Vocal cord palsy resulting from spontaneous carotid dissection

OBJECTIVES/HYPOTHESIS

Vocal cord palsy has a variety of causes, such as malignant tumors of the thyroid, lung, or upper mediastinum, aortic aneurysm, surgery of the thyroid, and infectious diseases.

STUDY DESIGN

Case report.

METHODS

A 43-year-old biologist had a holocephalic headache and right-sided neck pain for 1 day. Five days later, he developed paralysis of the right-side vocal cord. In addition, an angiotensin converting enzyme (ACE) inhibitor was administered because the patient had high systolic and diastolic blood pressures, which were formerly not known to the patient. Five days after admission, a temporary sensorimotor hemiparesis occurred.

RESULTS

Neurological examination revealed, in addition to the known paralysis of the right-side vocal cord, right-side palatoplegia, right-side hypoglossal nerve palsy, and mild dysphagia. Duplex sonography showed evidence of lumen narrowing of the right-side internal carotid artery caused by an hypoechogenic mural hematoma. Magnetic resonance imaging (0.5 T, Philips Gyroscan) revealed a circumscribed dissection of the right-side internal carotid artery from the carotid bifurcation to the petrosal segment. The diffusion-weighted magnetic resonance imaging scan of the brain also demonstrated multiple embolic ischemic lesions in the right hemisphere.

CONCLUSION

Internal carotid artery dissection must be included in the differential diagnosis of lower cranial nerve palsy and should be assessed by duplex ultrasonography and magnetic resonance imaging.

Hypoglossal neurinoma presenting with intratumoral hemorrhage

Focal or microscopic hemorrhage in a neurinoma is common, but tumor origin from the hypoglossal nerve and extensive symptomatic intratumoral hemorrhage are both rare. A 59-year-old male presented with severe neck pain, nausea and vomiting of 1-day duration, accompanied by right hypoglossal nerve palsy. Neuroimaging disclosed a tumor located in the right cerebellomedullary fissure and containing a hematoma. The right hypoglossal canal was slightly dilated. The intracranial tumor was resected via a suboccipital approach. Histological examination demonstrated spindle-shaped tumor cells with nuclear palisading and also relative hypervascularity with hyaline degeneration of the vessels. Extensive hemorrhage was present, as was necrosis. Thickening and hyalinization of arterial walls, a common occurrence in neurinomas, may have contributed to symptomatic intratumoral hemorrhage.

Repetitive hypoglossal nerve stimulation in myasthenia gravis

OBJECTIVES

To assess the diagnostic efficacy of repetitive nerve stimulation (RNS) of the hypoglossal nerve in patients with myasthenia gravis (MG) and bulbar symptoms (dysphagia, dysarthria).

METHODS

Twenty patients with MG and 25 normal controls had RNS of the hypoglossal nerve. All patients also had single fibre electromyography (SFEMG) of the orbicularis oculi and RNS with recordings of the nasalis, trapezius and abductor pollicis brevis muscles.

RESULTS

All patients had positive SFEMG studies. Nine patients with bulbar symptoms had positive hypoglossal RNS, including 3 with negative RNS recordings in other muscles. Eleven patients with no bulbar symptoms showed negative hypoglossal RNS, including two with positive RNS recordings from other muscles.

CONCLUSIONS

Abnormal RNS of the hypoglossal nerve correlates well with bulbar dysfunction and further characterises the extent of neuromuscular transmission defect in MG patients.

Hemilingual spasm: a new neurosurgical entity? Case report

Hemilingual spasm is a little-known movement disorder, presenting as intermittent paroxysmal involuntary contractions of half of the tongue muscles. The authors report a case of hemilingual spasm caused by an arachnoid cyst. After marsupialization of the cyst, the patient's symptoms immediately resolved. There has been no recurrence of hemilingual spasm during the follow-up period of more than 40 months.

The relationship between Bunina bodies, skein-like inclusions and neuronal loss in amyotrophic lateral sclerosis

Specific pathological hallmarks have been described in amyotrophic lateral sclerosis (ALS), which include motor neuronal loss, Bunina bodies (BBs) and skein like inclusions (SLIs). We investigated the relation between these three lesions in the cervical and lumbar anterior horns and the hypoglossal nuclei of 20 ALS patients and 9 controls using a quantitative light microscopy study. Immunohistochemistry with anti-cystatin C and anti-ubiquitin was used to detect the BBs and SLIs, respectively. A significant relation between the severity of neuronal loss and the proportion of SLI-containing neurons was found in the spinal cord, whereas no relation was found with BBs. We therefore propose that BBs and SLIs participate in two different steps of the cascade leading to neuronal loss.

Detailed anatomy of the intracranial segment of the hypoglossal nerve: neurovascular relationships and landmarks on magnetic resonance imaging sequences

OBJECT

The thin hypoglossal nerve can be very difficult to distinguish on magnetic resonance (MR) images. The authors used a combination of sequences to increase the reliability of MR imaging in its demonstration of the 12th cranial nerve as well as to assess the course of the nerve, display its relationships to adjacent vessels, and provide landmarks for evaluating the nerve in daily practice.

METHODS

The study group consisted of 34 volunteers (68 nerves) in whom a three-dimensional (3D) Fourier-transformation constructive interference in steady-state (CISS) sequence and a 3D T1-weighted contrast-enhanced magnetization-prepared rapid-acquisition gradient-echo (MPRAGE) sequence were applied. Two trained neuroradiologists collaboratively identified the hypoglossal trigone, preolivary sulcus, 12th cranial nerve, posterior inferior cerebellar artery, vertebral artery, 12th nerve root sleeve, and the hypoglossal canal on each side. The 3D CISS sequence successfully demonstrated the hypoglossal trigone (100% of images), 12th nerve root bundles (100% of images), and 12th nerve sleeves (88.2% of images). The canalicular segment was exhibited with the aid of plain 3D CISS sequences in 74% of images and by using contrast-enhanced 3D CISS sequences and contrast-enhanced MPRAGE sequences in 100% of images. The landmarks that proved useful to identify the cisternal segment of the 12th cranial nerve included the hypoglossal trigone, preolivary sulcus, and 12th nerve root sleeve. Neurovascular contact was identified in 61% of root bundles. The roots were distorted in 44% of these contacts.

CONCLUSIONS

The contrast-enhanced 3D CISS sequence consistently displayed the cisternal segment as well as the canalicular segments of the hypoglossal nerve and is, therefore, the best sequence to visualize the complete cranial course of this nerve. Landmarks such as the 12th nerve sleeves can assist in the identification of this nerve.

Discharge patterns of hypoglossal motoneurons during fictive breathing, coughing, and swallowing

We performed a series of experiments to study the intracellular activity of 58 hypoglossal motoneurons (HMs) in decerebrate, paralyzed, and ventilated cats. Changes in membrane potentials (MP) and discharge activities were evaluated during fictive breathing (FB), swallowing (FS), and coughing (FC). FS and FC were elicited by electrical stimulation of the superior laryngeal nerves. FB, FS, and FC all exhibited characteristic discharge patterns of the phrenic, abdominal, pharyngeal branch of the vagus, and hypoglossal nerves. Thirty-nine HMs displayed respiratory modulation, and 19 were nonrespiratory modulated. Nine HMs did not exhibit MP changes during FB, FS, and FC. During FS, 49 HMs exhibited MP changes consisting of depolarization, hyperpolarization or hyperpolarization-depolarization. HMs involved in FS were either respiratory modulated (n = 38) or not (n = 11). Only 20 HMs displayed MP changes and/or discharge activity during FC. All but two HMs fired during the expiratory phase of FC or at the end of this reflex. All HMs involved in FC (n = 20) were also modulated during both FB and FS. Our results suggest that the XII nucleus is functionally divided into common and distinct subsets of HMs based on their spontaneous activities and responses observed during FS and FC. The changes in MP and discharge frequencies observed during the three behaviors also suggest that HMs are driven by specific premotor neurons during FS, whereas a common premotor pathway is involved during FB and FC.

Prenatal nicotine exposure increases apnoea and reduces nicotinic potentiation of hypoglossal inspiratory output in mice

We examined the effects of in utero nicotine exposure on postnatal development of breathing pattern and ventilatory responses to hypoxia (7.4 % O2) using whole-body plethysmography in mice at postnatal day 0 (P0), P3, P9, P19 and P42. Nicotine delayed early postnatal changes in breathing pattern. During normoxia, control and nicotine-exposed P0 mice exhibited a high frequency of apnoea (f(A)) which declined by P3 in control animals (from 6.7 +/- 0.7 to 2.2 +/- 0.7 min(-1)) but persisted in P3 nicotine-exposed animals (5.4 +/- 1.3 min(-1)). Hypoxia induced a rapid and sustained reduction in f(A) except in P0 nicotine-exposed animals where it fell initially and then increased throughout the hypoxic period. During recovery, f(A) increased above control levels in both groups at P0. By P3 this increase was reduced in control but persisted in nicotine-exposed animals. To examine the origin of differences in respiratory behaviour, we compared the activity of hypoglossal (XII) nerves and motoneurons in medullary slice preparations. The frequency and variability of the respiratory rhythm and the envelope of inspiratory activity in XII nerves and motoneurons were indistinguishable between control and nicotine-exposed animals. Activation of postsynaptic nicotine receptors caused an inward current in XII motoneurons that potentiated XII nerve burst amplitude by 25 +/- 5 % in control but only 14 +/- 3 % in nicotine-exposed animals. Increased apnoea following nicotine exposure does not appear to reflect changes in basal activity of rhythm or pattern-generating networks, but may result, in part, from reduced nicotinic modulation of XII motoneurons.

Selected contribution: Time-dependent hypoxic respiratory responses in female rats are influenced by age and by the estrus cycle

Age affects time-dependent respiratory responses to episodic hypoxia in male rats, particularly long-term facilitation (LTF), a serotonin-dependent respiratory "memory" [Zabka AG, Behan M, and Mitchell GS, J Physiol (Lond) 531: 509, 2001]. Because age and gender influence serotonergic function, we tested the hypotheses that the short-term hypoxic response (STHR), posthypoxia frequency decline (PHFD) and LTF of phrenic and hypoglossal (XII) motor output change with age and stage of the estrus cycle in female rats. Young (3-4 mo) and middle-aged (13 mo) female Sprague-Dawley rats were anesthetized, paralyzed, vagotomized, and ventilated. STHR was measured during and PHFD after the first of three 5-min episodes of isocapnic hypoxia (arterial P(O)(2) 35-45 Torr). LTF was assessed 60 min postepisodic hypoxia. Phrenic and XII STHR increased with age (P < 0.05). PHFD was unaffected by age or gender. Phrenic LTF increased with age in both estrus and diestrus (P < 0.05), whereas XII LTF increased in middle-aged female rats during diestrus only. Age and gender influence time-dependent hypoxic phrenic and XII responses in a complex manner.

Altered respiratory motor drive after spinal cord injury: supraspinal and bilateral effects of a unilateral lesion

Because some bulbospinal respiratory premotor neurons have bilateral projections to the phrenic nuclei, we investigated whether changes in contralateral phrenic motoneuron function would occur after unilateral axotomy via C(2) hemisection. Phrenic neurograms were recorded under baseline conditions and during hypercapnic and hypoxic challenge in C(2) hemisected, normal, and sham-operated rats at 1 and 2 months after injury. The rats were anesthetized, vagotomized, and mechanically ventilated. No group differences were seen in contralateral neurograms at 1 month after injury. At 2 months, however, there was a statistically significant decrease in respiratory rate (RR) at normocapnia, an elevated RR during hypoxia, and an attenuated increase in phrenic neurogram amplitude during hypercapnia in the C(2)-hemisected animals. To test whether C(2) hemisection had induced a supraspinal change in respiratory motor drive, we recorded ipsilateral and contralateral hypoglossal neurograms during hypercapnia. As with the phrenic motor function data, no change in hypoglossal output was evident until 2 months had elapsed when hypoglossal amplitudes were significantly decreased bilaterally. Last, the influence of serotonin-containing neurons on the injury-induced change in phrenic motoneuron function was examined in rats treated with the serotonin neurotoxin, 5,7-dihydroxytryptamine. Pretreatment with 5,7-dihydroxytryptamine prevented the effects of C(2) hemisection on contralateral phrenic neurogram amplitude and normalized the change in RR during hypoxia. The results of this study show novel neuroplastic changes in segmental and brainstem respiratory motor output after C(2) hemisection that coincided with the spontaneous recovery of some ipsilateral phrenic function. Some of these effects may be modulated by serotonin-containing neurons.

Sensitivity of transcranial magnetic stimulation of cortico-bulbar vs. cortico-spinal tract involvement in Amyotrophic Lateral Sclerosis (ALS)

BACKGROUND

An upper motor neuron (UMN) lesion in amyotrophic lateral sclerosis (ALS) is often difficult to identify because clinical signs may be discrete or masked by severe simultaneous LMN lesions. We compared the diagnostic sensitivity of transcranial magnetic stimulation (TMS) to cranial muscles and limb muscles in the detection of UMN lesions.

DESIGN

We investigated corticobulbar and corticospinal tract function to the tongue/orofacial muscles and abductor digiti minimi/tibial anterior muscles with TMS in 51 patients with ALS to compare the diagnostic yield in the detection of UMN dysfunction. An UMN lesion was assumed when the following were found: the peripheral conduction time and amplitude of the M-wave were within the normal range, the response to cortical stimulation was absent, the TMS evoked/M-wave amplitude ratio was reduced, and the central motor conduction time or the interside difference was delayed (> mean+2.5 SD).

RESULTS

On the basis of these criteria a UMN lesion to the orofacial muscles was identified in 24 patients (47%), to the tongue in 27 (53%), and to the upper and lower limbs in 13 (25%) and 22 patients (43%), respectively. Combined abnormalities from all sites increased the diagnostic yield to 39 patients (76%). TMS of the limb muscles confirmed a UMN lesion in only 15 (54%) of the 28 patients with clinically confirmed UMN involvement. This number increased to 23 patients (82%) if tongue and orofacial muscles were taken into acount.

CONCLUSION

Our results indicate the early and in most cases subclinical corticobulbar tract involvement of the central motor pathways to the orofacial muscles and tongue in ALS. TMS of the tongue and orofacial muscles had a higher sensitivity in identifying UMN lesions than that of the upper and lower limbs.

Long term facilitation of respiratory motor output decreases with age in male rats

Long term facilitation (LTF) is a serotonin-dependent augmentation of respiratory motor output (phrenic and hypoglossal) following episodic hypoxia. Since ageing influences respiratory control mechanisms and serotonergic function, we tested the hypothesis that LTF decreases with age in male rats. Young (3-4 month) and aged (13 month) male Sprague-Dawley rats were anaesthetized with urethane, vagotomized, paralysed and pump ventilated. Integrated phrenic and hypoglossal (XII) nerve activities were measured before (baseline), during and for 60 min after three 5 min episodes of isocapnic hypoxia (Pa,O2 35-45 mmHg) separated by 5 min of hyperoxia (Pa,O2 > 150 mmHg). In young rats, LTF was observed as an augmentation in peak integrated phrenic (n = 8) and XII (n = 7) amplitudes following episodic hypoxia (56 +/- 14 and 73 +/- 16 % (means +/- S.E.M.) at 60 min post-hypoxia, respectively; both P < 0.05). In aged rats, LTF was significantly increased compared to baseline in phrenic (25 +/- 8 % at 60 min, P < 0.05), but not in XII (4 +/- 7 %, P > 0.05) motor output. LTF was significantly greater in young than in aged rats in both motor outputs (P < 0.05). Decreased phrenic and XII LTF suggests that serotonergic modulation of respiratory motor output decreases in ageing male rats. We speculate that decreased serotonergic modulation may contribute to age-related breathing disorders.

[Damage to cranial and peripheral nerves following patency restoration of the internal carotid artery]

The aim of the study was an assessment of the incidence of injury to cranial and peripheral nerves as complication of patency restoration of the internal carotid artery, and analysis of the effect of peripheral nerve injury on the results of carotid patency restoration. From Oct 1987 to Sept 1999 543 procedures were carried out for restoration of patency of the internal carotid artery. After the operation hypoglossus nerve injury was found in 7 cases (1.4%), vagus injury in 9 (1.8%). Signs of exclusively recurrent laryngeal nerve damage were found in 6 cases (1.2%). Glossopharyngeus nerve was damaged in 2 cases (0.4%), transient phrenic nerve palsy as a result of conduction anaesthesia was noted in 2 cases (0.4%). Damage to the transverse cervical nerve was found in 96 cases (60%). In 2 patients (1.2%) lower position of mouth angle was due to section of the mandibular ramus of the facial nerve. In another 2 cases skin sensation disturbances were a consequence of lesion of the auricularis magnus nerve and always they coexisted with signs of transverse cervical nerve damage.

IN CONCLUSION

damage to the cranial nerves during operation for carotid patency restoration are frequent but mostly they are not connected with any health risks and often they regress spontaneously.

Endothelin-converting enzymes and endothelin receptor B messenger RNAs are expressed in different neural cell species and these messenger RNAs are coordinately induced in neurons and astrocytes respectively following nerve injury

There is some evidence that endothelins may be a signal mediator between neuronal and glial cells, at least in some regions of the brain. To evaluate this possibility, the localization of messenger RNAs for endothelin-converting enzymes and endothelin receptor B in the rat brain were examined using in situ hybridization histochemistry. The messenger RNAs for endothelin-converting enzyme-1 and endothelin-converting enzyme-2 were expressed mainly in neurons located in various brain regions, whereas the messenger RNA for endothelin receptor B was mainly localized in the astrocytes located throughout the brainstem, Bergmann glia, choroid plexus and ependymal cells. The localization patterns of endothelin-converting enzyme and endothelin receptor B messenger RNAs were strikingly different. For instance, in the cerebellum, endothelin-converting enzyme-1 messenger RNA was localized in Purkinje cells, and endothelin-converting enzyme-2 mRNA was expressed in Purkinje cells and granule cells. On the other hand, endothelin receptor B messenger RNA was expressed in Bergmann glia and the astrocytes located in the granule cell layer. This suggests that final cleavages of big endothelins are performed on neuronal cells, and the major target of the processed endothelins could be astrocytes, which express endothelin receptor B most abundantly in the brain. Since evidence that endothelin is implicated in brain injury has also accumulated, we examined whether the expressions of endothelin-converting enzymes and endothelin receptor B are regulated by nerve injury. Following hypoglossal nerve injury, expression of messenger RNA for endothelin-converting enzymes-1 and -2 and endothelin receptor B was enhanced in the injured motor neurons and astrocytes respectively. The up-regulation of these messenger RNAs was also confirmed by a reverse transcription-polymerase chain reaction based strategyThese results lead us to suggest that endothelin can be an inducible intercellular mediator between injured neurons and astrocytes in response to nerve injury.

Inhibitory mechanisms in hypoxic respiratory depression studied in an in vitro preparation

A medullary-spinal cord preparation without the pons isolated from the neonatal rat was used to investigate the role of inhibitory neurotransmitters in the respiratory depression induced by hypoxia (hypoxic respiratory depression; HRD). The burst frequency (C(4)-f) and peak amplitudes of the integrated activity of the C(4) roots (integral C(4)) and of the hypoglossal nerve (integral XII) were recorded. A marked decrease in C(4)-f (to 36+/-6% of control, P<0. 05) with no change in the peak amplitudes of integral C(4) or integral XII was observed 17-21 min after superfusion with hypoxic CSF bubbled with 5% CO(2) in N(2). Antagonists of GABA(A) (bicuculline; 10 microM), GABA(B) (phaclofen; 0.2-0.5 mM), glycine (strychnine; 10 mM), adenosine (aminophylline; 100 mM) or opioid (naloxone; 1 mM) receptors were added to the bathing solution to block inhibitory synaptic transmission. Among these antagonists, only strychnine and naloxone alleviated HRD reducing the decline in C(4)-f to 57+/-11 and 53+/-6%, respectively (P<0.05). Posthypoxic neural arrest (PHNA) following resumption of oxygenation was shortened by the application of aminophylline, strychnine or naloxone (by 91+/-17, 96+/-25 and 40+/-6 s, respectively, P<0.05). These findings indicate that the reduction in the frequency component of HRD depends on glycinergic and opioid-mediated neuronal inhibition in an in vitro medullary spinal cord preparation. It was also observed that the duration of PHNA was positively correlated with the severity of the fall in C(4)-f (r=0.60, P<0.01).

Serotonergic stimulation of the genioglossus and the response to nasal continuous positive airway pressure

In obstructive sleep apnea (OSA), abnormal pharyngeal collapsibility may be offset by increased mechanoreflex-mediated activity of dilator muscles while awake, but this reflex is inhibited during sleep and during application of nasal continuous positive airway pressure (CPAP). Direct activation of upper airway (UA) motor neurons in the hypoglossal nucleus by a selective serotonin reuptake inhibitor (SSRI), paroxetine hydrochloride, may increase genioglossal electromyographic (EMG) activity (EMGgg) in a manner resistant to mechanoreflex inhibition. We studied the effects of paroxetine on EMGgg using an intraoral surface electrode during eupnea or room air breathing (RA), hypercapnia (HYP), and CPAP application in the presence of hypercapnia (CPAP + HYP) in 11 normal volunteers, using a double-blind, placebo-controlled crossover design. After 5 d of paroxetine, EMGgg activity increased significantly within each condition (p = 0.02). EMGgg during the conditions of HYP and HYP + CPAP were significantly greater than during RA for both placebo and paroxetine treatments (p = 0.006). EMGgg activity in HYP persisted during HYP + CPAP on paroxetine (183% versus 182% of placebo, respectively). We conclude that paroxetine produces an augmentation in EMGgg in normal subjects during wakefulness and that this effect persists during mechanoreflex inhibition. This is consistent with a central serotonergic effect.

Melatonin attenuates neuronal NADPH-d/NOS expression in the hypoglossal nucleus of adult rats following peripheral nerve injury

Oxidative stress and massive production of nitric oxide (NO) have been implicated in the neuropathogenesis following peripheral nerve injury. This study was aimed to ascertain whether melatonin would exert its neuroprotective effect on the lesioned hypoglossal neurons after peripheral axotomy, since it is known to reduce the oxidative damage in a variety of experimental neuropathologies in which NO is involved. Right-sided hypoglossal nerve transection was performed in adult rats following which the animals were given two different doses of melatonin administered intraperitoneally for 3, 7, 14, 21 and 30 successive days. Nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry and neuronal nitric oxide synthase (nNOS) immunohistochemistry were carried out to detect the neuronal NADPH-d/NOS expression in the hypoglossal nucleus (HN). At various time intervals following axotomy, the neurons in the affected HN were induced to express NADPH-d/NOS reactivity on the lesioned side peaking at 14 days. However, the enzyme expression was markedly depressed by melatonin treatment in a dose-dependent manner in terms of frequency of labelled neurons and staining intensity. It is suggested that the suppressive effect of melatonin on NADPH-d/NOS expression may be attributed to its antioxidant properties. Hence, in consideration of therapeutic strategies for reducing the oxidative stress following peripheral nerve injury, melatonin may prove to be beneficial.

[Neuromuscular reinnervation of mimetic muscles. A histomorphologic study of the zygomatic muscle of the rabbit]

To evaluate occurrences of reinnervation and degeneration, the portio auricularis of the zygomatic muscle was reinnervated (either primary or secondary reinnervation) with an interval of 6 weeks, using a neuromuscular transplant of the sternohyoid muscle, which was left at the ansa hypoglossi. Histological examination was performed 6 and 12 weeks later. Enzymatic stains for myofibrillar ATPase were used for differentiation of muscle fibre types. Histomorphological features of denervation and reinnervation were analysed. Six weeks after denervation and primary neuromuscular transplantation, type grouping in regions close to the transplanted muscle were detectable as signs of reinnervation. After a period of 12 weeks, the progressing reinnervation was proved by type grouping in distal areas of the muscle far from the area of transplantation. At the same time, differentiation of fibre typing in the type grouping areas increased. All denervated and reinnervated muscles had pathological variations of fibre diameter. Primary reinnervated muscles showed tendency of normalization in variation of diameter. Compared with primary reinnervated muscles, secondary reinnervated muscles with an interval of 6 weeks showed pronounced polymorphology of fibres and a high pathological increase of the variation of fibre diameters. The interfascicular space was significantly spread. The tendency of reinnervation with incidence of fibre type grouping was comparable to primary reinnervated muscles and also occurred 6 weeks after transplantation.

Closed-loop stimulation of hypoglossal nerve in a dog model of upper airway obstruction

Electrical stimulation of upper airway (UAW) muscles has been under investigation as a treatment method for obstructive sleep apnea (OSA). Particular attention has been given to the electrical activation of the genioglossal muscle, either directly or via the stimulation of the hypoglossal nerve (HG), since the genioglossus is the main tongue protrusor muscle. Regardless of the stimulation site or method, an implantable electrical stimulation device for OSA patients will require a reliable method for detection of obstructive breaths to apply the stimulation when needed. In this paper, we test the hypothesis that the activity of the HG nerve can be used as a feedback signal for closed-loop stimulation of the HG nerve in an animal model of UAW obstruction where a force is applied on the submental region to physically narrow the airways. As an advantage, the method uses a single electrode for both recording and stimulation of the HG nerve. Simple linear filtering techniques were found to be adequate for producing the trigger signal for the electrical stimulation from the HG recordings. Esophageal pressure, which was used to estimate the size of the UAW passage, returned to the preloading values during closed-loop stimulation of the HG nerve. The data demonstrate the feasibility of the closed-loop stimulation of the HG nerve using its activity as the feedback signal.

[Regeneration after delayed nerve suture]

The influence of the time delay of a nerve suture on axonal regeneration after nerve lesion is still unknown. We used the rat as an animal model and studied the influence of a 14- and 224-day delayed hypoglossal-facial nerve anastomosis (HFA) and compared results to immediate HFA. After injection of horseradish peroxidase into the whiskerpad we counted the retrogradely labelled neurons in the hypoglossal nucleus 7-112 days after operation to quantify the axonal reinnervation. Additionally, the amplitude of the evoked compound action potential of the whiskerpad was measured after hypoglossal nerve stimulation. By 112 days after immediate HFA only 931 +/- 27 hypoglossal neurons reinnervated the muscle (for 75% of normal innervation). After 14 days delayed HFA reinnervation was accelerated and enhanced with 1293 +/- 81 (104%) neurons. Even after 224 days delayed HFA reinnervation was possible, with 760 +/- 80 neurons (61%) present. We conclude that short-term delayed nerve suture improves axonal reinnervation.

Hypoglossal schwannoma: an uncommon cause of twelfth-nerve palsy

Hypoglossal schwannoma is an uncommon cause of 12th nerve palsy. We here report a pathologically proven case of left 12th nerve schwannoma in a 56-year-old woman who presented with progressive left tongue hemiatrophy and in whom cranial MRI disclosed a mass near the foramen jugular. Surgery showed a mass involving the hypoglossal nerve and the pathological examination was diagnostic of schwannoma.

Respiratory response to spontaneous contractions of the urinary bladder in awake and decerebrate rats

Spontaneous contractions of the urinary bladder (SBCs) have been shown to decrease the frequency and depth of respiration in anesthetized or unanesthetized, decerebrate cats. The respiratory responses to bladder voiding reflexes in the awake state have not been previously addressed. Because a chronic rat model for the study of bladder function has been established and breathing measurements can be made in the awake rat, we chose the rat as an experimental model to assess whether SBCs would alter breathing in the conscious, intact animal. Respiratory frequency increased during bladder contractions but tidal volume remained unaffected. To assess whether the respiratory response to bladder reflexes in rats differed from that previously observed in cats, we also studied decerebrate, vagotomized, paralyzed and artificially ventilated rats. Contrary to the respiratory inhibition observed in decerebrate cats, phrenic and hypoglossal nerve activities remained unaffected during SBCs in decerebrate rats. These results indicate a species difference in the coupling between respiration and bladder voiding reflexes.

Chronic recordings of hypoglossal nerve activity in a dog model of upper airway obstruction

The activity of the hypoglossal nerve was recorded during pharyngeal loading in sleeping dogs with chronically implanted cuff electrodes. Three self-coiling spiral-cuff electrodes were implanted in two beagles for durations of 17, 7, and 6 mo. During quiet wakefulness and sleep, phasic hypoglossal activity was either very small or not observable above the baseline noise. Applying a perpendicular force on the submental region by using a mechanical device to narrow the pharyngeal airway passage increased the phasic hypoglossal activity, the phasic esophageal pressure, and the inspiratory time in the next breath during non-rapid-eye-movement sleep. The phasic hypoglossal activity sustained at the elevated level while the force was present and increased with increasing amounts of loading. The hypoglossal nerve was very active in rapid-eye-movement sleep, especially when the submental force was present. The data demonstrate the feasibility of chronic recordings of the hypoglossal nerve with cuff electrodes and show that hypoglossal activity has a fast and sustained response to the internal loading of the pharynx induced by applying a submental force during non-rapid-eye-movement sleep.

Differential responses of respiratory nuclei to anoxia in rhythmic brain stem slices of mice

The response of the neonatal respiratory system to hypoxia is characterized by an initial increase in ventilation, which is followed within a few minutes by a depression of ventilation below baseline levels. We used the transverse medullary slice of newborn mice as a model system for central respiratory control to investigate the effects of short-lasting periods of anoxia. Extracellular population activity was simultaneously recorded from the ventral respiratory group (VRG) and the hypoglossus (XII) nucleus (a respiration-related motor output nucleus). During anoxia, respiratory frequency was modulated in a biphasic manner and phase-locked in both the VRG and the XII. The amplitude of phasic respiratory bursts was increased only in the XII and not in the VRG. This increase in XII burst amplitude commenced approximately 1 min after the anoxic onset concomitant with a transient increase in tonic activity. The burst amplitude remained elevated throughout the entire 5 min of anoxia. Inspiratory burst amplitude in the VRG, in contrary, remained constant or even decreased during anoxia. These findings represent the first simultaneous extracellular cell population recordings of two respiratory nuclei. They provide important data indicating that rhythm generation is altered in the VRG without a concomitant alteration in the VRG burst amplitude, whereas the burst amplitude is modulated only in the XII nucleus. This has important implications because it suggests that rhythm generation and motor pattern generation are regulated separately within the respiratory network.

[Hypoglossal nerve in its intralingual trajectory: anatomy and clinical implications]

There is little literature on the intralingual trajectory of the hypoglosal nerve. We performed an anatomical dissection on 6 cadavers and completed our study with histological examinations. The 12th cranial nerve enters the lower part of the tongue laterally, reaching the anterior border of the hypoglossal muscle where it follows the ascending lingual artery medially to terminate anteriorly to the lingual V. Its terminal branches spread out horizontally in each half of the tongue. There is a paramedial branch, found in all cases, which projects downwardly, posteriorly and medially at the basilingual portion of the genioglossal muscle. These anatomic findings indicate that basiglossectomy removing the entire base of the tongue can be performed without functional sequelae. A certain degree of somatotopy is also found with specific fibers reaching the protractor and retractor muscles. This nerve distribution supports attempts at selective electrical stimulation of the hypoglossal nerve with the aim of dilating the upper airways in patients with sleep apnea syndrome.