, electromyographic (EMG) activity recorded from six speech muscles was quantified during repetitions of a test sentence by normal and athetoid adult subjects. In the athetoid subjects the articulation of the test sentence was disrupted intermittently by involuntary activity which usually occurred in the time intervals between the syllables in the test sentence, rather than during articulation of the syllables themselves. The EMG activity associated with each syllable in the test sentence was partitioned into reproducible and variable components. The ratio of the reproducible component to the variable component--the signal-to-noise ratio--did not differ significantly between the two subject groups. In the athetoid subjects, however, the reproducible component of the EMG activity was grossly abnormal. We concluded that this abnormal voluntary activity, rather than variable involuntary activity, was the primary cause of athetoid dysarthria.     

Muscle-building therapy in treatment of nasal valve collapse

OBJECTIVES: The purpose of this paper is to describe the outcome of muscle-building therapy for nasal muscles in cases of nasal valve stenosis or collapse. The present study was performed to investigate the best way to combine transcutaneous and intranasal surface electromyography (sEMG) biofeedback training of muscles involved in nasal valve function with a home exercise program and electric stimulation of nasal muscles. METHODS: A randomized pilot study of 3 groups of patients (n1=12, n2=12, n3=10; total 34 patients) presenting with symptoms of obstructed nasal breathing was conducted. All selected patients demonstrated nasal valve stenosis with a positive Cottler maneuver and clinically evident nasal valve collapse. Follow-up ranged from 8 to 12 months. Treatment for Group 1 included transcutaneous and intranasal electric stimulation of nasal muscles only. Treatment for Group 2 included biofeedback training and home exercise program of specific nasal movements, and treatment for Group 3 included surface and intranasal EMG biofeedback assisted specific strategies for nasal muscle education, home exercises and electric stimulation. RESULTS: All patients in these groups exhibited subjective improvement. For Group 3, in 80% the improvement was proved objectively; for Group 2, in 75% the improvement was proved objectively; for Group 1, in 58,33% the improvement was proved objectively. We found no significant difference between the results in Groups 3 and 2 and poorer results in Group 1. CONCLUSION: Relieve of nasal valve stenosis and collapse can be achieved with a complex muscle-building therapy as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention. Electric stimulation of the muscles does not contribute significantly in achieving of good results.     

Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball

OBJECTIVE: This study aimed to evaluate the recruitment of cervical muscles during nasal inspiration before and after breathing and postural exercises on the Swiss Ball in children with Mouth Breathing Syndrome (MBS). METHOD: Surface electromyography from the sternocleidomastoid (SCM), sub-occipitals and upper Trapezius muscles was recorded during nasal inspiration, before and at the end of three months of the treatment. A physical therapy program consisting in muscular stretching and strengthening exercises along with naso-diaphragmatic breathing on the Swiss Ball were carried out for body posture realignment and respiratory training. Nineteen mouth breathing children, mean age of 10.6 years, both genres, were the subjects of this study. In order to establish a comparison between the eletromyographic results (normalized values) obtained from pre and post-physical therapy program it was used the Wilcoxon non-parametric test for dependent data. RESULTS: It was found a significant decrease (p<0.01) in the electromyographic activity during nasal inspiration in all tested muscles after treatment (11.3-3.6% in the SCM, 22.4-11.7% in the sub-occipitals and 8.9-3.1% in the upper Trapezius). At the end of the treatment, the assessed muscles reached lower activity electromyographic levels during nasal inspiration and they became closer of those in the quiet position. CONCLUSION: The lower activity after the physical therapy program in these muscles indicates a less effort of the accessory inspiratory muscles, probably due to a better performance of diaphragm muscle with the improvement of the body posture.     

The site and function of the nasal valve

Previous observers have suggested that the main site of respiratory airflow resistance is localized to the vestibular region of the nose. This resistive segment of the airway was investigated using a “head-out” body plethysmograph in subjects with anatomically normal noses (a) untreated, (b) congested and (c) decongested. In all three conditions, 2/3 of the total nasal airflow resistance was found within the bony cavum in the vicinity of the pyriform aperture and about 1/3, in the cartilaginous vestibule. As might be expected, caval resistance changed proportionately with the degree of mucosal congestion; but, more surprisingly, vestibular resistance changed similarly. This was due in part to the observed forward expansion of the anterior ends of the inferior turbinates with congestion. EMG recordings in subjects breathing through both nostrils demonstrated a gradation of inspiratory alar dilator muscle activity with increased minute ventilation and with mucosal congestion, and there was no evidence of inspiratory alar collapse. But with elevated ventilation through one nostril only, or when the alar muscles were paralyzed by lidocaine block of the VIIth nerve, alar collapse occurred. These findings are of importance in the management of the congested but anatomically normal nose and in surgery of the nasal tip.     

The effects of nasal dilation on snoring and obstructive sleep apnea.

The effects of nasal valve dilation on snoring and obstructed breathing were studied in 11 patients with habitual snoring and/or obstructive sleep apnea. The anterior part of the nose, the valve region, was dilated by means of a plastic device. Ten patients underwent polysomnographic investigation including pulse oximetry and measurement of snoring noise with and without the nasal dilator in a randomized manner. Snoring, nocturnal arousals, and daytime hypersomnolence were rated by the patient and partner on a questionnaire before and after a 10-day treatment period with the dilator. The nasal airflow, as assessed by rhinomanometry when awake in the sitting position, increased by 18% (range, 5.5% to 45%) when the nasal dilator was used. The frequency and severity of obstructed breathing decreased significantly with the nasal dilator. The apnea index with and without the nasal dilator was 6.4 (range, 1.3 to 15) and 18 (range, 1.8 to 60), respectively. The mean decrease of the apnea index was 47%. The overnight minimum arterial oxygen saturation (with and without the nasal dilator was 84% (range, 76% to 88%) and 78% (range, 68% to 89%), respectively. There was a substantial decrease in snoring noise (number of epochs with Leq values, equal energy level, above 55 or 60 dB) with the dilator in all patients who presented with snoring noise above these levels during the control night. No subjective effects on arousal frequency or daytime hypersomnolence were reported. Four of 11 patients were positive to continue using the nasal dilator.     

Efficiency of external nasal dilators in pediatric nasal septal deviation

Inroduction

Nasal septal deviation results from irregular development of the nasomaxillary complex and trauma. Treatment of nasal septal deviation in pediatric patients is one of the biggest challenges in rhinology. Surgery may alter craniofacial growth patterns, and so it may be indicated only in the selected cases. The use of external nasal dilators is a relatively new treatment modality in nasal obstruction.

Objective

This study was performed to assess the efficacy of external nasal dilator in pediatric nasal septal deviation patients.

Methods

Seventy-six children who were diagnosed with nasal septal deviation at our outpatient clinic were included in the study. The patients were divided into 2 groups: the external nasal dilator group was composed of 48 children that had used an external nasal dilator for at least 1 month and still been using, while the control group was comprised of 28 children that had not received any treatment and had not used an external nasal dilator. The parents of the children were asked to complete the obstructive sleep apnea 18 questionnaire. In addition, the external nasal dilator group was asked to complete the questionnaire after stopping external nasal dilator use for 2 weeks and the control group also repeated the obstructive sleep apnea 18 questionnaire.

Results

The obstructive sleep apnea 18 questionnaire results were significantly different between the external nasal dilator group and the control group at the beginning of the study (i.e., when patients in the external nasal dilator group were still using their dilators, P = 0.000). On the other hand, there was no difference between the 2 groups after the patients in the external nasal dilator group had stopped using their external nasal dilator (P = 0.670).

Conclusion

External nasal dilator use relieved nasal septal deviation, which narrows the nasal valve. The results of this study suggest that external nasal dilator could be used in patients that are not candidates for septoplasty.     

烟雾示踪剂在显示鼻腔呼气相气流变化中的研究

目的 研究鼻腔呼气相气流曲线及不同解剖部位气流的变化。方法 对10例鼻内镜检查鼻腔黏膜及结构正常的吸烟志愿者,采用吸烟的方式将电子烟的烟雾吸入,储存于口咽及以下气道内,以1、1.5、2s一个呼气周期均匀呼气,观察鼻腔气流变化。 结果 咽部气流在鼻咽顶部气流由垂直直线上升变为曲线前移,大部分以层流方式进入总鼻道,少量气体由下鼻甲后端进入下鼻道以湍流方式运动,极少量气体以层流的方式进入嗅裂及中鼻道, 鼻阈以湍流为主。 结论 鼻咽顶与鼻腔交界的坎阻挡气流导致呼出气流改变运动方向,使气流压低主要经总鼻道底部流出,极少经上鼻道流出,下鼻道气流以湍流为主。呼出气流对中鼻道及嗅裂影响较小。     

Electrical activity from the superior pharyngeal constrictor during reflexive and nonreflexive tasks

The purpose of this investigation was to determine, in a quantitative manner, which, if any, nonswallowing tasks produce significant levels of activation in the superior pharyngeal constrictor muscle of normal human subjects. Bipolar hooked wire electrodes were inserted in the superior pharyngeal constrictor muscle of 15 healthy subjects. Electrode placement was controlled. Each subject performed two reflexive tasks, six voluntary tasks requiring phonation, and four nonspeech voluntary tasks. The electromyogram (EMG) was rectified and integrated. The resulting number was then transformed by taking its natural logarithm. An ANOVA was performed and a linear model was estimated. The magnitude of the EMG activity was related to the location of the electrodes. The largest values were recorded in the lateral-superior placement, followed by the lateral-inferior, medial-inferior and medial-superior. The superior pharyngeal contrictor was found to be a muscle activated primarily during reflexive activity. There was a general trend in the amplitude of EMG activity in relationship to task. Swallowing produced the greatest amount of activity and a gag produced about 60% of the activity produced by the swallow. Two tasks, production of the work /hok/ in which the phoneme /k/ was stressed, and a "modified Valsalva," which was actually a hard /k/ held for several seconds, produced the next greatest level of EMG.     

Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children

INTRODUCTION: The mouth breathing resulting from nasal obstruction has been highly incident, mostly as a consequence of allergic rhinitis. In children, such condition is more concerned because it causes alteration during their development, which may generate deformities. OBJECTIVE: To evaluate the efficacy of a program of combined postural exercise and breathing, on the cervical muscles and body posture in school-age mouth breathing children. MATERIALS AND METHODS: Nineteen mouth breathing children, mean age of 10.6 years, both genders, were recruited either from a public school or from a speech-therapy service. The evaluation procedures were electromyographic recordings from the sternocleidomastoid (SCM), sub-occipitals (SOC) and upper trapezius (UT) muscles and computerized photographic analysis pre and post-treatment. The subjects were submitted to a 12-week of a Physical Therapy Program (PTP) consisted by (a) muscular stretching and strengthening exercises using a Swiss ball combined to (b) naso-diaphragmatic re-education. RESULTS: There was a significant reduction (p<0.05) in the electrical activity on the assessed muscles during quiet position (5, 19 and 7.1% to 3, 2 and 10.3% for SCM, SOC and UT, respectively) and aligned posture (7, 19 and 8% to 4, 9 and 2.6% for SCM, SOC and UT, respectively) after treatment. Improvement in the postural deviation, especially reduction in forward head posture and abducted scapula were demonstrated in the computerized photographic analysis. CONCLUSION: A combination of postural and breathing exercises was effective in restoring muscle imbalances and posture in a group of school-age mouth breathing children, as measured by changes in electrical activity and positional data.     

鼻丘气房和额隐窝内侧壁的解剖观测与手术切除

为提高鼻窦炎、鼻息肉的手术效果，对尸头和颅骨的鼻外侧壁骨结构进行解剖观测。结果示：中鼻甲垂直部前端附着处与筛顶间有约1．5cm的距离，此间即为鼻丘气房和额隐窝的所在部位，而鼻丘气房内侧壁恰好位于中鼻甲起端附着处上方。提示手术时切除中鼻甲起端附着缘上后方骨质，就开放了鼻丘和额隐窝的内侧壁。然后小心清除其内的病变组织，就能保持鼻窦开放，引流通畅，恢复通气，减少鼻息肉复发。并经对15例患者术后随访0．5～1．5年，均获满意疗效而得到证实。     

Mechanisms of nasal obstruction in sleep

Pathophysiological aspects of the nasal and pharyngeal airways are discussed with particular reference to breathing disorders in sleep. Hypotonus of dilator muscles in sleep permits the pharynx to comply with inspiratory pressures. If airflow resistances are increased by nasal disease, complete inspiratory obstructive closure of the pharynx and apnea can result from nasal breathing in sleeping subjects. Recumbency increases resistive swelling of inflamed nasal mucosa. Furthermore in patients with normal mucosa and unilateral nasal obstruction, contralateral recumbency induces contralateral obstruction which increases resistance to nasal breathing; and in either dorsal or lateral recumbency the congestive phase of the spontaneous nasal cycle acts in a similar way. Examples of breathing disorders in sleep and impaired quality of sleep in patients with obstructive mucosal disease and both bilateral and unilateral structural abnormalities arc cited.     

Comparison of upper and lower lip muscle activity between stutterers and fluent speakers

OBJECTIVE: There is a widespread clinical view that stuttering is associated with high levels of muscles activity. The proposal of this research was to compare stutterers and fluent speakers with respect to the electromyographic activity of the upper and lower lip muscles. METHODS: Ten individuals who stutter and 10 fluent speakers (control group) paired by gender and age were studied (mean age: 13.4 years). Groups were defined by the speech sample analysis of the ABFW-Language Test. A K6-I EMG (Myo-tronics Co., Seattle, WA, USA) with double disposable silver electrodes (Duotrodes, Myo-tronics Co., Seattle, WA) being used in order to analyze lip muscle activity. The clinical conditions investigated were movements during speech, orofacial non-speech tasks, and rest. Electromyographic data were normalized by lip pursing activity. The non-parametric Mann-Whitney test was used for the comparison of speech fluency profile, and the Student t-test for independent samples for group comparison regarding electromyographic data. RESULTS: There was a statistically significant difference between groups regarding speech fluency profile and upper lip activity in the following conditions: lip lateralization to the right and to the left and rest before exercises (P<0.05). There was no significant difference between groups regarding lower lip activity (P>0.05). CONCLUSION: The EMG activity of the upper lip muscle in the group with stuttering was significantly lower than in the control group in some of the clinical conditions analyzed. There was no significant difference between groups regarding the lower lip muscle. The subjects who stutter did not present higher levels of muscle activity in lip muscles than fluent speakers.     

Respiration-related movements of the nose in dogs

We studied the respiration-related movements of the canine nose by examining the respiratory oscillations of intranasal balloon pressure and EMG activities of the dilator nares in dogs. Under spontaneous respiration, balloon pressure decreased and EMG activities increased during the early inspiratory phase. These respiratory movements of the nose differed and changed reciprocally in strength between the two sides of the body spontaneously, after painful stimulation or intranasal histamine administration. When the muscle relaxant was administered and the respiration was controlled by the ventilation pump, the intranasal balloon pressure increased during the inspiratory phase. This phenomenon had a completely inverted pattern compared with that during spontaneous respiration. Furthermore, even when the ventilation pump was stopped, respiration-like spontaneous oscillations of the intranasal balloon pressure were recognized. These were abolished by sectioning of the ipsilateral cervical sympathetic nerve trunk. From these findings, the respiration-related movements of the nose were thought to be controlled not only by the cardiac output and the vagal nerve reflexes but also by respiratory activities in the nervous systems controlling the nose, which might be originated from the medullary respiratory centres.