Cerebral areas processing swallowing and tongue movement are overlapping but distinct: a functional magnetic resonance imaging study

Effects of oropharyngeal air-pulse stimulation on swallowing in healthy older adults

While previous research has shown that air-pulse stimulation of the oropharynx facilitates saliva swallowing in young adults, the effects of air pulses in older adults have not been examined. Responses to air-pulse stimulation may differ in young and older adults given age-related changes in sensation, swallowing physiology, and swallow-related brain activation. Therefore, this study sought to determine the effects of oropharyngeal air-pulse stimulation on saliva swallowing rates in 18 healthy older adults. Saliva swallowing rates were monitored across six conditions: baseline without mouthpiece, baseline with mouthpiece in situ, unilateral right oropharyngeal stimulation, unilateral left oropharyngeal stimulation, bilateral oropharyngeal stimulation, and sham stimulation. Results indicated that bilateral oropharyngeal air-pulse stimulation was associated with a statistically significant increase in mean saliva swallowing rate compared to baseline without mouthpiece, baseline with mouthpiece in situ, and sham stimulation. In previous studies, young adults reported an irrepressible urge to swallow in response to oropharyngeal air-pulse delivery, but the older adults in the current study did not perceive the air-pulse stimulation as being associated with swallowing or other behaviors. These findings indicate that oropharyngeal air-pulse stimulation facilitates the elicitation of saliva swallowing in older adults.

Time-dependent hemispheric shift of the cortical control of volitional swallowing

An important part of the cortical processing of swallowing takes place in the sensorimotor cortex, predominantly in the left hemisphere. However, until now, only deglutition related brain activation with low time resolution exceeding a time interval of 1 s has been reported. In this study, we have examined the chronological sequence of cortical swallowing processing in humans by means of high temporal resolution magnetoencephalography (MEG). The cortical MEG activity was recorded during self-paced volitional swallowing in 10 healthy subjects. Data were analyzed using synthetic aperture magnetometry and the group analysis was performed using a permutation test. Swallowing-related muscle activity was recorded by electromyography. Within the time interval of 1 s of the most pronounced muscular swallowing execution, the MEG analysis revealed neural activation in the primary sensorimotor cortex. During the first 600 ms, only left hemispheric activation was found, bihemispheric activation during the next 200 ms and a right hemispheric activation during the last 200 ms. Thus, our results demonstrate a time-dependent shift of neural activation from left to right sensorimotor cortex during deglutition with left hemispheric dominance in the early stage of volitional swallowing and right hemispheric dominance during its later part.

Dysphagia in the elderly

The capacity to swallow or eat is a basic human need and can be a great pleasure. Older adults look forward to sharing mealtimes and participating in social interactions. The loss of capacity to swallow and dine can have far-reaching implications. With age, the ability to swallow undergoes changes that increase the risk for disordered swallowing, with devastating health implications for older adults. With the growth in the aging population, dysphagia is becoming a national health care burden and concern. Upward of 40% of people in institutionalized settings are dysphagic. There is a need to address dysphagia in ambulatory, acute care, and long-term care settings.

Dysphagia in stroke and neurologic disease

Dysphagia is a common problem in neurologic disease. The authors describe rates of dysphagia in selected neurologic diseases, and the evaluation and treatment of dysphagia in this population. Applicable physiology and aspects of neural control are reviewed. The decision-making process to determine oral feeding versus alternative means of alimentation is examined.

Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy

The assessment and management of patients in long-term care who have oropharyngeal dysphagia has developed into an apparently complex and distinct field of practice. It is unfortunate that it lacks an evidence base, the efficacy of treatment is not established, and many clinicians are unfamiliar with appropriate and effective interventions because of a lack of training. Some commonly used interventions are not only ineffective but potentially hazardous. Physicians must become more familiar with the assessment process and appropriate management.

The neurobiology of swallowing and dysphagia

The neurobiological study of swallowing and its dysfunction, defined as dysphagia, has evolved over two centuries beginning with electrical stimulation applied directly to the central nervous system, and then followed by systematic investigations that have used lesioning, transmagnetic stimulation, magnetoencephalography, and functional magnetic resonance imaging. The field has evolved from mapping the central neural pathway and peripheral nerves, to defining the importance of specific regions of the lower brain stem in terms of interneurons that provide sequential control for multiple muscles in the most complex reflex elicited by the nervous system, the pharyngeal phase of swallowing. The field is now emerging into defining how the higher cortical regions interact with this brain stem control and is providing a broader perspective of how the intact nervous system functions to control the three phases of swallowing (i.e., oral, pharyngeal, and esophageal). Much of the present interest focuses on how to retrain a damaged nervous system using a variety of stimulus techniques, which follow fundamentals in rehabilitation of the nervous system.

Neuroscience of Swallowing: Strategies in Rehabilitation

The development of strategies to rehabilitate patients with dysphagia depends on an understanding of both the underlying neuroscientific principles that control normal swallowing and how a damaged central nervous system can respond. Strategies can incorporate the sensory and motor systems, as well as use the plasticity of the cortex and neuromuscular system. Treating dysphagia could involve stimulating the sensory system more often through the two primary nerves involved with swallowing, the glossopharyngeal and superior laryngeal nerves, as well as by enhancing the trigeminal sensory input. Enhancement of the motor system can occur by using muscles in special exercises or by electrically stimulating the target muscles directly. The cortex can be modified by increased sensory input, which will adapt the sensorimotor cortex. In addition, techniques of directly stimulating the cortex hold promise for rehabilitation.

Neurophysiology of swallowing: effects of age and bolus type

This study examined age-related changes in swallowing from an integrated biomechanical and functional imaging perspective in order to more comprehensively characterize changes in swallowing associated with age. We examined swallowing-related fMRI brain activity and videoflouroscopic biomechanics of three bolus types (saliva, water and barium) in 12 young and 11 older adults. We found that age-related neurophysiological changes in swallowing are evident. The group of older adults recruited more cortical regions than young adults, including the pericentral gyri and inferior frontal gyrus pars opercularis and pars triangularis (primarily right-sided). Saliva swallows elicited significantly higher BOLD responses in regions important for swallowing compared to water and barium. In separate videofluoroscopy sessions, we obtained durational measures of supine swallowing. The older cohort had significantly longer delays before the onset of the pharyngeal swallow response and increased residue of ingested material in the pharynx. These findings suggest that older adults without neurological insult elicit more cortical involvement to complete the same swallowing tasks as younger adults.

Neural control of the gastrointestinal tract: implications for Parkinson disease

Disorders of swallowing and gastrointestinal motility are prominent nonmotor manifestations of Parkinson disease (PD). Motility of the gut is controlled both by extrinsic inputs from the dorsal motor nucleus of the vagus (DMV) and paravertebral sympathetic ganglia and by local reflexes mediated by intrinsic neurons of the enteric nervous system (ENS). Both the ENS and the DMV are affected by Lewy body pathology at early stages of PD. This early involvement provides insights into the pathophysiology of gastrointestinal dysmotility in this disorder and may constitute an important step in the etiopathogenesis of Lewy body disease.

Supratentorial regions of acute ischemia associated with clinically important swallowing disorders: a pilot study

BACKGROUND AND PURPOSE

Dysphagia is a common problem after stroke associated with significant morbidity and mortality. Except for patients with brain stem strokes, particularly lateral medullary strokes, it is difficult to predict which cases are likely to develop swallowing dysfunction based on their neuroimaging. Clear models of swallowing control and integration of cortico-bulbar input have not been defined and the role of subcortical structures is unclear. The purpose of this study was to identify supratentorial regions of interest (ROIs) that might be related to clinically important dysphagia in acute stroke patients, focusing on subcortical structures.

METHODS

We studied 29 acute supratentorial ischemic stroke cases admitted to our institution between 2001 and 2005 diagnoses with first ischemic stroke and without history of swallowing dysfunction. Subjects had MRI within 24 hours. Cases were defined as those subjects who were diagnosed as dysphagic after clinical evaluation by a speech language pathologist (SLP) and whose dysphagia was considered clinically significant, ie, requiring treatment by diet modification. Controls were defined as those patients who: (1) passed the stroke unit's dysphagia screening, (2) had a clinical evaluation by SLP that did not result in a diagnosis of dysphagia or diet modifications, or (3) had no documented evidence of dysphagia evaluation or treatment during hospitalization and were discharged on a regular diet. A trained technician, blinded to case-control status, examined 12 ROIs for dysfunctional tissue in diffusion and perfusion-weighted images. The odds ratio (OR) of dysphagia was calculated for each ROI. Logistic regression models were used to adjust for stroke severity (NIHSS) and volume.

RESULTS

Analysis of data on 14 cases and 15 controls demonstrated significant differences in the unadjusted odds of dysphagia for the following ROIs: (1) primary somatosensory, motor, and motor supplementary areas (PSSM; OR=10, P=0.009); (2) orbitofrontal cortex (OFC; OR=6.5, P=0.04); (3) putamen, caudate, basal ganglia (PCBG; OR=5.33, P=0.047); and (4) internal capsule (IC; OR=26; P=0.005). Nonsignificant differences were found in the insula and temporopolar cortex. Adjusted OR of dysphagia for subjects with strokes affecting the IC was 17.8 (P=0.03). Adjusted odds ratios for the PSSM, OFC, and PCBG were not statistically significant.

CONCLUSIONS

Significantly increased odds of dysphagia were found in subjects with IC involvement. Other supratentorial areas that may be associated with dysphagia include the PSSM, OFC, and PCBG. Analysis of additional areas was limited by the number of subjects in our sample. Future studies with larger sample size are feasible and will contribute to the development of a full swallowing control model.

Sensory stimulation activates both motor and sensory components of the swallowing system

Volitional swallowing in humans involves the coordination of both brainstem and cerebral swallowing control regions. Peripheral sensory inputs are necessary for safe and efficient swallowing, and their importance to the patterned components of swallowing has been demonstrated. However, the role of sensory inputs to the cerebral system during volitional swallowing is less clear. We used four conditions applied during functional magnetic resonance imaging to differentiate between sensory, motor planning, and motor execution components for cerebral control of swallowing. Oral air pulse stimulation was used to examine the effect of sensory input, covert swallowing was used to engage motor planning for swallowing, and overt swallowing was used to activate the volitional swallowing system. Breath-holding was also included to determine whether its effects could account for the activation seen during overt swallowing. Oral air pulse stimulation, covert swallowing and overt swallowing all produced activation in the primary motor cortex, cingulate cortex, putamen and insula. Additional regions of the swallowing cerebral system that were activated by the oral air pulse stimulation condition included the primary and secondary somatosensory cortex and thalamus. Although air pulse stimulation was on the right side only, bilateral cerebral activation occurred. On the other hand, covert swallowing minimally activated sensory regions, but did activate the supplementary motor area and other motor regions. Breath-holding did not account for the activation during overt swallowing. The effectiveness of oral-sensory stimulation for engaging both sensory and motor components of the cerebral swallowing system demonstrates the importance of sensory input in cerebral swallowing control.

How the brain laughs

Laughter is an affective nonspeech vocalization that is not reserved to humans, but can also be observed in other mammalians, in particular monkeys and great apes. This observation makes laughter an interesting subject for brain research as it allows us to learn more about parallels and differences of human and animal communication by studying the neural underpinnings of expressive and perceptive laughter. In the first part of this review we will briefly sketch the acoustic structure of a bout of laughter and relate this to the differential anatomy of the larynx and the vocal tract in human and monkey. The subsequent part of the article introduces the present knowledge on behavioral and brain mechanisms of "laughter-like responses" and other affective vocalizations in monkeys and apes, before we describe the scant evidence on the cerebral organization of laughter provided by neuroimaging studies. Our review indicates that a densely intertwined network of auditory and (pre-) motor functions subserves perceptive and expressive aspects of human laughter. Even though there is a tendency in the present literature to suggest a rightward asymmetry of the cortical representation of laughter, there is no doubt that left cortical areas are also involved. In addition, subcortical areas, namely the amygdala, have also been identified as part of this network. Furthermore, we can conclude from our overview that research on the brain mechanisms of affective vocalizations in monkeys and great apes report the recruitment of similar cortical and subcortical areas similar to those attributed to laughter in humans. Therefore, we propose the existence of equivalent brain representations of emotional tone in human and great apes. This reasoning receives support from neuroethological models that describe laughter as a primal behavioral tool used by individuals - be they human or ape - to prompt other individuals of a peer group and to create a mirthful context for social interaction and communication.

Disgust sensitivity predicts the insula and pallidal response to pictures of disgusting foods

The anterior insula has been implicated in coding disgust from facial, pictorial and olfactory cues, and in the experience of this emotion. Personality research has shown considerable variation in individuals' trait propensity to experience disgust ('disgust sensitivity'). Our study explored the neural expression of this trait, and demonstrates that individual variation in disgust sensitivity is significantly correlated with participants' ventroanterior insular response to viewing pictures of disgusting, but not appetizing or bland, foods. Similar correlations were also seen in the pallidum and orofacial regions of motor and somatosensory cortices. Our results also accord with comparative research showing an anterior to posterior gradient in the rat pallidum reflecting increased 'liking' of foods [Smith, K. S. and Berridge, K. C. (2005) J. Neurosci., 25, 849-8637].

Functional oropharyngeal sensory disruption interferes with the cortical control of swallowing

Background

Sensory input is crucial to the initiation and modulation of swallowing. From a clinical point of view, oropharyngeal sensory deficits have been shown to be an important cause of dysphagia and aspiration in stroke patients. In the present study we therefore investigated effects of functional oropharyngeal disruption on the cortical control of swallowing. We employed whole-head MEG to study cortical activity during self-paced volitional swallowing with and without topical oropharyngeal anesthesia in ten healthy subjects. A simple swallowing screening-test confirmed that anesthesia caused swallowing difficulties with decreased swallowing speed and reduced volume per swallow in all subjects investigated. Data were analyzed by means of synthetic aperture magnetometry (SAM) and the group analysis of the individual SAM data was performed using a permutation test.

Results

The analysis of normal swallowing revealed bilateral activation of the mid-lateral primary sensorimotor cortex. Oropharyngeal anesthesia led to a pronounced decrease of both sensory and motor activation.

Conclusion

Our results suggest that a short-term decrease in oropharyngeal sensory input impedes the cortical control of swallowing. Apart from diminished sensory activity, a reduced activation of the primary motor cortex was found. These findings facilitate our understanding of the pathophysiology of dysphagia.

Cortical lateralization of bilateral symmetric chin movements and clinical relevance in tumor patients—A high field BOLD–FMRI study

Although unilateral lesion studies concerning the opercular part of primary motor cortex report clinically severe motor deficits (e.g. anarthria, masticatory paralysis), functional lateralization of this area has not yet been addressed in neuroimaging studies. Using BOLD-FMRI, this study provides the first quantitative evaluation of a possible cortical lateralization of symmetric chin movements (rhythmic contraction of masticatory muscles) in right-handed healthy subjects and presurgical patients suffering tumorous lesions in the opercular primary motor cortex. Data were analyzed according to "activation volume" and "activation intensity". At group level, results showed a strong left-hemispheric dominance for chin movements in the group of healthy subjects. In contrast, patients indicated dominance of the healthy hemisphere. Here, a clinically relevant dissociation was found between "activation volume" and "activation intensity": Although "activation volume" may be clearly lateralized to the healthy hemisphere, "activation intensity" may indicate residual functionally important tissue close to the pathological tissue. In these cases, consideration of BOLD-FMRI maps with the exclusive focus on "activation volume" may lead to erroneous presurgical conclusions. We conclude that comprehensive analyses of presurgical fMRI data may help to avoid sustained postoperative motor deficits and dysarthria in patients with lesions in the opercular part of primary motor cortex.

A Larynx Area in the Human Motor Cortex

The map of the human motor cortex has lacked a representation for the intrinsic musculature of the larynx ever since the electrical stimulation studies of Penfield. In addition, there has been no attempt to localize this area using neuroimaging techniques. Because of the central importance of laryngeal function to vocalization, we sought to localize an area controlling the intrinsic muscles of the larynx by using functional magnetic resonance imaging and to place this area in a somatotopic context. We had subjects perform a series of oral tasks designed to isolate elementary components of phonation and articulation, including vocalization of a vowel, lip movement, and tongue movement. In addition, and for the first time in a neuroimaging study, we had subjects perform "glottal stops," in other words forced closure of the glottis in the absence of vocalizing. The results demonstrated a larynx-specific area in the motor cortex that is activated comparably by vocal and nonvocal laryngeal tasks. Converging evidence suggests that this area is the principal vocal center of the human motor cortex. Finally, the location of this larynx area is strikingly different from that reported in the monkey. We discuss the implications of this observation for the evolution of vocal communication in humans.

Functional neuroanatomy of human voluntary cough and sniff production

Cough and sniff are both spontaneous respiratory behaviors that can be initiated voluntarily in humans. Disturbances of cough may be life threatening, while inability to sniff impairs the sense of smell in neurological patients. Cortical mechanisms of voluntary cough and sniff production have been predicted to exist; however, the localization and function of supramedullary areas responsible for these behaviors are poorly understood. We used functional magnetic resonance imaging to identify the central control of voluntary cough and sniff compared with breathing. We determined that both voluntary cough and sniff require a widespread pattern of sensorimotor activation along the Sylvian fissure convergent with voluntary breathing. Task-specific activation occurred in a pontomesencephalic region during voluntary coughing and in the hippocampus and piriform cortex during voluntary sniffing. Identification of the localization of cortical activation for cough control in humans may help potential drug development to target these regions in patients with chronic cough. Understanding the sensorimotor sniff control mechanisms may provide a new view on the cerebral functional reorganization of olfactory control in patients with neurological disorders.

Normal swallowing and functional magnetic resonance imaging: a systematic review

Unknowns about the neurophysiology of normal and disordered swallowing have stimulated exciting and important research questions. Previously, these questions were answered using clinical and animal studies. However, recent technologic advances have moved brain-imaging techniques such as functional magnetic resonance imaging (fMRI) to the forefront of swallowing neurophysiology research. This systematic review has summarized the methods and results of studies of swallowing neurophysiology of healthy adults using fMRI. A comprehensive electronic and hand search for original research was conducted, including few search limitations to yield the maximum possible number of relevant studies. The participants, study design, tasks, and brain image acquisition were reviewed and the results indicate that the primary motor and sensory areas were most consistently active in the healthy adult participants across the relevant studies. Other prevalent areas of activation included the anterior cingulate cortex and insular cortex. Review limitations and suggested future directions are also discussed.

A rapid sound-action association effect in human insular cortex

Background

Learning to play a musical piece is a prime example of complex sensorimotor learning in humans. Recent studies using electroencephalography (EEG) and transcranial magnetic stimulation (TMS) indicate that passive listening to melodies previously rehearsed by subjects on a musical instrument evokes differential brain activation as compared with unrehearsed melodies. These changes were already evident after 20–30 minutes of training. The exact brain regions involved in these differential brain responses have not yet been delineated.

Methodology/Principal Finding

Using functional MRI (fMRI), we investigated subjects who passively listened to simple piano melodies from two conditions: In the ‘actively learned melodies’ condition subjects learned to play a piece on the piano during a short training session of a maximum of 30 minutes before the fMRI experiment, and in the ‘passively learned melodies’ condition subjects listened passively to and were thus familiarized with the piece. We found increased fMRI responses to actively compared with passively learned melodies in the left anterior insula, extending to the left fronto-opercular cortex. The area of significant activation overlapped the insular sensorimotor hand area as determined by our meta-analysis of previous functional imaging studies.

Conclusions/Significance

Our results provide evidence for differential brain responses to action-related sounds after short periods of learning in the human insular cortex. As the hand sensorimotor area of the insular cortex appears to be involved in these responses, re-activation of movement representations stored in the insular sensorimotor cortex may have contributed to the observed effect. The insular cortex may therefore play a role in the initial learning phase of action-perception associations.

Cerebral cortical processing of swallowing in older adults

While brain-imaging studies in young adults have implicated multiple cortical regions in swallowing, investigations in older subjects are lacking. This study examined the neural representations of voluntary saliva swallowing and water swallowing in older adults. Nine healthy females were examined with event-related functional magnetic resonance imaging (fMRI) while laryngeal swallow-related movements were recorded. Swallowing in the older adults, like young adults, activated multiple cortical regions, most prominently the lateral pericentral, perisylvian, and anterior cingulate cortex. Activation of the postcentral gyrus was lateralized to the left hemisphere for saliva and water swallowing, consistent with our findings in young female subjects. Comparison of saliva and water swallowing revealed a fourfold increase in the brain volume activated by the water swallow compared to the saliva swallow, particularly within the right premotor and prefrontal cortex. This task-specific activation pattern may represent a compensatory response to the demands of the water swallow in the face of age-related diminution of oral sensorimotor function.

Clustered functional MRI of overt speech production

To investigate the neural network of overt speech production, event-related fMRI was performed in 9 young healthy adult volunteers. A clustered image acquisition technique was chosen to minimize speech-related movement artifacts. Functional images were acquired during the production of oral movements and of speech of increasing complexity (isolated vowel as well as monosyllabic and trisyllabic utterances). This imaging technique and behavioral task enabled depiction of the articulo-phonologic network of speech production from the supplementary motor area at the cranial end to the red nucleus at the caudal end. Speaking a single vowel and performing simple oral movements involved very similar activation of the cortical and subcortical motor systems. More complex, polysyllabic utterances were associated with additional activation in the bilateral cerebellum, reflecting increased demand on speech motor control, and additional activation in the bilateral temporal cortex, reflecting the stronger involvement of phonologic processing.

Oropharyngeal stimulation with air-pulse trains increases swallowing frequency in healthy adults

This study sought to determine whether air-pulse trains delivered to the peritonsillar area would facilitate swallowing in healthy subjects. Trains of unilateral or bilateral air pulses were delivered to the peritonsillar area via tubing embedded in a dental splint, while swallows were simultaneously identified from their associated laryngeal and respiratory movements. Results from four subjects indicated that oropharyngeal air-pulse stimulation evoked an irrepressible urge to swallow, followed by an overt swallow as verified by laryngeal and respiratory movements. Moreover, air-pulse stimulation was associated with a significant increase in swallowing frequency. Mean latency of swallowing following bilateral stimulation tended to be less than the latency of swallowing following unilateral stimulation. These findings in healthy adults suggest the possibility that oropharyngeal air-pulse stimulation may have clinical utility in dysphagic individuals.

Strategies for block-design fMRI experiments during task-related motion of structures of the oral cavity

Functional MRI (fMRI) studies of jaw motion, speech, and swallowing disorders have been hampered by motion artifacts. Tissue motion perturbs the static magnetic field, creating geometric distortions in echo-planar images that lead to many false positives in activation maps. These problems have restricted blood oxygenation level-dependent (BOLD) fMRI studies involving orofacial muscles to event-related designs, which offer weak contrast-to-noise ratios when compared to block designs. Two new approaches are described that greatly reduce false positives in the activation maps created by the distortions in block-design fMRI studies involving jaw and tongue motion during chewing. First, an appropriate task duration of 10-14 s was found to maximize functional contrast while minimizing motion artifacts. Second, three motion-sensitive postprocessing methods were applied successively to examine the temporal and spatial characteristics of responses and identify and remove false positives caused by motion artifacts. These techniques are shown to allow the use of block design in an fMRI study of a jaw motion task. Extension to speech and swallowing tasks is discussed.

Central nervous system control of the laryngeal muscles in humans

Laryngeal muscle control may vary for different functions such as: voice for speech communication, emotional expression during laughter and cry, breathing, swallowing, and cough. This review discusses the control of the human laryngeal muscles for some of these different functions. Sensori-motor aspects of laryngeal control have been studied by eliciting various laryngeal reflexes. The role of audition in learning and monitoring ongoing voice production for speech is well known; while the role of somatosensory feedback is less well understood. Reflexive control systems involving central pattern generators may contribute to swallowing, breathing and cough with greater cortical control during volitional tasks such as voice production for speech. Volitional control is much less well understood for each of these functions and likely involves the integration of cortical and subcortical circuits. The new frontier is the study of the central control of the laryngeal musculature for voice, swallowing and breathing and how volitional and reflexive control systems may interact in humans.

The functional neuroanatomy of coordinated orofacial movements: sparse sampling fMRI of whistling

Whistling serves as a model for a skilful coordinated orofacial movement with sensorimotor integration of auditory and proprioceptive input. The neural substrate of whistling was investigated by sparse sampling functional MRI (fMRI) where the motor task occurred during a silent interval between successive image acquisitions to minimize task-related imaging artefacts. Whistling recruited a symmetrically represented neural network including primary motor and ventral premotor cortex (PMv), SMA, cingulate gyrus, basal ganglia, primary and secondary somatosensory cortex, amygdala, thalamus and cerebellum. A temporal analysis revealed higher activity of left sensory cortex, right PMv and cerebellum during late execution compared to initiation of whistling. Task-related signal changes in right PMv and right paravermal cerebellum were found to correlate with the amplitude of the whistle sound in a separate correlation analysis. The findings emphasize the role of ventral premotor cortex, cerebellum and somatosensory areas as integrators of afferent input within a distributed orofacial sensorimotor network.