Innervation of human soft palate muscles.

Our objective was to determine the branching and distribution of the motor nerves supplying the human soft palate muscles. Six adult specimens of the soft palate in continuity with the pharynx, larynx, and tongue were processed with Sihler's stain, a technique that can render large specimens transparent while counterstaining their nerves. The cranial nerves were identified and dissection followed their branches as they divided into smaller divisions toward their terminations in individual muscles. The results showed that both the glossopharyngeal (IX) and vagus (X) nerves have three distinct branches, superior, middle, and inferior. Only the middle branches of each nerve contributed to the pharyngeal plexus to which the facial nerve also contributed. The pharyngeal plexus was divided into two parts, a superior innervating the palatal and neighboring muscles and an inferior innervating pharyngeal constrictors. The superior branches of the IX and X nerves contributed innervation to the palatoglossus, whereas their middle branches innervated the palatopharyngeus. The palatoglossus and palatopharyngeus muscles appeared to be composed of at least two neuromuscular compartments. The lesser palatine nerve not only supplied the palatal mucosa and palatine glandular tissue but also innervated the musculus uvulae, palatopharyngeus, and levator veli palatine. The latter muscle also received its innervation from the superior branch of X nerve. The findings would be useful for better understanding the neural control of the soft palate and for developing novel neuromodulation therapies to treat certain upper airway disorders such as obstructive sleep apnea.

Palatoglossus coupling in selective upper airway stimulation.

OBJECTIVES/HYPOTHESIS: Selective upper airway stimulation (sUAS) of the hypoglossal nerve is a useful therapy to treat patients with obstructive sleep apnea. Is it known that multiple obstructions can be solved by this stimulation technique, even at the retropalatal region. The aim of this study was to verify the palatoglossus coupling at the soft palate during stimulation. STUDY DESIGN: Single-center, prospective clinical trail. METHODS: Twenty patients who received an sUAS implant from April 2015 to April 2016 were included. A drug-induced sedated endoscopy (DISE) was performed before surgery. Six to 12 months after activation of the system, patients' tongue motions were recorded, an awake transnasal endoscopy was performed with stimulation turned on, and a DISE with stimulation off and on was done. RESULTS: Patients with a bilateral protrusion of the tongue base showed a significantly increased opening at the retropalatal level compared to ipsilateral protrusions. Furthermore, patients with a clear activation of the geniohyoid muscle showed a better reduction in apnea-hypopnea index. CONCLUSIONS: A bilateral protrusion of the tongue base during sUAS seems to be accompanied with a better opening of the soft palate. This effect can be explained by the palatoglossal coupling, due to its linkage of the muscles within the soft palate to those of the lateral tongue body. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:E378-E383, 2017.

The innervation of the soft palate muscles involved in cleft palate: a review of the literature.

OBJECTIVE: Surgical techniques to obtain adequate soft palate repair in cleft palate patients elaborate on the muscle repair; however, there is little available information regarding the innervation of muscles. Improved insights into the innervation of the musculature will likely allow improvements in the repair of the cleft palate and subsequently decrease the incidence of velopharyngeal insufficiency. We performed a literature review focusing on recent advances in the understanding of soft palate muscle innervation. MATERIAL AND METHODS: The Medline and Embase databases were searched for anatomical studies concerning the innervation of the soft palate. RESULTS: Our literature review highlights the lack of accurate information about the innervation of the levator veli palatini and palatopharyngeus muscles. It is probable that the lesser palatine nerve and the pharyngeal plexus dually innervate the levator veli palatini and palatopharyngeus muscles. Nerves of the superior-extravelar part of the levator veli palatini and palatopharyngeus muscles enter the muscle form the lateral side. Subsequently, the lesser palatine nerve enters from the lateral side of the inferior-velar part of the levator veli palatini muscle. This knowledge could aid surgeons during reconstruction of the cleft musculature. The innervation of the tensor veli palatini muscle by a small branch of the mandibular nerve was confirmed in all studies. CONCLUSION: Both the levator veli palatini and palatopharyngeus muscles receive motor fibres from the accessory nerve (through the vagus nerve and the glossopharyngeal nerve) and also the lesser palatine nerve. A small branch of the mandibular nerve innervates the tensor veli palatini muscle. CLINICAL RELEVANCE: Knowledge about these nerves could aid the cleft surgeon to perform a more careful dissection of the lateral side of the musculature.

Central and peripheral motor drive to the palatal muscles.

AIM OF THE STUDY: To characterize the motor command of the soft palate muscles using a magnetic stimulation technique. MATERIAL AND METHODS: Motor evoked potentials (MEPs) were recorded in 10 right-handed and 5 left-handed subjects at the midline of the palate or on the right or left hemipalate to peripheral and cortical magnetic stimulation. RESULTS: Mean palatal MEP amplitude ranged from 0.06 to 0.26mV to peripheral stimulation and from 0.36 to 1.09mV to cortical stimulation. In hemipalate recordings, MEPs to peripheral stimulation had greater amplitude when recorded ipsilaterally to the stimulation side, whereas MEPs to cortical stimulation were symmetrical. In midline recordings, right-handed subjects showed greater palatal MEP amplitude to right (rather than left) peripheral stimulation and to left (rather than right) cortical stimulation. Mean palatal MEP latency ranged from 4.0 to 4.1ms to peripheral stimulation and from 9.0 to 10.2ms to cortical stimulation; mean central conduction time ranged from 4.9 to 6.2ms. CONCLUSION: Palatal MEPs were easily and reliably obtained, including selective responses in each hemipalate. A bilateral cortical command of the palate is supported by our results, with a possible predominant motor drive from the left hemisphere in right-handed subjects.

Three-dimensional imaging of palatal muscles in the human embryo and fetus: Development of levator veli palatini and clinical importance of the lesser palatine nerve.

BACKGROUND: After palatoplasty, incomplete velopharyngeal closure in speech articulation sometimes persists, despite restoration of deglutition function. The levator veli palatini (LVP) is believed to be significantly involved with velopharyngeal function in articulation; however, the development and innervation of LVP remain obscure. The development of LVP in human embryos and fetuses has not been systematically analyzed using the Carnegie stage (CS) to standardize documentation of development. RESULTS: The anlage of LVP starts to develop at CS 21 beneath the aperture of the auditory tube (AT) to the pharynx. At CS 23, LVP runs along AT over its full length, as evidenced by three-dimensional image reconstruction. In the fetal stage, the lesser palatine nerve (LPN) is in contact with LVP. CONCLUSIONS: The positional relationship between LVP and AT three-dimensionally, suggesting that LVP might be derived from the second branchial arch. Based on histological evidence, we hypothesize that motor components from the facial nerve may run along LPN, believed to be purely sensory. The multiple innervation of LVP by LPN and pharyngeal plexus may explain the postpalatoplasty discrepancy between the partial impairment in articulation vs. the functional restoration of deglutition. That is, the contribution of LPN is greater in articulation than in deglutition.

Palatoglossus muscle neuroanatomy: a review

The palatoglossus muscle is classically described as an extrinsic muscle of the tongue. However, this descriptionis not consensus among the researchers, is one that sometimes it is not considered a muscle of the tongue.Thus, the objective of this study is to discuss some neuroanatomical aspects of palatoglossus muscle that mayhelp explain this aspect. Furthermore, this study shall be useful for clinicians, surgeons and academics thatmanipulate and keep particular interest for this anatomical site.

[Denervation change of tensor veli palati in obstructive sleep apnea hypopnea syndrome].

OBJECTIVE: To explore the denervation change of Tensor Veli Palati in patients with OSAHS by determine the mRNA and protein expression of NCAM. METHOD: The OSAHS group was consisted of 30 OSAHS patients and the normal control group was consisted of 10 chronic tonsillitis patients without OSAHS. Real-time quantitative RT-PCR and Western blot methods were used to determine the NCAM expression in specimens. RESULT: (1) The mRNA and protein expression level of NCAM in the OSAHS group increased significantly compared with that in control group (P < 0.05). (2) There was positive correlation between AHI and the protein expression level of NCAM in the OSAHS group (r = 0.803, P < 0.01). CONCLUSION: These results indicate that the denervation change of tensor veli palati appear in OSAHS patients, and the severity of OSAHS are relevant with the degree of denervation.

Nerve supply to the soft palate muscles with special reference to the distribution of the lesser palatine nerve.

OBJECTIVE: Descriptions of the innervation of the soft palate muscles in previous studies have varied according to the author. In the present study, distribution of the lesser palatine nerve, through which motor fibers of the facial nerve are considered to reach soft palate muscles, and that of the pharyngeal plexus in the soft palate were investigated in order to reexamine the innervation of the soft palate muscles according to anatomical evidence. RESULTS: Observations suggested that the levator veli palatini and palatopharyngeus were doubly innervated by branches of the lesser palatine nerve and pharyngeal plexus, and that the musculus uvulae was innervated by only the lesser palatine nerve. CONCLUSION: The soft palate is considered to be located in the border region between the areas of distribution of the lesser palatine nerve and pharyngeal plexus. This may be why controversies exist in previous studies about the innervation of the soft palate muscles.

Upper airway muscle inflammation and denervation changes in obstructive sleep apnea.

Inflammatory cell infiltration and afferent neuropathy have been shown in the upper airway (UA) mucosa of subjects with obstructive sleep apnea (OSA). We hypothesized that inflammatory and denervation changes also involve the muscular layer of the pharynx in OSA. Morphometric analysis was performed on UA tissue from nonsnoring control subjects (n = 7) and patients with OSA (n = 11) following palatal surgery. As compared with control subjects, inflammatory cells were increased in the muscular layer of patients with OSA, with CD4+ and activated CD25+ T cells (both increased approximately threefold) predominating. Inflammation was also present in UA mucosa, but with a different pattern consisting of CD8+ (2.8-fold increase) and activated CD25+ (3.2-fold increase) T cell predominance. As ascertained by immunoreactivity for the panneuronal marker PGP9.5, there was a dramatic (5.7-fold) increase in intramuscular nerve fibers in OSA patients compared with control subjects, as well as direct evidence of denervation based on positive immunostaining of the muscle fiber sarcolemmal membrane for the neural cell adhesion molecule in patients with OSA. These data suggest that inflammatory cell infiltration and denervation changes affect not only the mucosa, but also the UA muscle of patients with OSA. This may have important implications for the ability to generate adequate muscular dilating forces during sleep.

Combined anomalies of the palate in Mohr syndrome: is preoperative electromyography of the palate useful?

The authors present a girl with typical characteristics of oral-facial-digital syndrome type II (Mohr syndrome) with a cleft soft palate and pendulous tongue nodules. Because of feeding difficulties, electromyography was performed of both morphologically identical halves of the soft palate. One half showed a normal muscle action potential and in the other half electrical silence was registered. Exploratory surgery during palatoplasty showed a fatty hamartoma in the half of the palate in which no electric potentials had been registered.

An anatomical study of the levator veli palatini and superior constrictor with special reference to their nerve supply.

We dissected 50 head halves of 25 Japanese cadavers (10 males, 15 females) to investigate the innervations of the levator veli palatini (LVP) and superior constrictor pharyngis. The branches supplying the LVP were classified into the following three types according to their origins: supplying branches that originated from the pharyngeal branch of the glossopharyngeal nerve (type I, four sides, 8%), branches that originated from a communicating branch between the pharyngeal branches of the glossopharyngeal and vagus nerves (type II, 36 sides, 72%), and those that originated from the pharyngeal branch of the vagus nerve (type III, 10 sides, 20%). In previous studies, supplying branches of type I were seldom described. Regarding the innervation of the superior constrictor, some variations were observed, and we consider it likely that there is a close relationship between these variations and the type of innervation of the LVP.

Single motor unit activity in levator veli palatini during speech and nonspeech tasks.

OBJECTIVE: This article assesses the control of velar movement by relating observed recruitment patterns of single motor unit activity in levator veli palatini observed during speech and nonspeech tasks in a single subject to intraoral pressure demands. METHODS: Electromyographic activity was recorded from a single motor unit in levator veli palatini during repetitions of "Say (----) again" with selected consonant-vowel-consonant and consonant-vowel syllables, sustained high pressure consonants, and blowing tasks. Single motor unit firing characteristics (e.g., frequency of occurrence, firing frequency) were related to intraoral air pressures recorded during the sustained consonant and blowing tasks. RESULTS: Levator single motor unit activity was always present during the /s/ in "say" and the first and second /s/ in /sis/. Activity was observed less consistently during the production of the /s/ in /sus/, the /p/ in /p Lambda/, and the /g/ in "again." Single motor unit firing frequency ranged from 16.1 Hz to 22 Hz during phrase productions. Recruitment was observed during sustained productions of high-pressure consonants when intraoral pressures exceeded 15 cm H(2)O. Increases in intraoral air pressure were associated with 25% to 85% increases in single motor unit firing frequencies. During nonspeech blowing tasks, single motor unit activity was observed when intraoral air pressure exceeded approximately 12 cm H(2)O. Increases in intraoral air pressure were again associated with increased single motor unit firing rates. CONCLUSIONS: Results showed evidence of both preprogrammed and feedback-controlled responses by levator veli palatini to changes in task intraoral pressure demands.

Central distribution of neuronal cell bodies innervating the levator veli palatini muscle and associated pattern of myosin heavy chain isoform expression in rat.

The levator veli palatini (LVP) is a muscle that plays a very important role in the complex functions regulating velopharyngeal function. Although previous studies have indicated that the contraction properties of the LVP closely resemble those of the intrinsic laryngeal muscle, histological evidence has not yet been obtained. The LVP is generally considered to be innervated by the glossopharyngeal nerve, which contains efferent and afferent components. LVP motoneurons are localized in the nucleus ambiguus (Amb), and afferent neurons project into the bilateral regions of the nucleus of the solitary tract (NST). However, the position of neuronal cell bodies on afferent neurons has remained unknown. The present study examined serial muscle cross-sections using monoclonal antibodies specific for myosin heavy chain (MyHC), to characterize muscle fibers of the LVP, clarify the central distribution of LVP motoneurons within the Amb and afferent terminals within the NST, and elucidate the location of LVP afferent neuronal cell bodies. Clear separation was observed within the LVP between fibers containing only fast MyHC and others positive for both slow and fast MyHC. Horseradish peroxidase (HRP)-labeled motoneurons in the Amb were separated into rostral and caudal divisions, corresponding to the Bötzinger complex and the rostral ventral respiratory group, respectively. HRP-labeled afferent neuronal cell bodies were observed in a glossopharyngo-vagal complex ganglion, and HRP-labeled afferent terminals were observed in bilateral lateral regions of the NST. These results suggest a relationship between MyHC isoform expression and the central distribution of LVP motoneurons or central projections of afferent neurons, with regard to activity of the LVP during both inspiration and expiration.

Modulation of symptomatic palatal tremor by magnetic stimulation of the motor cortex.

OBJECTIVES: Magnetic stimulation of the motor cortex can be used to determine the involvement of the cortex in rhythmic movement disorders. Symptomatic palatal tremor (SPT) is thought to come from a pacemaker that is relatively resistant to internal and external stimulation. In this study, we investigated the effect of magnetic stimulation of motor cortex on SPT. METHODS: Five male patients, aged 67-79 years, with SPT after brain stem infarction or hemorrhage, all had a synchronous mouth angle twitch with the palatal movement. Electromyographic activity was recorded with a monopolar needle electrode from orbicularis oris. In experiment 1, transcranial magnetic stimulation (TMS) was delivered at 200% motor threshold (MT) to reset SPT. In experiment 2, the effect of TMS intensities was studied at 80-240% MT in two SPT patients. To determine the influence of the TMS, we used the resetting index (RI). RESULTS: TMS reset the tremor in all 5 SPT patients at 200% MT with RIs of 0.86-0.96. The latency of the tremor reappearance after TMS was longer than the pre-stimulus tremor interval, and the intervals between the subsequent tremor bursts were also prolonged. The degree of tremor resetting was closely correlated with the magnetic stimulus intensity and the latency of the tremor reappearance after TMS. CONCLUSIONS: Stimulation of the motor cortex may modulate the generator of SPT.

Reconstructing the pathway of the tensor veli palatini motor nerve during early mouse development.

The motor axons innervating the tensor veli palatini (TVP) navigate a long distance from the trigeminal motor nucleus to their target. The pathway and time course of the TVP motor nerve during this navigation process remain poorly understood. The aim of this study was to elucidate the peripheral development of the TVP motor nerve, and to confirm when the morphological relationship is established between the nerve and target muscle progenitors. Using immunohistochemistry, carbocyanine fluorescent labeling, and computerized three-dimensional image-reconstruction methods, we demonstrated the development of the TVP motor nerve in mouse embryos. Further, the morphological relationship between the extending mandibular nerve and myogenic cells stained for MyoD1 was examined. The peripheral pathfinding of the TVP motor nerve was divided into three continuous stages: (1) the earliest trigeminal motor axons leave the metencephalon and enter the primordium of the trigeminal ganglion at E9.5, when MyoD1-positive cells can already be detected in the mesenchymal core of the mandibular arch; (2) converging with the sensory root, the trigeminal motor root excites the trigeminal ganglion and begins to approach the mandibular muscle precursors at E10.5; (3) collateral branching occurs at E12.5. By E13.5, a nerve branch splits from the mandibular nerve to innervate the TVP, which appears as an individual muscle mass. These results suggest that the early process of mandibular motor nerve extension is correlated with the trigeminal ganglion cells, whereas when growing out of the ganglion, the mandibular nerve has a close relationship with target myogenic cells throughout the later process of pathway finding.

Palatal tremor, progressive multiple cranial nerve palsies, and cerebellar ataxia: a case report and review of literature of palatal tremors in neurodegenerative disease.

We describe a patient with an unusual clinical presentation of progressive multiple cranial nerve palsies, cerebellar ataxia, and palatal tremor (PT) resulting from an unknown etiology. Magnetic resonance imaging showed evidence of hypertrophy of the inferior olivary nuclei, brain stem atrophy, and marked cerebellar atrophy. This combination of progressive multiple cranial nerve palsies, cerebellar ataxia, and PT has never been reported in the literature. We have also reviewed the literature of PT secondary to neurodegenerative causes. In a total of 23 patients, the common causes are sporadic olivopontocerebellar atrophy (OPCA; 22%), Alexander's disease (22%), unknown etiology (43.4%), and occasionally progressive supranuclear palsy (4.3%) and spinocerebellar degeneration (4.3%). Most patients present with progressive cerebellar ataxia and approximately two thirds of them have rhythmic tremors elsewhere. Ear clicks are observed in 13% and evidence of hypertrophy of the inferior olivary nucleus in 25% of the patients. The common neurodegenerative causes of PT are OPCA/multiple system atrophy, Alexander's disease, and, in most of them, the result of an unknown cause.

Innervation of the palpebral conjunctiva and the superior tarsal muscle in the cynomolgous monkey: a retrograde fluorescent tracing study.

Retrograde fluorescent transport of Fast Blue (FB) and Diamidino Yellow (DY) was used to study the localisation of neurons that innervate the palpebral conjunctiva and the superior tarsal muscle in the cynomolgous monkey. Labelled cell bodies of sensory neurons including a few double labelled cell bodies were found in the ophthalmic part of the ipsilateral trigeminal ganglion. Labelled cell bodies of the sympathetic neurons including a few double labelled cell bodies were located in the middle and cranial part of the ipsilateral superior cervical ganglion, with a few in the contralateral ganglion. Labelled cell bodies of the parasympathetic neurons were all found in the ipsilateral pterygopalatine ganglion and randomly distributed. Neurons were disposed in the opthalmic part of the trigeminal and superior cervical ganglia, whereas parasympathetic neurons were distributed randomly. Cells of the nodose, ciliary, geniculate, otic and first 3 spinal ganglia were unlabelled. Tracing FB and DY from the palpebral conjunctiva and superior tarsal muscle respectively, revealed double labelled neurons in the trigeminal and superior cervical ganglia, probably indicating the presence of collaterals of axons serving both the palpebral conjunctiva and the superior tarsal muscle.