Myofunctional therapy (oropharyngeal exercises) for obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea (OSA) is a syndrome characterised by episodes of apnoea (complete cessation of breathing) or hypopnoea (insufficient breathing) during sleep. Classical symptoms of the disease - such as snoring, unsatisfactory rest and daytime sleepiness - are experienced mainly by men; women report more unspecific symptoms such as low energy or fatigue, tiredness, initial insomnia and morning headaches. OSA is associated with an increased risk of occupational injuries, metabolic diseases, cardiovascular diseases, mortality, and being involved in traffic accidents. Continuous positive airway pressure (CPAP) - delivered by a machine which uses a hose and mask or nosepiece to deliver constant and steady air pressure- is considered the first treatment option for most people with OSA. However, adherence to treatment is often suboptimal. Myofunctional therapy could be an alternative for many patients. Myofunctional therapy consists of combinations of oropharyngeal exercises - i.e. mouth and throat exercises. These combinations typically include both isotonic and isometric exercises involving several muscles and areas of the mouth, pharynx and upper respiratory tract, to work on functions such as speaking, breathing, blowing, sucking, chewing and swallowing. OBJECTIVES: To evaluate the benefits and harms of myofunctional therapy (oropharyngeal exercises) for the treatment of obstructive sleep apnoea. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 1 May 2020). We found other trials at web-based clinical trials registers. SELECTION CRITERIA: We included RCTs that recruited adults and children with a diagnosis of OSA. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were daytime sleepiness, morbidity and mortality. MAIN RESULTS: We found nine studies eligible for inclusion in this review and nine ongoing studies. The nine included RCTs analysed a total of 347 participants, 69 of them women and 13 children. The adults' mean ages ranged from 46 to 51, daytime sleepiness scores from eight to 14, and severity of the condition from mild to severe OSA. The studies' duration ranged from two to four months. None of the studies assessed accidents, cardiovascular diseases or mortality outcomes. We sought data about adverse events, but none of the included studies reported these. In adults, compared to sham therapy, myofunctional therapy: probably reduces daytime sleepiness (Epworth Sleepiness Scale (ESS), MD (mean difference) -4.52 points, 95% Confidence Interval (CI) -6.67 to -2.36; two studies, 82 participants; moderate-certainty evidence); may increase sleep quality (MD -3.90 points, 95% CI -6.31 to -1.49; one study, 31 participants; low-certainty evidence); may result in a large reduction in Apnoea-Hypopnoea Index (AHI, MD -13.20 points, 95% CI -18.48 to -7.93; two studies, 82 participants; low-certainty evidence); may have little to no effect in reduction of snoring frequency but the evidence is very uncertain (Standardised Mean Difference (SMD) -0.53 points, 95% CI -1.03 to -0.03; two studies, 67 participants; very low-certainty evidence); and probably reduces subjective snoring intensity slightly (MD -1.9 points, 95% CI -3.69 to -0.11 one study, 51 participants; moderate-certainty evidence). Compared to waiting list, myofunctional therapy may: reduce daytime sleepiness (ESS, change from baseline MD -3.00 points, 95% CI -5.47 to -0.53; one study, 25 participants; low-certainty evidence); result in little to no difference in sleep quality (MD -0.70 points, 95% CI -2.01 to 0.61; one study, 25 participants; low-certainty evidence); and reduce AHI (MD -6.20 points, 95% CI -11.94 to -0.46; one study, 25 participants; low-certainty evidence). Compared to CPAP, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.30 points, 95% CI -1.65 to 2.25; one study, 54 participants; low-certainty evidence); and may increase AHI (MD 9.60 points, 95% CI 2.46 to 16.74; one study, 54 participants; low-certainty evidence). Compared to CPAP plus myofunctional therapy, myofunctional therapy alone may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.56 to 2.96; one study, 49 participants; low-certainty evidence) and may increase AHI (MD 10.50 points, 95% CI 3.43 to 17.57; one study, 49 participants; low-certainty evidence). Compared to respiratory exercises plus nasal dilator strip, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.46 to 2.86; one study, 58 participants; low-certainty evidence); probably increases sleep quality slightly (-1.94 points, 95% CI -3.17 to -0.72; two studies, 97 participants; moderate-certainty evidence); and may result in little to no difference in AHI (MD -3.80 points, 95% CI -9.05 to 1.45; one study, 58 participants; low-certainty evidence). Compared to standard medical treatment, myofunctional therapy may reduce daytime sleepiness (MD -6.40 points, 95% CI -9.82 to -2.98; one study, 26 participants; low-certainty evidence) and may increase sleep quality (MD -3.10 points, 95% CI -5.12 to -1.08; one study, 26 participants; low-certainty evidence). In children, compared to nasal washing alone, myofunctional therapy and nasal washing may result in little to no difference in AHI (MD 3.00, 95% CI -0.26 to 6.26; one study, 13 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness and may increase sleep quality in the short term. The certainty of the evidence for all comparisons ranges from moderate to very low, mainly due to lack of blinding of the assessors of subjective outcomes, incomplete outcome data and imprecision. More studies are needed. In future studies, outcome assessors should be blinded. New trials should recruit more participants, including more women and children, and have longer treatment and follow-up periods.

Neural Transmission from Oropharyngeal Bitter Receptors to the Medulla is Partially or Completely Labelled-Line.

The ground breaking advances in taste cell receptor cell physiology over the last 20 years have established a functional basis which enables neural pathways to be mapped. There is.only one, or perhaps several, types of taste receptors for salt, sour, sweet and umami (meaty) tastes and stimulation of each receptor type elicits responses in different cognitive regions. These findings support the labelled-line neural pathway model. In contrast, there are 25 types of the bitter taste receptors which all produce the same cognitive sensation, a finding which supports the across-fiber pattern model. This paper compiles the findings.of several human studies investigating the impact of bitter tastants on postprandial hemodynamics, to demonstrate that diverse bitter tastants are capable of eliciting a range of characteristic reflex cephalic phase responses in the autonomic and cardiovascular systems. These findings indicate that neural pathways from the oropharyngeal bitter taste receptors to the nucleus of the solitary tract are either partially or completely labelled-line. Consequently, the hedonics of a bitter tastant are not an accurate indicator of the cephalic phase responses elicited by the tastant. The finding that secondary metabolites present in dietary condiments modulate autonomic activity and in particular postprandial hemodynamics is novel and adds a new dimension to our understanding of the ways in which humans are influenced by their diet, both in health and disease. These findings suggest that condiments play a role in food digestion, unrelated to their. hedonistic qualities. Consequently, condiments may be of significance to those with digestive disorders and especially for diabetics experiencing gastroparesis and/or postprandial hypotension. Additionally, the findings suggest a noninvasive method to assess the integrity of multiple neural pathways. For investigators exploring the effect of condiments on autonomic reflexes, traditional cuisines may be a valuable source as they are full of uncharted human recordings.

Thermal tomography imaging in photonic traditional Chinese medicine information therapy with holistic effect for health whole nursing.

A photonic traditional Chinese medicine (TCM) information therapy was developed that has applications in whole health nursing including the prevention and treatment of ischemic cardiovascular and cerebrovascular diseases as well as the conditioning of the subhealth state. This therapy utilizes the beam of a 630 nm LED light to irradiate the oropharynx, while simultaneously employing two beams of 650 nm LED light to irradiate corresponding acupuncture points resulting in a synergistic outcome. This method was named "1 + 2 phototherapy." The principle mechanism of the therapy is a series of photon induced biological effects that are triggered by stimulating the photosensitive tissues of the oropharynx. This tissue includes the oral mucosa, capillaries, lymph nodes, saliva glands, nerves, and Jingluo and is stimulated by light beams of certain photon energy and imitative acupuncture information. Thermal tomography imaging shows that the average temperature of the upper-body was improved significantly after oropharyngeal irradiation under irradiation of "Futu point": the heat radiation of the spine, as well as chest, shoulders, arms, and clavicle, increased under irradiation of "Hoku," whereas the overall average temperature was below the temperature before irradiation. The experiment indicates that this therapy can promote blood circulation, regulate varied physiological parameters, and have holistic effects in whole health nursing.

The acoustic effect of vocal tract adjustments in zebra finches.

Vocal production in songbirds requires the control of the respiratory system, the syrinx as sound source and the vocal tract as acoustic filter. Vocal tract movements consist of beak, tongue and hyoid movements, which change the volume of the oropharyngeal-esophageal cavity (OEC), glottal movements and tracheal length changes. The respective contributions of each movement to filter properties are not completely understood, but the effects of this filtering are thought to be very important for acoustic communication in birds. One of the most striking movements of the upper vocal tract during vocal behavior in songbirds involves the OEC. This study measured the acoustic effect of OEC adjustments in zebra finches by comparing resonance acoustics between an utterance with OEC expansion (calls) and a similar utterance without OEC expansion (respiratory sounds induced by a bilateral syringeal denervation). X-ray cineradiography confirmed the presence of an OEC motor pattern during song and call production, and a custom-built Hall-effect collar system confirmed that OEC expansion movements were not present during respiratory sounds. The spectral emphasis during zebra finch call production ranging between 2.5 and 5 kHz was not present during respiratory sounds, indicating strongly that it can be attributed to the OEC expansion.

Sensory characterization of the irritant properties of oleocanthal, a natural anti-inflammatory agent in extra virgin olive oils.

Oleocanthal is an olive oil phenolic possessing anti-inflammatory activity. Anecdotal evidence suggests that oleocanthal elicits a stinging sensation felt only at the back of the throat (oropharynx). Due to this compound possessing potentially health-benefiting properties, investigation into the sensory aspects of oleocanthal is warranted to aid in future research. The important link between the perceptual aspects of oleocanthal and health benefits is the notion that variation in sensitivity to oleocanthal irritation may relate to potential differences in sensitivity to the pharmacologic action of this compound. The current study assessed the unique irritant attributes of oleocanthal including its location of irritation, temporal profile, and individual differences in the perceived irritation. We show that the irritation elicited by oleocanthal was localized to the oropharynx (P < 0.001) with little or no irritation in the anterior oral cavity. Peak irritation was perceived 15 s postexposure and lasted over 180 s. Oleocanthal irritation was more variable among individuals compared with the irritation elicited by CO(2) and the sweetness of sucrose. There was no correlation between intensity ratings of oleocanthal and CO(2) and oleocanthal and sucrose (r = -0.15, n = 50, P = 0.92 and r = 0.17, n = 84, P = 0.12, respectively), suggesting that independent mechanisms underlie the irritation of CO(2) and oleocanthal. The unusual spatial localization and independence of acid (CO(2)) sensations suggest that distinct nociceptors for oleocanthal are located in the oropharyngeal region of the oral cavity.

Altering the gag reflex via a palm pressure point.

BACKGROUND: The gag reflex regularly interferes with dental procedures. The authors hypothesize that applying pressure to a specific point on the palm alters the gag reflex and that hypersensitive gag reflexes may be categorized according to oropharyngeal landmarks. METHODS: Thirty-six neurologically intact subjects underwent a series of gag reflex trials (baseline, sham and treatment). The authors developed a hand pressure device for subjects to wear, which provided a consistent force, and they described a gag trigger point index (GTPI) scale. On the basis of the GTPI, they divided subjects into a hypersensitive group and an expected-sensitivity (control) group. RESULTS: The trigger point of the gag reflex moved posteriorly in all subjects as a result of pressure to the palm point. Statistical results from repeated measures analysis of variance support the GTPI baseline data, and group assignments helped predict mean GTPI scores across conditions. The authors noted a significant treatment-group interaction effect, which indicated that the difference in mean GTPI responses between the hypersensitive and expected-sensitivity groups depended on the treatment being used. CONCLUSIONS: The authors introduce a treatment involving the stimulation of a pressure point that consistently altered the gag reflex trigger. The results of the study show the need for a more detailed, systematic approach to studying the hypersensitive gag reflex. CLINICAL IMPLICATIONS: The change in trigger point in the hypersensitive group represented a functional gain. Application of the pressure point during dental procedures would decrease the likelihood of triggering a gag reflex.

Evaluating oral stimulation as a treatment for dysphagia after stroke.

Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 +/- 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 +/- 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 +/- 0.07 s and pharyngeal transit time was 0.94 +/- 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 +/- 3.01; sham: 24.9 +/- 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.

Dilation of the oropharynx via selective stimulation of the hypoglossal nerve.

The functional effects of selective hypoglossal nerve (HG) stimulation with a multi-contact peripheral nerve electrode were assessed using images of the upper airways and the tongue in anesthetized beagles. A biphasic pulse train of 50 Hz frequency and 2 s duration was applied through each one of the tripolar contact sets of the nerve electrode while the pharyngeal images were acquired into a computer. The stimulation current was limited to 20% above the activation threshold for maximum selectivity. The images showed that various contact sets could generate several different activation patterns of the tongue muscles resulting in medial and/or lateral dilation and closing of the airways at the tongue root. Some of these patterns translated into an increase in the oropharyngeal size while others did not have any effect. The pharyngeal sizes were not statistically different during stimulation either between the two different positions of the head (30 degrees and 60 degrees), or when the lateral contacts were compared with the medial ones. The contacts that had the least effect generated an average of 53 +/- 15% pharyngeal dilation relative to the best contacts, indicating that the results are marginally sensitive to the contact position around the HG nerve trunk. These results suggest that selective HG nerve stimulation can be a useful technique to produce multiple tongue activation patterns that can dilate the pharynx. This may in turn increase the size of the patient population who can benefit from HG nerve stimulation as a treatment method for obstructive sleep apnea.

Emergence of oropharyngeal, laryngeal and swallowing activity in the developing fetal upper aerodigestive tract: an ultrasound evaluation.

The developing fetal upper aerodigestive system provides the structural support for respiratory and ingestive functions necessary to sustain life at birth. This study investigated prenatal development of upper aerodigestive anatomy and the association of emerging functions as predictors of postnatal feeding skills. Biometric measures of oral, lingual, pharyngeal and laryngeal structures were obtained in fetuses 15-38 weeks gestational age using a four-plane sonographic technique. Accompanying ingestive behaviors were tallied across development. The data from 62 healthy controls were compared to seven cases at risk for postnatal feeding and swallowing dysfunction (Type II Arnold Chiari Malformation, trisomy 18, polyhydramnios, intrauterine growth restriction, Brachmann-de Lange Syndrome). Significant (p<0.001) linear regressions occurred in pharyngeal and lingual growth across gestation while ingestive behavior such as suckling emerged in a sequence of basic to complex movement patterns. Jaw and lip movements progressed from simple mouth opening to repetitive open-close movements important for postnatal suckling. Lingual movements increased in complexity from simple forward thrusting and cupping to anterior-posterior motions necessary for successful suckling at term. Laryngeal movements varied from shallow flutter-like movements along the lumen to more complex and complete adduction-abduction patterns. Fetal swallowing primarily occurred in the presence of concomitant oral-facial stimulatory activity. Significant variations (p<0.01) in the form and function of the ingestive system occurred in comparisons of gestational age-matched controls to at-risk cases. We postulate that prenatal developmental indices of emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance the care of the premature, medically fragile neonate.

[Efficacy of the cuffed oropharyngeal airway in spontaneously breathing patients].

A cuffed oropharyngeal airway (COPA) was used in 20 adult patients for airway management under epidural and brachial plexus block supplemented with light general anesthesia. Insertion of a COPA was successful at first attempt in 17 of 20 patients (85%). Sore throat developed in one patient (5%). Aspiration regurgitation, or laryngospasm was not observed. We conclude that a COPA can be an efficient airway device is spontaneously breathing patients under anesthesia.

Neuronal activation of the hypothalamic magnocellular system in response to oropharyngeal stimuli in the rat.

The present study was designed to delineate the neuronal site, the nature, and the gastrointestinal origin of the stimulation of the hypothalamic magnocellular system induced by the ingestion of sweetened condensed milk. Concomitant localization of the c-fos protein (Fos) with either arginine-vasopressin (AVP) mRNA or oxytocin (OT) mRNA in the paraventricular nucleus of the hypothalamus (PVH) and the supraoptic nucleus (SON) revealed that the hypothalamic neurons containing AVP and OT were activated following ingestion of sweetened condensed milk. Expression of c-fos mRNA was also determined in rats implanted with a gastric cannula that allowed for real, sham, and gastric feeding of sweetened condensed milk. The results provide evidence that the stimulation of the PVH and SON induced by sweetened condensed milk originate from oropharyngeal stimuli. Indeed, in real-and sham-fed rats, the postprandial levels of c-fos mRNA in the PVH and SON were significantly higher than the preprandial values, whereas there was no early postprandial rise in c-fos mRNA levels within the magnocellular division of the PVH and SON after gastric feeding. The results of this study also suggested that the stimulation of the PVH and SON induced by sweetened condensed milk was related to the hypertonicity of the milk, indeed, ingestion of an hypertonic solution of sucrose with a carbohydrate content close to that of sweetened condensed milk led to a stimulation of the PVH and SON that was comparable to that induced by the milk, whereas ingestion of an isotonic solution of sucrose did not trigger any significant activation of the PVH and SON. Taken together, the present results indicate that magnocellular neurosecretory neurons are sensitive to oropharyngeal stimuli and further support the view of the existence of oropharyngeal osmoreceptors.

Laryngeal movement, oropharyngeal pressure, and submental muscle contraction during swallowing.

This study examined temporal relationships of laryngeal movement, oropharyngeal pressure and submental muscle contraction during swallowing. Techniques used to obtain the temporal measures were electroglottography (EGG), oropharyngeal manometry, and submental surface electromyography. Liquid bolus swallows were performed by 40 normal subjects evenly divided by young and elderly, men and women. Results of this investigation suggest that the EGG waveform is reflective of the temporal aspects of laryngeal movement during swallowing and that the EGG has potential as a behavioral modification technique in swallowing therapy. A case study is presented to illustrate the use of the electroglottograph for biofeedback.

Oral aspects of aging.

The physician who is aware of oral problems can play an essential role in providing comprehensive care for the elderly. The average person 65 years or older visits the physician at least six times a year, but is seen by the dentist about once a year. Because of more frequent contact, the physician has a greater opportunity to identify important dental problems of the geriatric patient.