LUCAS How Teeth Work 1st Ed 2004

Craniofacial Muscles
Linda K. McLoon Francisco H. Andrade

Editors
Craniofacial Muscles
A New Framework for Understanding
the Effector Side of Craniofacial
Muscle Control
Editors
Linda K. McLoon
Department of Ophthalmology
University of Minnesota
Minneapolis, MN, USA
Francisco H. Andrade
Department of Physiology
University of Kentucky
Lexington, KY, USA
ISBN 978-1-4614-4465-7
ISBN 978-1-4614-4466-4 (eBook)
DOI 10.1007/978-1-4614-4466-4
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2012945590
Springer Science+Business Media New York 2013
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Contents
Part I
Overview
1 The Craniofacial Muscles: Arguments for Uniqueness .......................

Francisco H. Andrade and Linda K. McLoon
Part II
2
Development
Head Muscle Development .....................................................................

Itamar Harel and Eldad Tzahor
Part III
11
Extraocular Muscles
Extraocular Muscle Structure and Function........................................

Linda K. McLoon, Christy L. Willoughby,
and Francisco H. Andrade
31
Motor Control of Extraocular Muscle ..................................................

Vallabh E. Das
51
Extraocular Muscles Response to Neuromuscular Diseases

and Specific Pathologies .........................................................................
Fatima Pedrosa Domellf
75
Part IV Masticatory Muscles

6
Masticatory Muscle Structure and Function........................................

Mark Lewis, Nigel Hunt, and Rishma Shah
91
Motor Control of Masticatory Muscles ................................................. 111

Barry J. Sessle, Limor Avivi-Arber, and Gregory M. Murray
vi
Contents
Masticatory Muscle Response to Neuromuscular Diseases

and Specific Pathologies ......................................................................... 131
Sadie L. Hebert, Christy L. Willoughby, Francisco H. Andrade,
and Linda K. McLoon
Part V Laryngeal and Pharyngeal Muscles

9
Structure and Function of the Laryngeal and Pharyngeal

Muscles ..................................................................................................... 141
Lisa A. Vinney and Nadine P. Connor
10
Motor Control and Biomechanics of Laryngeal

and Pharyngeal Muscles ......................................................................... 167
Christy L. Ludlow
11
Laryngeal Muscle Response to Neuromuscular Diseases

J.C. Stemple, L. Fry, and R.D. Andreatta
Part VI Tongue Musculature

12 Tongue Structure and Function ............................................................. 207
Alan Sokoloff and Thomas Burkholder
13 Tongue Biomechanics and Motor Control ............................................ 229
Mary Snyder Shall
14 Tongue Muscle Response to Neuromuscular Diseases
Zi-Jun Liu
Part VII Facial Muscles
15
Facial Nerve Innervation and Facial Palsies ........................................ 265

Adriaan O. Grobbelaar and Alex C.S. Woollard
16
Spastic Facial Muscle Disorders ............................................................ 287

Juwan Park, Andrew R. Harrison, and Michael S. Lee
Part VIII
17
Summary and Conclusions
Comparison of the Craniofacial Muscles: A Unifying

Hypothesis................................................................................................ 325
Linda K. McLoon and Francisco H. Andrade
Index ................................................................................................................. 337
Contributors
Francisco H. Andrade Department of Physiology, University of Kentucky,

Lexington, KY, USA
R.D. Andreatta Division of Communication Sciences and Disorders, University
of Kentucky, Lexington, KY, USA
Limor Avivi-Arber University of Toronto, Toronto, ON, Canada
Thomas Burkholder School of Applied Physiology, Georgia Institute of
Technology, Altanta, GA, USA
Nadine P. Connor Departments of Communicative Disorders and Surgery,
University of Wisconsin-Madison, Madison, WI, USA
Vallabh E. Das College of Optometry, University of Houston, Houston, TX, USA
L. Fry Division of Communication Sciences and Disorders, University of
Kentucky, Lexington, KY, USA
Adriaan O. Grobbelaar Institute for Plastic Surgery Research and Education,
Royal Free Hospital, London, UK
Itamar Harel Department of Biological Regulation, Weizmann Institute of
Science, Rehovot, Israel
Andrew R. Harrison Department of Ophthalmology, University of Minnesota,
Sadie L. Hebert Departments of Ophthalmology and Neuroscience, University of
Minnesota, Minneapolis, MN, USA
Nigel Hunt UCL Eastman Dental Institute, London, UK
Michael S. Lee Department of Ophthalmology, University of Minnesota,
vii
viii
Contributors
Mark Lewis School of Sport, Exercise and Health, Loughborough University,

Loughborough, Leicestershire, UK and UCL Eastman Dental Institute, London,
UK
Zi-Jun Liu Department of Orthodontics, University of Washington, Seattle,
WA, USA
Christy L. Ludlow Department of Communication Sciences and Disorders, James
Madison University, Harrisonburg, VA, USA
Linda K. McLoon Department of Ophthalmology, University of Minnesota,
Gregory M. Murray University of Sydney, Sydney, Australia
Juwan Park Department of Ophthalmology, University of Minnesota,
Fatima Pedrosa Domellf Department of Ophthalmology, Ume University,
Ume, Sweden
Barry J. Sessle University of Toronto, Toronto, ON, Canada
Rishma Shah UCL Eastman Dental Institute, London, UK
Mary Snyder Shall Department of Physical Therapy, Virginia Commonwealth
University, Richmond, VA, USA
Alan Sokoloff Department of Physiology, Emory University, Atlanta, GA, USA
J.C. Stemple Division of Communication Sciences and Disorders, University of
Kentucky, Lexington, KY, USA
Eldad Tzahor Department of Biological Regulation, Weizmann Institute
of Science, Rehovot, Israel
Lisa A. Vinney Departments of Communicative Disorders and Surgery, University
of Wisconsin-Madison, Madison, WI, USA
Christy L. Willoughby Departments of Ophthalmology and Neuroscience,
University of Minnesota, Minneapolis, MN, USA
Alex C.S. Woollard Institute for Plastic Surgery Research and Education,
Royal Free Hospital, London, UK
Part I
Overview
Chapter 1
The Craniofacial Muscles: Arguments

for Uniqueness
Francisco H. Andrade and Linda K. McLoon
1.1
Introduction
The craniofacial muscles are small skeletal muscles associated with head and neck
structures and involved in a wide array of non-locomotor activities such as mastication, swallowing, breathing, vocalization, facial expression, and even vision and
other special senses. These muscles are the new kids on the block, starting with their
relatively recent appearance with the evolution of the head and neck in vertebrates
and to our growing understanding of their distinctive development programs, functions, and pathologies. For convenience, we can group the craniofacial muscles
according to their developmental origin: extraocular muscles, branchiomeric muscles (facial, masticatory, pharyngeal, and laryngeal muscles), and tongue muscles
(Noden and Francis-West 2006). There is growing recognition of clinical relevance
of the craniofacial muscles in terms of diseases that are specic to them (strabismus,
laryngeal dystonias, facial paralysis, and many others), but also their characteristic
divergent response to certain systemic neuromuscular disorders (sparing by some
muscular dystrophies, targeting by myasthenia gravis, to name a few). These are the
basic arguments for the uniqueness of the craniofacial muscles that serve as the
central theme for the following chapters.
F.H. Andrade, Ph.D. (*)

Department of Physiology, University of Kentucky,
800 Rose Street, Lexington, KY 40536-0298, USA
e-mail: paco.andrade@uky.edu
L.K. McLoon, Ph.D.
Department of Ophthalmology, University of Minnesota, 2001 6th Street SE,
Minneapolis, MN 55455, USA
L.K. McLoon and F.H. Andrade (eds.), Craniofacial Muscles: A New Framework
for Understanding the Effector Side of Craniofacial Muscle Control,
DOI 10.1007/978-1-4614-4466-4_1, Springer Science+Business Media New York 2013
1.2
F.H. Andrade and L.K. McLoon
Origin of Head and Neck Musculature
Craniofacial evolution is one of the key steps in the origin and diversication of
vertebrates (Trainor et al. 2003). The Craniata, a clade within the phylum Chordata
(animals with notochords at one point in their lives), arose during the Cambrian
explosion (~525 million years ago). In contrast to other chordates, the craniates
have heads with complex (vesicular) brains encased in a rigid cranium and specialized sensory organs, including laterally placed eyes. Properly speaking, a skull is
composed of the cranium and the jaw. The latter is an even more recent evolutionary
feature: its presence separates the jawed vertebrates (Gnathostomata, the great
majority of vertebrates, including mammals) from the older members of the Craniata
clade, the jawless shes (lampreys and hagshes). The appearance of the head and
neck is one of the factors that allowed vertebrates to shift from lter feeding to
active predation, greater motility, and a faster metabolic rate. At least partly due to
these characteristics, vertebrates have a presence in a broad range of terrestrial and
aquatic environments. Among many other distinguishing features, vertebrates have
a complex muscular digestive system, and the cardiovascular system has a heart
with two or more chambers, all additions required to cope with greater metabolic
demands imposed by their larger size and active lifestyle.
The craniofacial muscles allow for a broad motor repertoire in the head and neck.
It will become apparent in the next chapters that these muscles build on the striated
muscle stereotype to serve the unique motor needs of craniofacial structures. In
other words, the craniofacial muscles do not have quite the same developmental
origin as other striated muscles, skeletal or cardiac. To start, craniofacial muscles
are non-somitic; they do not follow the progression from mesoderm to segmented
somites, which characterizes the development of trunk and limb muscles. Instead,
the cranial mesoderm that originates craniofacial muscles differentiates along limits
set by molecular rather than anatomical boundaries (Sambasivan et al. 2011).
Craniofacial muscles can trace their most primitive origins to trunk musculature, as
evidenced by shared steps in their respective myogenic programs. However, the
developmental programs for craniofacial muscles show a level of complexity that
bets both their relatively recent appearance and the allocation of craniofacial
mesoderm for multiple fates. For example, some craniofacial muscles follow a
developmental program very similar to that of the heart, hinting at a common evolutionary origin (Kelly 2010). Neural crest plasticity and independent gene regulation (from other muscle groups) are needed for greater adaptability to environmental
pressures (Trainor et al. 2003). This inherent plasticity in the craniofacial developmental program gives rise to the diverse cranial phenotypes we see around us today:
wide range of beaks in birds, the repurposing of mandibular bones for hearing (all
the way to four middle ear bones in mammals), the sensory and motor function of
the elephants trunk, the muscles of facial expression in humans, and the enhanced
sensory role of the nose of the star-nosed mole.
The Craniofacial Muscles: Arguments for Uniqueness
1.3
Craniofacial Muscle Function
The structures of the head and neck protect the brain, provide support for delicate
sensory organs, and are needed for feeding and exploratory behaviors. The craniofacial muscles, which include the extraocular, facial, masticatory, pharyngeal, laryngeal, and tongue muscles, are required for all motor activities of the head and neck.
The extraocular muscles are responsible for the coordinated voluntary and reexive
movement of the vision organs, the eyes. Their anatomical arrangement and innervation are highly conserved, suggesting that the ocular motor system is fairly
ancient, maybe predating some trunk and limb muscles. With rare exceptions, even
the most primitive vertebrates have at least six extraocular muscles for each eye
(Noden and Francis-West 2006). As is the case in other underused motor systems,
these muscles are poorly developed in a non-vision-dependent species, the naked
mole-rat (McMullen et al. 2010). An even more extreme example of functional
extraocular muscle adaptation occurs in the billsh, whose enlarged dorsal (superior) extraocular muscles serve as heat-generating organs to maintain the brain
warmer than the environment (Block and Franzini-Armstrong 1988).
The branchiomeric muscles control jaw movement, facial expression, and laryngeal and pharyngeal function. Jaw (masticatory) muscles are important for feeding
and sound production; together with some neck muscles, they arise from the rst
and second branchial arches (Kuratani 2004). These are versatile muscles that are
adapted to diverse jaw articulation plans and feeding behaviors. Mammals are
unique in having muscles of facial expression and external ear movement. The pharyngeal and laryngeal muscles in mammals are mostly responsible for coordinated
swallowing and breathing (i.e., normally, we do not swallow and breathe at the
same time). The laryngeal muscles are also involved in airway protective reexes
and sound production (Lang et al. 2002).
A tongue containing voluntary muscles is present in most amphibians, and all
reptiles, birds, and mammals, pointing to an association with the terrestrial lifestyle,
and adapted for feeding and a sensory role (Iwasaki 2002).
1.4
Craniofacial Muscles and Neuromuscular Disease
The non-locomotor activities of feeding, sound production, breathing, facial expression, and vision are performed by the craniofacial muscles, and are altered by diseases affecting these muscles. For example, strabismus impairs vision secondary to
the loss of coordinated eye movements, laryngeal muscle dysfunction alters phonation and airway protective reexes, facial muscle paralysis affects facial expression
and mastication. In addition, structural factors such as craniofacial shape and the
position of its muscles predispose to conditions such as obstructive sleep apnea,
which affect humans almost exclusively, apparently because of the morphological
adaptations required for speech (Davidson 2003).
F.H. Andrade and L.K. McLoon
The aforementioned examples are commonly the specic craniofacial consequences of systemic neuromuscular diseases. Of greater interest and perhaps more
signicant is the divergent response of at least some craniofacial muscles to major
neuromuscular disorders. The most extensively studied example are the extraocular muscles, which are spared by Duchenne muscular dystrophy and other dystrophies affecting the dystrophinglycoprotein complex, yet targeted by myasthenia
gravis and certain mitochondrial myopathies (Kaminski and Ruff 1997; Porter and
Baker 1996; Rowland et al. 1997). The extraocular muscles, and more appropriately their motor neurons, are also spared by amyotrophic lateral sclerosis (ALS);
at most, patients on long-term ventilator support may eventually have ocular motor
involvement (Hayashi et al. 1987). The laryngeal muscles are also insensitive to
dystrophin deciency, the primary defect in Duchenne muscular dystrophy (Fry
et al. 2010; Thomas et al. 2008). Oculopharyngeal muscular dystrophy, a trinucleotide repeat disease, affects many craniofacial muscles. Ptosis and dysphagia are
the most common signs, and include gaze limitations, tongue weakness and atrophy, dysphonia, and facial weakness. There are also dystonias that target specic
subgroups of craniofacial muscles, blepharospasm and laryngeal dystonia being
the frequent examples.
It is unquestionably important to elucidate the pathogenesis of each neuromuscular disease in order to cure it or at least minimize its consequences. The contrasting response of craniofacial muscles to major generalized neuromuscular disorders
gives us a window into disease-modifying strategies.
1.5 A Preamble
The purpose of this chapter is to set the stage for this book, presenting a brief argument for the uniqueness of the craniofacial muscles. The biology of these small
muscles is relatively unexplored. We are just beginning to understand their developmental programs and the features that make them extreme examples of the skeletal
muscle stereotype. The following chapters present an extensive survey of our knowledge of the craniofacial muscles by addressing their development, structure, function, and pathology.
References
Block BA, Franzini-Armstrong C (1988) The structure of the membrane systems in a novel muscle
cell modied for heat production. J Cell Biol 107:10991112
Davidson TM (2003) The Great Leap Forward: the anatomic basis for the acquisition of speech
and obstructive sleep apnea. Sleep Med 4:185194
Fry LT, Stemple JC, Andreatta RD, Harrison AL, Andrade FH (2010) Effect of dystrophin
deciency on selected intrinsic laryngeal muscles of the mdx mouse. J Speech Lang Hear Res
53:633647
The Craniofacial Muscles: Arguments for Uniqueness
Hayashi H, Kato S, Kawada T, Tsubaki T (1987) Amyotrophic lateral sclerosis: oculomotor function
in patients on respirators. Neurology 37:14311432
Iwasaki S (2002) Evolution of the structure and function of the vertebrate tongue. J Anat
201:113
Kaminski H, Ruff R (1997) Ocular muscle involvement by myasthenia gravis. Ann Neurol
41:419420
Kelly RG (2010) Core issues in craniofacial myogenesis. Exp Cell Res 316:30343041
Kuratani S (2004) Evolution of the vertebrate jaw: comparative embryology and molecular developmental biology reveals the factors behind evolutionary novelty. J Anat 205:335347
Lang IM, Dana N, Medda BK, Shaker R (2002) Mechanisms of airway protection during retching,
vomiting, and swallowing. Am J Physiol Gastrointest Liver Physiol 283:G529G536
McMullen CA, Andrade FH, Crish SD (2010) Underdeveloped extraocular muscles in the naked
mole-rat (Heterocephalus glaber). Anat Rec 293:918923
Noden DM, Francis-West P (2006) The differentiation and morphogenesis of craniofacial muscles.
Dev Dyn 235:11941218
Porter JD, Baker RS (1996) Muscles of a different color: the unusual properties or the extraocular muscles may predispose or protect them in neurogenic and myogenic disease. Neurology
46:3037
Rowland LP, Hirano M, DiMauro S, Schon EA (1997) Oculopharyngeal muscular dystrophy,
other ocular myopathies, and progressive external ophthalmoplegia. Neuromuscul Disord
7(suppl 1):S15S21
Sambasivan R, Kuratani S, Tajbakhsh S (2011) An eye on the head: the development and evolution
of craniofacial muscles. Development 138:24012415
Thomas LB, Joseph GL, Adkins TD, Andrade FH, Stemple JC (2008) Laryngeal muscles are
spared in the dystrophin decient mdx mouse. J Speech Lang Hear Res 51:586595
Trainor PA, Melton KR, Manzanares M (2003) Origins and plasticity of neural crest cells and their
roles in jaw and craniofacial evolution. Int J Dev Biol 47:541553
Part II
Development
Chapter 2
Head Muscle Development

Itamar Harel and Eldad Tzahor
2.1
Skeletal Muscle Formation
Vertebrate movement depends on trunk skeletal muscles, which are derived from
the segmented paraxial mesoderm known as somites (Christ and Ordahl 1995).
During embryogenesis, muscle precursor cells proliferate extensively prior to their
differentiation and fusion into muscle bers containing multiple nuclei. Skeletal
muscle was the rst tissue in which a determination gene for cell fate, MyoD, was
identied in vertebrates (Weintraub et al. 1991). Molecular and technical advances
in the last two decades have resulted in a detailed understanding of the embryology
of this tissue and its genetic regulation by key transcription factors, including the
paired/homeobox genes Pax3 and Pax7, and the myogenic regulatory genes Myf5,
MyoD, Mrf4, and Myogenin (MRFs: myogenic regulatory factors (Kassar-Duchossoy
et al. 2004)). These genes are crucial for regulating muscle cell fate, as shown by
genetic loss-of-function analyses. Because many transcription factors that regulate
the fate of muscle progenitors have been identied, skeletal muscle tissue constitutes
an ideal model for the study of organogenesis and regeneration (Tajbakhsh 2005).
Questions related to the inductive processes and the molecular events underpinning
embryonic myogenesis are currently under intensive study worldwide. Answers to
these questions may provide basic insights into developmental biology, as well as to
the growing eld of regenerative medicine as myogenesis in adult muscle stem cells
recapitulates that of the embryo.
I. Harel E. Tzahor (*)

Department of Biological Regulation, Weizmann Institute of Science, Rehovot 76100, Israel
e-mail: eldad.tzahor@weizmann.ac.il
11
12
2.2
I. Harel and E. Tzahor
Head Muscles
In contrast to our understanding of how skeletal muscle is formed in the trunk, much
less is known about the tissues and molecules that induce the formation of the head
musculature. This chapter summarizes studies of the origins, composition, signaling, genetics, and evolution of distinct craniofacial muscles. Cellular and molecular
parallels are drawn between cardiac and pharyngeal arch muscle developmental
programs, and argue for the tissues common evolutionary origins. It is clear that the
developmental paths that lead to the formation of skeletal muscles in the head
appear to be distinct from those operating in the trunk. Considerable cellular and
genetic variations also exist among the different craniofacial muscle groups.
Approximately 60 muscles are present in the vertebrate head, which, rather than
serving for locomotion, move the eyes, control the cranial openings and facial
expression, facilitate food uptake and, in humans, speech (Noden 1983a; Noden and
Francis-West 2006; Wachtler and Jacob 1986) (Fig. 2.1a, b). These head muscles
encompass the extraocular muscles (EOM), the muscles of mastication that open
and close the jaw apparatus (derived from pharyngeal arch 1; PA1) and the muscles
of facial expression (derived from pharyngeal arch 2; PA2). The muscles of the third
pharyngeal arch (also known as branchial arches) operate the pharynx and larynx.
A number of these head muscles, including the hypobranchial muscles, the tongue
muscles, and the muscles of the posterior PAs, develop from the somites (Fig. 2.1a, b).
While head muscles exhibit the same tissue architecture as muscles in the trunk,
their development is remarkably distinct.
Fig. 2.1 The anatomy and mesodermal origins of craniofacial muscles in the mouse. (a) A transverse
section of an E16.5 embryonic head stained for the muscle marker MyHC (red ). DAPI staining
(gray) is seen in the background. Distinct marked muscles are detailed in (b) with respect to their
muscle subgroups and their origins. (b) An anatomical cartoon of adult mouse head highlighting
the craniofacial muscles shown also in (a)
2 Head Muscle Development
2.3
13
Head Muscles Are Heterogeneous in Terms of Their

Mesodermal Origins
Head muscles are highly heterogeneous in their structure, function, anatomical

position, and developmental origins. In contrast to the segmented paraxial mesoderm (the somites) in the trunk, the head mesoderm lacks any sign of segmentation
(Noden and Trainor 2005). Myoblasts that form head muscles arise within several
precursor populations, including prechordal, paraxial, and splanchnic (lateral)
mesoderm, and migrate into regions where the connective tissue progenitors may be
either ectodermal (neural crest) or mesodermal in origin (Noden and Trainor 2005).
In the past, craniofacial development was widely viewed within the context of the
neural crest cells, leading to the misconception (often seen in textbooks) that the
head musculature originates from neural crest cells. In fact, all head muscles derive
from mesodermal cells (Couly et al. 1992; Harel et al. 2009; Noden 1983a).
Head mesoderm precursors undergo gastrulation in the primitive streak, prior to
those of trunk mesoderm (Kinder et al. 1999; Psychoyos and Stern 1996). Pharyngeal
muscles are derived from the pharyngeal arch mesodermal core, which constitutes a
subset of head mesoderm surrounding the pharynx. The pharyngeal mesoderm (PM)
is divided into two subdomains: the loosely connected mesenchymal paraxial mesoderm, located on both sides of the neural tube and notochord (Fig. 2.2a, b), and the
medial splanchnic mesoderm, which is maintained as epithelial tissue, although
there seems to be no clear division between these two mesodermal populations
(Fig. 2.2, Tzahor and Evans 2011).
During embryonic ventral folding, the lateral splanchnic mesoderm is located on
the ventral side, beneath the oor of the pharynx (Fig. 2.2b). Both paraxial and
splanchnic mesodermal cells converge to form the mesodermal core within the pharyngeal arches (Nathan et al. 2008) (Fig. 2.2c, d). Hence, the PM includes both
paraxial and lateral splanchnic mesoderm cells that surround the pharynx (Fig. 2.2,
green). Taken together, PM cells contribute to the cores of the PAs (Fig. 2.2d) and
give rise to signicant areas of the heart and pharyngeal muscles. Moreover, PM
cells are found in close proximity to the pharyngeal endoderm, ectoderm, and neural crest cells, all of which tightly inuence pharyngeal muscle development
(Fig. 2.2d) (summarized below).
In addition to their contribution to the pharyngeal muscles, PM cells give rise to
cardiac progenitors (Grifone and Kelly 2007; Tzahor 2009; Tzahor and Evans 2011).
Studies in both chick and mouse embryos have shown that cardiac progenitor cells
populating the cardiac outow tract and right ventricle, collectively referred to as
the anterior heart eld (Kelly et al. 2001; Mjaatvedt et al. 2001; Waldo et al. 2001),
are progressively added by PM cells during heart looping stages. In the mouse, the
anterior heart eld is a subset of the second heart eld, which contributes to the outow
tract and right ventricle, and will later contribute a majority of cells to the atria.
Thus, a subset of PM cells constitutes the second heart eld, in contrast to the
more lateral splanchnic mesoderm, known as the rst heart eld (Fig. 2.2a, d, red),
14
Fig. 2.2 Pharyngeal mesoderm cells give rise to parts of the heart and the pharyngeal muscles.
(ad) Schematic illustration of the anatomy of the pharyngeal mesoderm in a 1.53-day-old chick
embryo is shown. Pharyngeal mesoderm cells (green) in the anterior part of the embryo surround
the pharynx. Later, these cells ll the mesoderm core of the pharyngeal arches, and are incorporated into the arterial pole of the heart (e.g., outow tract). The rst heart eld (red) is restricted to
the lateral splanchnic mesoderm that later contributes to the linear heart tube. Second heart eld
cells (green) are PM cells that contribute to the arterial pole of the heart. PM cells interact and
migrate together with cranial neural crest cells. Cardiac neural crest cells are part of the cranial
neural crest population, migrating into the outow tract via the posterior arches (arches 36)
which is contiguous with the PM, differentiates earlier, and eventually populates the
left ventricle (reviewed in Buckingham et al. 2005; Dyer and Kirby 2009; Evans
et al. 2010; Tzahor and Evans 2011; Tzahor and Lassar 2001; Vincent and
Buckingham 2010).
2.4
Head Muscle Satellite Cells
Recent studies have begun to uncover an unexpected heterogeneity in head muscles

with respect to their origins, genetic lineages, and transcriptional programs, as well
as their proliferative, differentiative, and regenerative properties (Harel et al. 2009;
15
Fig. 2.3 Distinct mesoderm populations contribute to skeletal muscles and satellite cells in the
head and trunk. (a) Satellite cells, located on the surface of the myober, beneath its basement
membrane (basal lamina), serve as a source of myogenic cells for growth and repair of skeletal
muscles after birth. (b) Skeletal muscles and satellite cells in trunk and limb derive from somites
(paraxial mesoderm). Pharyngeal arch muscles and their associated satellite cells derive from both
cranial paraxial mesoderm and splanchnic mesoderm sources. Extraocular muscles derive from
prechordal and paraxial mesoderm
Ono et al. 2010; Sambasivan et al. 2009). Adult skeletal muscle possesses a
remarkable ability to regenerate following injury. The cells that are responsible for
this capacity are the satellite cells, adult stem cells positioned under the basal lamina
of muscle bers (Fig. 2.3a) that can give rise to both differentiated myogenic cells,
and also maintain their stemness by means of a self-renewal mechanism.
Satellite cells play a key role in the routine maintenance, hypertrophy, and repair
of damaged adult skeletal muscles (Buckingham 2006; Kuang and Rudnicki 2008;
Zammit et al. 2006). Until recently, however, the embryonic origins of satellite
cells in the head musculature had been enigmatic. Previous studies addressing the
origins of satellite cells in trunk and limb muscles (Gros et al. 2005; KassarDuchossoy et al. 2005; Relaix et al. 2005; Schienda et al. 2006) rmly established
that somites give rise to muscle progenitors (Fig. 2.3b), including proliferative
Pax3/Pax7 cells; some satellite cells later spatially localize under the basal lamina
and become quiescent.
Lineage tracing techniques in both avian and mouse models demonstrated that
PM cells contribute to distinct pharyngeal arch-derived muscles and their associated
16
satellite cells (Fig. 2.3b, Harel et al. 2009). In contrast, trunk muscle-associated satellite
cells (including tongue muscles) derive from the Pax3+ lineage; Pax3+ cells and
Pax3 expression are not seen in any other head muscles. In contrast, all head muscles and their satellite cells derive from the MesP1+ lineage (including the tongue
and EOM), whereas the Isl1 lineage solely marks the pharyngeal arch-derived muscles and their satellite cells (Harel et al. 2009). In addition to lineage distinction,
differences in gene expression and differentiation potentials were observed between
satellite cells in head vs. trunk-derived muscles (Harel et al. 2009; Ono et al. 2010;
Sambasivan et al. 2009). Transplantation of myober-associated head satellite cells
into damaged limb muscle contributed toward efcient muscle regeneration (Harel
et al. 2009; Sambasivan et al. 2009). Furthermore, in vitro experiments demonstrated the cardiogenic nature of head-, but not trunk-derived satellite cells (Harel
et al. 2009). Fewer head satellite cells from the masseter (see Fig. 2.1) are seen;
also, these cells are more proliferative, and display delayed differentiation relative
to the timing of differentiation of satellite cells derived from trunk muscles (Ono
et al. 2010). Taken together, these ndings highlight a link between myogenesis in
the early embryo and the generation of adult muscle progenitor pools required for
muscle maintenance and regeneration (Fig. 2.3).
Heterogeneity in skeletal muscles can also be seen during adulthood, as reected
in distinct genetic signatures and susceptibilities to myopathies in both head and
trunk skeletal muscles (Emery 2002; Porter et al. 2006). In humans, several diseases
are characteristic of skeletal muscle tissue, and one of the longstanding mysteries in
the eld is why some muscles, but not others, are affected, even though they are
often located in close anatomical proximity. For example, Duchenne Muscular
Dystrophy (DMD), seen in 1/3,500 male births, results in lethality by the time these
individuals reach their mid-twenties, even with extensive intervention and health
care support in the later stages of the disease. Strikingly, in DMD patients, most
muscles are affected; yet EOM and laryngeal muscles are largely spared. This
nding reects an underlying theme in muscle diseases: understanding why virtually all myopathies affect only a subset of muscles is of great scientic interest, with
potential clinical relevance. Hence the phenotypic outcome observed in diverse
myopathies maybe rooted in developmental underpinnings.
2.5
Distinct Genetic Programs in Trunk and Head Muscles
It appears that different intrinsic and extrinsic regulatory pathways control skeletal
muscle formation in the trunk and in the head, as indicated by genetic loss of myogenic transcription factors in mice (Kelly et al. 2004; Lu et al. 2002; Rudnicki et al.
1993; Tajbakhsh et al. 1997) as well as by manipulations of tissues and signaling
molecules in chick embryos (Hacker and Guthrie 1998; Mootoosamy and Dietrich
2002; Noden et al. 1999; Tzahor et al. 2003). While skeletal muscle formation in
both regions of the embryo requires either MyoD or Myf5 (Rudnicki et al. 1993),
mice lacking both Myf5 and Pax3 are completely devoid of trunk muscles, yet retain
17
normal head muscles (Tajbakhsh et al. 1997). Thus, in the absence of Myf5, Pax3 is
necessary for the expression of MyoD in the trunk, but not in the head, a nding
consistent with the fact that Pax3 is not expressed in head muscle progenitors (Harel
et al. 2009).
The bHLH transcription factors, Capsulin and MyoR, were shown to act as
upstream regulators (presumably repressors) of pharyngeal arch-derived muscle
development. In Capsulin/MyoR double mutants, the masseter, pterygoid, and temporalis muscles were missing, while distal lower jaw muscles (e.g., anterior digastric and mylohyoid) were not affected (Lu et al. 2002). In T-box transcription factor
Tbx1 mutants, pharyngeal arch-derived muscles were frequently hypoplastic and
asymmetric, whereas the EOM and tongue muscles were not affected (Kelly et al.
2004). Hence, pharyngeal arch-derived muscles require Tbx1 for robust bilateral
specication. Head muscle defects in Tbx1 mutants are likely due to an intrinsic
defect in the mesoderm (Dastjerdi et al. 2007), as well as to Tbx1s indirect function
in the endoderm and ectoderm (Arnold et al. 2006). Indeed, analyses of various
Tbx1 mutant embryos indicated that several broblast growth factor (FGF) family
members expressed in these adjacent tissues were down-regulated, demonstrating a
role for Tbx1 and FGF signaling during head muscle development (Hu et al. 2004;
Kelly et al. 2004; Knight et al. 2008; Vitelli et al. 2002; von Scheven et al. 2006).
Tbx1 and the bicoid-related homeodomain transcription factor Pitx2 are thought
to be linked to the same genetic pathway in many developmental processes, including cardiac and craniofacial muscle development (reviewed in Grifone and Kelly
2007). In both mouse and chick, Pitx2 is expressed in the head mesoderm and, subsequently, in the mesodermal core of PA1 (Dong et al. 2006; Shih et al. 2007). In
Pitx2 mutants, the EOM and PA1 muscles of mastication are affected. Pitx2 is
essential for EOM formation. Reducing Pitx2 gene dose results in small rectus muscles, while eliminating Pitx2 expression completely prevents the formation of all
the EOM (Diehl et al. 2006).
A recent study in mice that addressed the genetic programs promoting myogenesis in the head muscles revealed distinct requirements for Myf5 and Mrf4 in EOM
and in pharyngeal arch-derived muscles (Sambasivan et al. 2009). Furthermore, this
study suggests that Tbx1 in PM progenitors plays a similar role to that of Pax3 during somitogenesis. In zebrash, the functions of Myf5 and MyoD during head muscle formation are non-redundant: in this organism, the homeodomain transcription
factor Six1 seems to play a role in the genetic program regulating development of
subsets of muscles during head myogenesis (Lin et al. 2006, 2009).
In summary, embryological and genetic studies indicate that distinct regulatory
circuits control the formation of head and trunk skeletal muscles. These loss-offunction studies, combined with ndings from lineage tracing studies, highlight the
heterogeneity in head muscle development, such that distinct genetic programs regulate different groups of muscles within the head. An important open question in the
eld is how the aforementioned set of transcription factors expressed in head muscle
progenitors interacts in a hierarchical regulatory network to activate myogenesis in
the head.
18
2.6
Extrinsic Regulation of Head Muscle Development
The tissues and signaling molecules that promote skeletal muscle formation
(myogenesis) from muscle progenitors in the somites have been intensively studied
(Buckingham 2006; Pourquie 2001; Tajbakhsh 2005). Somitic myogenesis in the
trunk is affected by signals emanating from the axial tissues, the surface ectoderm,
and the lateral plate mesoderm. Wnt family members expressed in the dorsal neural
tube work together with Sonic hedgehog (Shh) expressed in the notochord to activate Myf5 and MyoD in the somite (Borycki et al. 2000; Gustafsson et al. 2002;
Munsterberg et al. 1995; Stern et al. 1995; Tajbakhsh et al. 1998). Bone morphogenic protein (BMP) signals from the lateral plate have been shown to delay the
activation of myogenic bHLH gene expression in the somites (Pourquie et al. 1996;
Reshef et al. 1998).
The differences between head and trunk myogenic programs reect the inuence
of both intrinsic (e.g., tissue-specic transcription factors) and extrinsic regulatory
pathways (e.g., signaling molecules). Although signals from the dorsal neural tube
promote myogenesis in the trunk (Munsterberg et al. 1995), such signals block myogenesis in PM explants (Tzahor et al. 2003). Accordingly, overexpression of Wnt
family members expressed in either the dorsal neural tube (Wnt3a) or surface ectoderm (Wnt13), or forced expression of stabilized b-catenin, which stimulates the
canonical Wnt-signaling pathway, block myogenesis in PM explants and in vivo
(Tzahor et al. 2003). In striking contrast, Wnt family members expressed in either the
dorsal neural tube or in surface ectoderm overlying the somites were shown to promote
skeletal myogenesis in this tissue (Capdevila et al. 1998; Ikeya and Takada 1998;
Munsterberg et al. 1995; Stern et al. 1995; Tajbakhsh et al. 1998; Takada et al. 1994).
In contrast to the differential effects of Wnt signaling on head vs. trunk
mesoderm, BMP signals were found to repress myogenesis in both head (TiroshFinkel et al. 2006; Tzahor et al. 2003) and trunk regions (Amthor et al. 1999;
Hirsinger et al. 1997; McMahon et al. 1998; Pourquie et al. 1996; Reshef et al.
1998). Accordingly, myogenesis in the head is induced by a combination of BMP
inhibitors such as Noggin and Gremlin, and a Wnt inhibitor (e.g., Frzb). These molecules were shown to be secreted by both CNC cells, and by other tissues surrounding the cranial muscle anlagen (Tzahor et al. 2003).
The expression of certain FGF family members in the mouse is Tbx1-dependent,
suggesting that FGF signaling may act downstream of Tbx1 function, although the
precise role of FGF signaling on head myogenesis is not entirely clear (Knight et al.
2008; von Scheven et al. 2006).
Taken together, in the trunk, signals from the neural tube and notochord
specically stimulate the development of the epaxial muscle anlagen, which remain
in the vicinity of the axial midline tissues to give rise to the deep muscles of the back
(Burke and Nowicki 2003). In contrast, head muscles develop at a distance from the
neural tube (the developing brain) in either the core of the PAs (pharyngeal muscles)
or around the eye (EOM). Hence, Wnt and BMP (and likely FGF) signals block
premature head muscle differentiation in the vicinity of the axial tissues. It is tempting
19
to speculate that these signals play a role in the delayed differentiation of head
muscle progenitors within regulatory circuits involving transcription factors such as
Tbx1, Pitx2, MyoR, Capsulin, and Isl1. Overexpression studies in chick PM explants
and in vivo have demonstrated that this is, indeed, the case (Harel et al. 2009 and
data not shown). Thus, Wnt, BMP, and FGF signaling pathways are thought to control the balance between myogenic precursor proliferation and differentiation in the
head. Whether some of these extrinsic signals play roles in the specication of head
muscle progenitors is a plausible assumption that remains to be validated.
2.7
Cranial Neural Crest Cells Affect Head Muscle

Patterning and Differentiation
Cranial neural crest cells surround the muscle anlagen in a highly organized fashion, separating the myoblasts from the overlying surface ectoderm (Noden 1983b;
Trainor et al. 1994). Cranial neural crest cells give rise to most of the skeletal
elements of the head, and also serve as precursors for connective tissues and tendons (Couly et al. 1993; Le Douarin et al. 1993). Neural crest cells affect the patterning of muscle, placodes, and connective tissue in the head. Both PM and cranial
neural crest cells migrate into the PAs, which form the templates of adult craniofacial structures (Hacker and Guthrie 1998; Noden 1983b; Noden and Trainor
2005; Trainor and Tam 1995; Trainor et al. 1994). In a similar fashion cranial neural crest cells affect the patterning of EOM formation within the orbit (Bohnsack
et al. 2011). Mesoderm-derived muscle progenitors fuse together to form myobers
within cranial neural crest-derived connective tissue in a precisely coordinated
manner.
Craniofacial shapes are amazingly diverse in vertebrates (Helms et al. 2005).
This diversity apparently reects the tight linkage between skeletal elements and
connective tissue, derived from the cranial neural crest, and the muscles, which are
mesoderm-derived. The relationship between muscle and skeletal elements within
the jaw region strongly affects feeding mechanics. This may reect on the ability of
vertebrates to rapidly modify the jaw complex, a critical evolutionary advantage
enabling the organism to accommodate to new ecological conditions (Herrel et al.
2005). In keeping with this view, the emergence of vertebrate predators is also associated with the increased muscularization of PA muscles, along with an increase in
size of the jaw skeleton (Takio et al. 2004).
The molecular mechanisms underlying head muscle patterningmyoblast guidance, positioning, and connection to specic attachment siteshave in the past
been poorly understood. Furthermore, the degree to which skeletal muscle
specication, differentiation, and patterning is intrinsic to muscle (mesoderm) progenitors, or controlled by extrinsic environmental signals (e.g., cranial neural crest
cells), is a fundamental embryological question. It has long been suggested that, in
addition to contributing to the formation of skeletal elements and connective tissue
20
in the head, cranial neural crest cells may also be involved in producing the signals
necessary for the patterning of the head musculature (Couly et al. 1992; Ericsson
et al. 2004; Grammatopoulos et al. 2000; Grenier et al. 2009; Heude et al. 2010;
Kontges and Lumsden 1996; Noden 1983a, b; Olsson et al. 2001; Rinon et al. 2007;
Schilling and Kimmel 1997; Tokita and Schneider 2009; Tzahor et al. 2003).
Because skeletal muscles in the head, except for EOM, still form (albeit in a
distorted fashion), following in vivo ablation of the cranial neural crest cells in
amphibian and chick embryos (Ericsson et al. 2004; Olsson et al. 2001; Tzahor et al.
2003; von Scheven et al. 2006, reviewed in Noden and Trainor 2005), the precise
impact of cranial neural crest cells on head muscle formation remains unclear. Thus,
while it is generally accepted that the cranial neural crest cells inuence cranial
muscle formation, exactly how cranial neural crest cells participate in this process
has yet to be elucidated. The current view in the eld is that cranial neural crestderived connective tissue progressively imposes the characteristic anatomical musculoskeletal architecture upon PM muscle progenitors (Heude et al. 2010; Rinon
et al. 2007; Tokita and Schneider 2009).
PM progenitors are exposed to signals from pharyngeal arch endoderm, ectoderm, and neural crest cells that together create a complex regulatory system
(reviewed in Rochais et al. 2009; Vincent and Buckingham 2010). Perturbation of
the balance of signals within this system can lead to abnormal cardiac and craniofacial development (see below). Neural crest ablation in the chick, for example, results
in increased FGF signaling and elevated proliferation in the PM (Hutson et al. 2006;
Rinon et al. 2007; Waldo et al. 2005). These ndings suggest that both cardiac neural crest (affecting caudal PM progenitors) and cranial neural crest cells (affecting
cranial PM) buffer proliferative signals (presumably FGFs) secreted from the endoderm and ectoderm, to promote PM migration and differentiation.
2.8 The Link Between Heart and Pharyngeal-Arch Derived

Muscle Development
The skeletal myogenic potential of PM cells and their contribution to pharyngeal
arch-derived muscles have long been documented (Noden and Francis-West 2006;
Wachtler and Jacob 1986). In contrast, the cardiogenic potential of these cells has
only been revealed over the last decade (reviewed in Black 2007; Buckingham
et al. 2005; Dyer and Kirby 2009; Evans et al. 2010; Tzahor and Evans 2011;
Vincent and Buckingham 2010). For example, PM explants dissected from early
chick embryos undergo cardiogenesis (Nathan et al. 2008; Tirosh-Finkel et al.
2006; Tzahor and Lassar 2001). The in vivo cardiogenic potential of PM was further revealed in chick embryos (Nathan et al. 2008; Rana et al. 2007; Tirosh-Finkel
et al. 2006). It has been shown that Wnt signaling (e.g., Wnt1 and Wnt3a from the
dorsal neural tube) inhibit PM-derived cardiogenesis (Nathan et al. 2008; Tzahor
and Lassar 2001). Considerable overlap in the expression of head muscle markers
(e.g., Myf5, Tcf21 (capsulin), Msc (MyoR), Tbx1, Pitx2) and cardiac markers such
21
as Islet1 and Nkx2.5 has been documented in the PM, suggesting that these cells
play a dual role in myogenesis and cardiogenesis (Bothe and Dietrich 2006; Nathan
et al. 2008; Tirosh-Finkel et al. 2006). Likewise, lineage studies in the mouse demonstrated an overlap in progenitor populations contributing to pharyngeal muscles
and second heart eld derivatives (Dong et al. 2006; Harel et al. 2009; Nathan et al.
2008; Verzi et al. 2005). Thus, the genetic program controlling development of
pharyngeal arch-derived muscles overlaps with that controlling the PM-derived
heart progenitors.
The LIM-homeodomain protein Islet1 (Isl1) is required for a broad subset of
cardiac progenitors in the mouse (Cai et al. 2003; Laugwitz et al. 2008; Lin et al.
2007; Sun et al. 2007). Gene expression and lineage experiments in the chick have
revealed that the core of the pharyngeal arch is divided along the proximaldistal
axis, such that paraxial mesoderm cells mainly contribute to the proximal region of
the core, while the splanchnic mesoderm contributes to its distal region (Nathan
et al. 2008). Isl1 is expressed in the distal part of the PM, and its expression is correlated with delayed differentiation of lower jaw muscles (Nathan et al. 2008).
Over-expression of Isl1 in the chick represses pharyngeal muscle differentiation
(Harel et al. 2009).
Lineage tracing experiments in the mouse, using an Isl1Cre line revealed the
signicant contribution of Isl1+ cells to the mesodermal core of the pharyngeal
arches (Harel et al. 2009; Nathan et al. 2008), as well as to the heart (Moretti et al.
2006). Isl1+ PM cells were shown to contribute to a subset of pharyngeal arch-derived
muscles (mylohyoid, stylohyoid, and digastric) at the base of the mandible, facilitating its opening. Isl1+ cells give rise to PA2 muscles controlling facial expression
(Harel et al. 2009; Nathan et al. 2008) and, to a lesser extent, the masseter, pterygoid,
and temporalis, the jaw closing muscles, indicating that this gene is not expressed
in all PM progenitors. In both species, tongue and EOM are not derived from the
Isl1 lineage (Harel et al. 2009; Nathan et al. 2008). Taken together, Isl1 marks a
subset of PM cells, and plays an important role in the development of distinct
PM-derived cardiovascular and skeletal muscle progenitors (Tzahor and Lassar
2001). The direct role of Isl1 in pharyngeal arch-derived muscle development has
yet to be resolved, as Isl1 knockout embryos die at around E10 (Cai et al. 2003).
A retrospective clonal analysis in the mouse, developed in the Buckingham lab,
demonstrated recently that head muscles and second heart eld derivatives originate
from multipotent PM progenitors (Lescroart et al. 2010). Two myogenic lineages
that link groups of head muscles to different parts of the heart were identied. The
rst muscle lineage gives rise to the temporalis and masseter as well as to the EOM.
Strikingly, this single cell clone also contributes to myocardial cells in the right
ventricle. The second lineage gives rise to a broad range of muscles controlling
facial expression, which derive from PA2 mesoderm, and also contributes myocardial cells at the arterial pole of the heart (Lescroart et al. 2010). In conclusion, this
study and others provide cellular and molecular insights into how pharyngeal
mesoderm cells form distinct pharyngeal arch-derived muscles and certain parts of
the heart.
22
2.9
Evolution of Pharyngeal Mesoderm: From Pharyngeal

Arch-Derived Muscles to the Heart
The architecture and function of muscle cells have been remarkably conserved
throughout evolution, suggesting that all muscle cells likely evolved from an ancestral developmental program involving a single contractile myogenic cell type (Baugh
and Hunter 2006; Fukushige et al. 2006). The fact that the developmental programs
of the heart and pharyngeal arch-derived muscles are tightly linked suggests that
these tissues share common evolutionary origins (Grifone and Kelly 2007; Tzahor
2009; Tzahor and Evans 2011). For example, nematodes are invertebrates that do
not possess a heart or dened circulatory system. Instead, their pharyngeal archderived muscle functions like a heart, and exhibits electrical activity similar to that
of mammalian cardiomyocytes. Furthermore, it has been shown that pharyngeal
arch-derived muscle development in nematodes is regulated by the homeobox gene
Nkx2.5 (ceh-22) (Harfe and Fire 1998) and may be functionally replaced by the
zebrash nkx2.5 (Haun et al. 1998, reviewed in Grifone and Kelly 2007; Olson
2006; Tzahor 2009; Tzahor and Evans 2011).
Tunicates belong to the Chordata phylum, and are considered as the sister
group of vertebrates (Davidson 2007). The tunicate Ciona intestinalis is a sessile
marine invertebrate. As in vertebrates, the Ciona heart is located ventrally and posterior to the pharynx, and anterior to the stomach; in the gastrulating embryo, its
heart arises from a pair of blastomeres expressing the MesP gene. Several studies
suggest signicant similarities in the gene regulatory networks controlling cardiogenesis in vertebrates and tunicates (Davidson 2007; Davidson et al. 2006; Satou
et al. 2004). The heart and pharyngeal arch-derived muscle cells in Ciona are seemingly distinct, based on the expression of different myosin heavy chain isoforms
(Ogasawara et al. 2002); yet both are derived from MesP+ cells.
Strikingly, Isl1+ PM cells in both Ciona (Stol et al. 2010) and vertebrates (Harel
et al. 2009; Nathan et al. 2008) give rise to pharyngeal arch-derived muscles (termed
siphon muscles in Ciona). These ndings suggest that the last common ancestor of
tunicates and vertebrates contained PM cells derived from MesP+ lineages that
expressed Isl1, FoxF, and Nkx2.5, and had the potential to give rise to both heart
tissue and pharyngeal arch-derived muscles (Stol et al. 2010, reviewed in Tzahor
and Evans 2011). With the increasing complexity of the vertebrate heart and, in
particular, during the heart tube elongation that occurs in vertebrates, Isl1+ PM cells
were recruited into the looping heart to give rise to cardiomyocytes. Hence, this
study implies that reallocation of PM cells into the looping heart represents the
emergence of the second heart eld in vertebrates. In addition, these ndings suggest a distinct evolutionary separation in the origins of the two heart elds.
2.10
23
Summary
Skeletal muscles throughout the body facilitate locomotion and movement due to
their contractile functionality. Two decades ago our view on skeletal muscle development argued for a common developmental program for this tissue that is governed by a set of MRFs. Our current view is gradually changing with the realization
that skeletal muscles are highly heterogeneous in terms of their developmental origins, the molecular networks that activate myogenesis, their function, and their malfunction under disease conditions. In particular, head muscle differs in these aspects
from the muscles in our body. Recent studies focusing on head muscle development
provide novel insights on the origins of these muscles and their molecular signatures. These insights are relevant to an understanding of head myogenesis, the link
between cardiac and craniofacial muscle development, as well as to the etiology of
craniofacial muscle myopathies.
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Part III
Extraocular Muscles
Chapter 3
Extraocular Muscle Structure and Function

Linda K. McLoon, Christy L. Willoughby, and Francisco H. Andrade
3.1
Introduction
It has become increasingly clear that skeletal muscles are not all the same, but have
signicant differences in terms of embryological development, ber type, physiological properties, metabolic properties, and disease prole. If one thinks about
skeletal muscle as a continuum from the least to most complex, with the leg muscle
soleus at one end, the extraocular muscles (EOMs) would be at the other end. The
combination of its unusual properties compared to other skeletal muscles has
resulted in the suggestion that the EOM represent a distinct allotype (Hoh and
Hughes 1988). The goal of this chapter is to summarize the characteristics of the
EOM that make them so unique amongst skeletal muscles.
3.2 Anatomy
The EOM are traditionally described as including 7 muscles in each orbit. Six muscles
move each eye in the orbit, 4 rectus muscles and 2 oblique muscles, and the location
of each determines its role in controlling eye position and movement. A seventh
L.K. McLoon, Ph.D. (*)

e-mail: mcloo001@umn.edu
C.L. Willoughby
Departments of Ophthalmology and Neuroscience,
University of Minnesota, Minneapolis, MN, USA
F.H. Andrade, Ph.D.
31
32
L.K. McLoon et al.
Fig. 3.1 Diagram of the anatomical locations of the extraocular muscles (EOM) within the orbit
from the superior view. The inferior rectus would be parallel to the superior rectus but cannot be
seen from this view. The inferior oblique takes its origin from the medial side of the inferior orbital
wall, and would run parallel to the direction of the SO from the trochlea (T) to the sclera. Superior
rectus (SR), medial rectus (MR), lateral rectus (LR), superior oblique (SO)
Fig. 3.2 The medial and lateral rectus muscles move the eye in the horizontal plane. To look to the
right, the lateral rectus of the right eye abducts the right eye, moving it away from the nose, and the
medial rectus adducts the left eye, moving it towards the nose
muscle, the levator palpebrae superioris muscle, acts to raise the eyelid. While an
interesting muscle, it will not be discussed further. The pathways of the EOM from the
orbit to the sclera determine eye position and direction of eye movements. The medial
and lateral rectus muscles both take their origin at the apex of the orbit from a common
tendinous ring and insert onto the sclera on the medial and lateral sides of the globe
anterior to the equator of the globe (Fig. 3.1). These muscles have the simplest action
of the six EOM, in that they control horizontal eye movements. The medial rectus
adducts the eye (moving it towards the nose) and the lateral rectus abducts the eye
(moving it away from the nose) (Fig. 3.2). Because the eyes move in a conjugate manner in most directions of gaze at distance, the medial and lateral rectus muscles within
33
Fig. 3.3 The medial orbital walls are parallel to each other, and the lateral wall forms a 45 angle
with the medial wall. If there was no tension on the EOMs the natural direction of gaze would be
at 22.5, rather than parallel to the medial wall. Thus, tone must be maintained in the medial rectus
muscles bilaterally in primary gaze (see Fig. 3.4d)
the same orbit (and attaching to the same globe) are referred to as agonist/antagonist
pairs. When a person looks to the right in the horizontal plane, the right lateral rectus
and the left medial rectus muscle act in a coordinated fashion; these muscle pairs are
referred to as yoked muscles. The superior and inferior rectus muscles also take their
origin from the same common tendinous ring at the apex of the orbit and insert into the
superior and inferior sides of the globe, anterior to the equator, and play a role in vertical eye movements. Due to the pyramidal shape of the bony orbit (Fig. 3.3), if you draw
a line parallel to the direction of these vertical muscles, it is clear that if one or the other
contracts, the eye would not move directly superiorly or inferiorly. Both also have a
rotational component, the net effect of which is to adduct the eye (move towards the
nose). This secondary action is actually torsional; thus the superior rectus elevates and
intorts the eye, while the inferior rectus depresses and extorts the eye.
The nal two EOM in the orbit are the superior and inferior oblique muscles. The
superior oblique muscle takes its origin from the apex of the bony orbit and runs in
the superior part of the orbit along the medial wall. It passes through a cartilaginous
pulley called the trochlea and makes an acute turn posteriorly to insert deep to
the superior rectus muscle on the superior surface of the globe, but posterior to the
equator of the globe. The passage through the trochlea places the effective origin at
the anteromedial orbital wall, and the insertion posterior to the equator results in the
primary action of the superior oblique to be intorsion, which results in abduction of
the eye (rotating away from the nose), and its secondary action is depression. The
inferior oblique takes its origin from the anteromedial inferior orbital wall and
courses posteriorly to insert on the globe posterior to the equator. The direction of
pull of this muscle is parallel to the superior oblique; its primary action is to extort
the eye, which results in abduction of the eye (rotating away from the nose), and its
secondary action is elevation. If you examine the shape of the orbit and the position
34
L.K. McLoon et al.
Fig. 3.4 Specically with reference to the right eye, the photographs demonstrate (a) elevation
and extortion, (b) elevation, (c) abduction, and (d) primary position of gaze. (a) To direct the gaze
to look right, up and out, that is elevate and extort, the inferior oblique muscle of the right eye must
contract. As the eyes move conjugately, the left eye must intort and elevate which is performed
by the superior rectus muscle of the left eye. (b) To look directly overhead, without bending the
neck, the superior rectus and inferior oblique muscles must co-contract. Both elevate, and their
co-contraction will essentially cancel out the extorsion and intorsion components of each of
these muscles seen when they contract alone
of the eyes needed to xate on a distant object in primary gaze (Fig. 3.4d), it is clear
that a certain amount of muscle tension must be maintained on the medial rectus
muscles bilaterally. In addition, due to the complex vectors of each muscle, for the
eyes to look up at the ceiling (without bending your neck), bilaterally the superior
rectus muscle must contractwhich elevates and intorts the eyeand the inferior
oblique must contractwhich extorts the eye and elevates. The combination of
contraction of these muscles results in elevation directly superiorly (Fig. 3.4b).
What this means is that the EOM are continuously active, even in the primary direction of gaze (Fig. 3.4d).
The EOM are innervated by three pairs of cranial nerves: the oculomotor nerve
(CNIII) innervates the superior rectus, medial rectus, inferior rectus, and the inferior
oblique muscles, the trochlear nerve (CNIV) innervates the superior oblique muscle,
and the abducens nerve (CNVI) innervates the lateral rectus muscle. The EOM are
densely innervated, resulting in very small motor units, with typical ring rates an
order of magnitude higher than seen in spinal motor neurons (Fuchs et al. 1988).
3.3
Embryological Origins
The EOM arise from non-segmented cranial mesoderm in contrast to the body and
limb skeletal muscles, which are derived from somites. While all of the craniofacial
muscles except tongue develop from non-segmented cranial mesoderm, the EOM
have a distinct genetic program that controls their initial formation in development.
These genes essentially have little overlap with the embryological development of
other craniofacial muscles (see Chap. 2, Harel and Tzahor 2012). Limb and body
skeletal muscle somite formation is dependent on the transcription factor Pax3
35
Fig. 3.5 Mesoderm-specic knockout of Pitx2 results in the absence of EOMs. Sagittal sections
behind the globe of the eye allow for visualization of all seven EOMs at later developmental time
points, such as e14.5. (a) Immunohistochemistry for developmental myosin heavy chain
(MyHCdev) shows T-Cre+;Pitx2ox/null mutant embryos have little (c) to no (d) differentiated EOM
at e14.5, as compared to T-Cre+;Pitx2+/+ (a) or T-Cre+;Pitx+/null (b) controls. SO superior oblique;
SR superior rectus; MR medial rectus; RB retractor bulbus; LR lateral rectus; IR inferior rectus; IO
inferior oblique. Used with permission from Elsevier: Zacharias et al. (2011)
(Tajbakhsh et al. 1997). However, eye muscle formation is completely unaffected in

mutants lacking Pax3 expression. In contrast, EOM formation in early development
is dependent on the gene dose of the transcription factor Pitx2; with reduced Pitx2
expression, the oblique muscles do not form, and several of the rectus muscles are
smaller. If the Pitx2 gene is knocked out, the EOM do not develop (Diehl et al.
2006; Zacharias et al. 2011) (Fig. 3.5). Formation of the EOM is also dependent on
optic vesicle and eye development as well as periocular neural crest cells (Bohnsack
et al. 2011). This relationship has a temporal component during development, as
shown in an elegant series of experiments using zebrash embryos (Bohnsack et al.
2011). If the eye does not form before neural crest cell migration into the periocular
mesenchyme, no EOM form; if eye development is halted after neural crest cell
migration, EOM develop. These observations are important for understanding the
anophthalmic orbits of human patients relative to the search for genetic mutations
known to correlate temporally with these developmental processes.
36
3.4
L.K. McLoon et al.
Unusual Characteristics of EOM Muscle Fibers
Muscles are composed of thousands of individual myobers, which are responsible

for the shortening velocity and overall force produced during contractions. The
EOM have arguably the fastest contractile properties of mammalian skeletal muscles (Close and Luff 1974), normally generate low force, and are very fatigue resistant (Asmussen and Gaunitz 1981; Fuchs and Binder 1983; Prsa et al. 2010). These
properties are due to a number of constitutive differences between EOM myobers
and those in other skeletal muscles. This discussion will include studies in both
human EOM as well as in a variety of animal species; while differences exist, the
general overall pattern of anatomy, metabolism, and physiology are similar.
The microscopic anatomy of the EOM is quite complex. First, cross-sections
through the EOM show that the muscles are not homogeneous, but rather are composed of two distinct layers (Fig. 3.6a). There is an outer orbital layer composed of
myobers of extremely small cross-sectional areas, averaging 260 160 mm2 in
human EOM (Kjellgren et al. 2003a, b). The inner global layer myobers are larger
in cross-sectional area, averaging 440 200 mm2 in human EOM, but still are
signicantly smaller than myobers from limb skeletal muscles, averaging from
6294 2,159 mm2 (SD) for the fastest ber types (myosin heavy chain isoform
(MyHC) type IIB) to 9,278 3496 mm2 for the slowest ber types (MyHC type I)
(Bottinelli et al. 1996). In contrast to limb skeletal muscles, these myobers do not
course from tendon to tendon, as rst shown in the 1970s (Mayr 1971; AlvaradoMallart and Pincon-Raymond 1976), and conrmed by serial reconstruction of individual myobers (Harrison et al. 2007). In addition, there are signicant numbers of
branched bers within the EOM (Mayr 1971; Alvarado-Mallart and PinconRaymond 1976). This complexity plays a role in the non-linear force summation of
electrically stimulated motor units in the ocular motor system (Shall et al. 2003).
3.5
Innervation
EOM motor control (Das 2012) and disease sparing and propensity (Pedrosa-Domellf
2012) in EOM will be discussed in the following two chapters. However, there are
some critical differences between the patterns of motor innervation of the EOM that
should be noted. Early studies demonstrated that there were two morphologically different endplates on EOM myobers (Kupfer 1960), larger endplates similar to those
seen in limb skeletal muscle, so-called en plaque endings, and smaller nerve terminals
that form multiple endings along individual myobers, the so-called en grappe endings (Fig. 3.7). Many EOM myobers have both en plaque and en grappe endings on
them, and this innervation pattern manifests by signicantly different contractile protein expression patterns and different contractile properties in different regions of
single myobers (Jacoby et al. 1989a, b). Serial reconstructions demonstrate that
there are singly and multiply innervated myobers in both the orbital and global
Fig. 3.6 The microscopic

anatomy of the EOM is quite
complex. Cross-sections
through the EOM show that
the muscles are not
homogeneous, but rather are
composed of two distinct
layers, the orbital (ORB) and
global (GLOB) layers. These
vary by muscle ber size,
which is much smaller in the
orbital layers, and by patterns
of expression of various
molecules. (a), (c), and (e)
are serial cross-sections from
the middle of the medial
rectus muscle of a macaque
monkey. (b), (d), and (f ) are
serial cross-sections from a
region midway between the
midregion of the muscle and
the tendon end. (a) and (b)
are immunostained for fast
myosin heavy chain (MyHC)
isoform, (c) and (d) are
immunostained for
embryonic MyHC isoform,
and (e) and (f) are
immunostained for neonatal
MyHC isoform. Note the
reduction in numbers of
bers positive for both the
fast and neonatal MyHC
isoforms as sections move
anteriorly and away from the
muscle midregion. Note the
small increase in the numbers
of bers in the orbital layer
positive for embryonic
MyHC as sections move
anteriorly and away from the
midregion
37
38
L.K. McLoon et al.
Fig. 3.7 Longitudinal sections through an EOM immunostained to visualize neuromuscular junctions
with antibodies to the postsynaptic nicotinic acetylcholine receptor (nAChR, green) and presynaptic synaptophysin (red ). En plaque neuromuscular junctions (horizontal arrow) and the
smaller en grappe neuromuscular junctions (vertically oriented arrows) that form multiple endings
along individual myobers are present
layers, as well as single bers with a central en plaque ending with en grappe endings
along the ber length (Pachter et al. 1976). These are found in the orbital layer. The
cause of this heterogeneity of nerve endings, which arise from the innervating motor
nerve, is unclear. However, it is well known that the nerve controls many of the properties of the myobers it innervates, and is, at least in part, responsible for the complex
properties of the myobers themselves.
In addition to containing multiply innervated myobers, neuromuscular junction
endplates in adult EOM also contain the embryonic gamma subunit of the nicotinic acetylcholine receptor (Horton et al. 1993). Histological evidence suggests
that the majority of en grappe endings include the gamma subunit; however, it is
also present in some en plaque nerve endings (Kaminski et al. 1996). This neuromuscular junctional complexity is presumed to be critical for the maintenance of at
least some of the unique properties of adult EOM. This was conrmed by the use
of a mouse with a conditional knock-out of the transcription factor Pitx2, which is
inactivated at birth (Zhou et al. 2009, 2011). By 3 months, expression of several
myosin heavy chain (MyHC) isoforms were reduced, specically type IIX
(MYHC1), alpha-cardiac (MYH6), type I (MYH7), and the EOM-specic isoform
(MYH13), resulting in muscles that were stronger, faster, and more fatigable. In
addition, the conditional loss of Pitx2 resulted in a decrease in multiply innervated
myobers. These studies beautifully illustrate that Pitx2 is one of the factors that
maintain the complex properties of EOM. Future research will focus on additional
factors that dene and control the EOM allotype.
3.6
39
Myosin Heavy Chain Isoforms
Early descriptions of EOM ber types used mitochondrial content and patterns of
innervation to divide the myobers into discrete populations (Mayr 1971). Three
ber types were described in the orbital layer: two were singly innervated with
either high or low mitochondrial density, and one was multiply innervated with low
mitochondrial density (Pachter 1983; Pachter and Colbjornsen 1983). Four ber
types were described in the global layer: three were singly innervated with high,
intermediate, or low mitochondrial density, and one was multiply innervated with
low mitochondrial density. If the original ber typing scheme is re-examined, it is
noted that in fact there is a continuum of mitochondrial density in EOM myobers
(Mayr 1971). In addition, when myosin heavy chain isoform patterns are overlaid
on this early ber typing system, it begins to break down.
Probably the most studied characteristic of the EOM is their complex co-expression
patterns of at least nine MyHC isoforms (Wieczorek et al. 1985). Limb and body
skeletal muscle is composed of four MyHC isoforms; from slowest to fastest in
terms of shortening velocity, they are: MyHC type1 (slow, b-cardiac, MYH7),
MyHC type 2A (fast MYH2), MyHC type 2X (2D, fast MYH1), and MyHC 2B
(fast MYH4). In addition to these isoforms, EOM also contain developmental (or
embryonic) MyHC (MyHCdev or MyHCemb, MYH3), neonatal (or perinatal)
MyHC (MyHCneo or MyHCperi, MYH8), alpha-cardiac MyHC (MyHCa-card,
MYH6) (Pedrosa-Domellf et al. 1992), and an EOM-specic MyHC (MyHCeom,
MYH13) (Asmussen et al. 1993; Rubinstein and Hoh 2000; Stirn Kranjc et al. 2009,
2000; Wasicky et al. 2000; Kjellgren et al. 2003a, b; Toniolo et al. 2007; Bicer and
Reiser 2009). Mammalian EOM also include myobers with slow-tonic contractile
characteristics (Hess and Pilar 1963), one of two mammalian muscles known to
contain bers with tonic contractile properties (tensor tympani is also reported to
express the slow tonic MyHC (Mascarello et al. 1982)). Recently two ancient
myosins, MYH14/7b and MYH15, were found in mammalian EOM (Rossi et al.
2010). MYH14 is found at low levels in developing skeletal muscles, heart, and all
EOM myobers, but disappears in adult muscle except for the slow-tonic EOM
myobers. MYH15 protein is found only in orbital layer slow-tonic myobers of
adult EOM. In fact, these slow-tonic myobers in EOM and tensor tympani are
unique in mammalian skeletal muscle (Bormioli et al. 1979). A recent study showed
that in addition to the traditional muscle MyHCs, approximately 20% of the global
layer slow bers also express non-muscle myosin IIB (nmMyHCIIB, MYH10),
as is also seen in cardiac muscle (Moncman and Andrade 2010). As both EOM and
cardiac muscle have a common lineage relationship (Lescroart et al. 2010), it is not
surprising that many of the unusual myosins and other proteins expressed in the
EOM, but not limb skeletal muscle, are expressed also in cardiac muscle.
Not only are multiple MyHC isoforms expressed in the muscles as a whole, but
the pattern of expression of these isoforms varies dramatically between orbital and
global layers and even along the length of EOM bers (Fig. 3.6b) (McLoon et al.
1999; Rubinstein and Hoh 2000; Kjellgren et al. 2003a, b; Stirn Kranjc et al. 2009;
40
L.K. McLoon et al.
Fig. 3.8 Co-expression of multiple myosin heavy chain isoforms in single hybrid bers in serially
sectioned cross-sections of rabbit inferior rectus muscle immunostained for the following six
MyHC isoforms: EOM specic, fast type IIA (IIA), embryonic (developmental, EMB), slow tonic,
slow type I (I), neonatal (perinatal, NEO). Green arrow indicates a myober that is positive for
IIA, EMB, NEO and slightly positive for slow tonic MyHC isoforms. The red arrow indicates a
myober positive for EMB, slow tonic, I and NEO MyHC isoforms
Zhou et al. 2010). To make this picture even more complex, it is clear that not all
myobers within the EOM course from tendon to tendon (Davidowitz et al. 1977;
McLoon et al. 1999; Shall et al. 2003; Harrison et al. 2007). This has physiological
implications, and may explain the loss of predicted force that occurs in EOM under
experimental conditions (Goldberg et al. 1997; Milller et al. 2002).
One of the most distinctive aspects of MyHC expression patterns in EOM is the
presence of multiple isoforms within single myobers, referred to in the limb skeletal
muscle literature as hybrid bers (Fig. 3.8). Limb skeletal muscles also contain
hybrid bers, which tend to increase when the muscle is subjected to stress or injury,
41
where they can represent a pool of up to 60% of total myobers (Caiozzo et al. 2000).
Diaphragm muscle shows a very high degree of polymorphism, up to 78%, including
myobers expressing both MyHC slow1 and MyHCIIX (Caiozzo et al. 2003). The
potential for hybrid bers increases in EOM simply by the numbers of MyHC isoforms that are expressed. Many studies in multiple species have demonstrated multiple isoforms within single bers (Pachter 1984; Jacoby et al. 1989a, b; Briggs and
Schachat 2002; Kjellgren et al. 2003a, b; Zhou et al. 2010; McLoon et al. 2011). In
an elegant study, individually dissected multiply innervated orbital layer myobers
were shown to express fast MyHC in the middle of the myober in the location of
the en plaque endplates but expressed slow-tonic MyHC in the ber ends where the
en grappe endplates were located (Jacoby et al. 1989a). Electrophysiological measurements conrmed that the central region of these bers displayed a spiking
response and twitch-like characteristics, while the tendon ends did not show a spiking response and instead displayed tonic characteristics (Jacoby et al. 1989b).
Examination of co-expression patterns in rabbit EOM demonstrated that the majority of myobers expressed more than one myosin, with up to six MyHC isoforms in
single ber segments (McLoon et al. 2011). Shortening velocity and force measurements were performed on single-skinned bers, and again a continuum of velocity
and forces were seen. What is particularly interesting is that while myobers containing MyHCIIB tended to have faster shortening velocities and bers with MyHC1
tended to be slower, there was no clear correlation between co-expression patterns of
MyHC isoforms and shortening velocity (McLoon et al. 2011), and a continuous
range for both force and shortening velocities was seen. In addition, there were a
number of the myobers that expressed both slow and fast MyHC isoforms, referred
to as mismatched bers in the limb skeletal muscle literature (Fig. 3.9). The role this
complex conguration of MyHC isoforms plays in controlling eye position and eye
movements is unknown. However, a previous study of ber polymorphism in plantaris muscle after overload or as a result of hypothyroidism showed that global alterations in numbers of hybrid bers resulted in a 15% decrease in maximal shortening
velocity (Caiozzo et al. 2000). Thus it is hypothesized that this complexity of MyHC
co-expression patterns must represent an important means for producing a wider spectrum of contractile properties than would be possible with myobers that contain a
single MyHC isoform.
3.7
Other Differentially Expressed Molecules in EOM
Additional molecules that control the contractile properties in EOM are also different than those seen in limb skeletal muscles. For example, while no unique troponin
T molecule appears to be expressed in EOM, the EOM up-regulate troponin isoforms that are only minor components in limb skeletal muscle (Briggs et al. 1988).
EOM myobers contain myosin-binding protein C-slow (MyBP-Cslow) in all
myobers and lack MyBP-Cfast (Kjellgren et al. 2006). In combination, these data
suggest that individual myobers within EOM contain unique mixtures of molecules that modulate contractility.
42
L.K. McLoon et al.
Fig. 3.9 An example of a mismatched ber (red arrow) in serially sectioned rabbit inferior rectus
muscle which is positive for (a) fast MyHC (IIA), (b) slow MyHC (I), and (c) slow tonic MyHC
In limb skeletal muscle bers, fast myobers (MyHCII) contain the fast isoform
of the sarco/endoplasmic reticulum Ca2+ ATPase (SERCA1) and slow myobers
(MyHC1) contain SERCA2. In contrast, 99% of the fast EOM myobers contain
SERCA1, and 86% of these also contain SERCA2 (Kjellgren et al. 2003a, b). On
the other hand, 100% of the slow EOM myobers contain SERCA2, but 54% also
43
contain SERCA1. Overall, calcium handling is also signicantly different in EOM

than in limb and body skeletal muscles. The EOM are more resistant to necrosis
induced by elevated cytosolic calcium levels (Khurana et al. 1995; Zeiger et al.
2010). This increased calcium buffering capacity in EOM is due to a combination
of factors: abundant sarcoplasmic reticulum (which increases SERCA content),
high concentrations of parvalbumin, a small cytosolic Ca2+-binding protein, and
mitochondria serving as fast Ca2+ sinks (Andrade et al. 2005; Celio and Heizmann
1982). This enhanced ability to regulate cytosolic Ca2+ concentration plays a role in
controlling contractile amplitude in the EOM.
The EOM are constantly active, have some of the fastest contractile properties
(Close and Luff 1974), are very fatigue-resistant (Fuchs and Binder 1983), and
while they normally need to produce only enough force to move the eye, they are
not intrinsically weaker than limb skeletal muscles (Frueh et al. 2001). The bases
for these properties as well as the maintenance of these properties during eye movements are an area of continued investigation. It has long been known that the EOM
have an extremely high density of mitochondria compared to non-cranial skeletal
muscles (Mayr 1971; Davidowitz et al. 1980). In addition, the EOM mitochondria
have a different mitochondrial biogenesis program than the one used by limb skeletal muscle (Andrade et al. 2005). Despite their large mitochondrial volume density,
paradoxically the EOM mitochondria have lower respiratory capacity (Patel et al.
2009). In addition, key enzymes controlling glycogen synthesis and breakdown are
repressed in the EOM, and glycogen content is correspondingly reduced (Porter
et al. 2001; Fischer et al. 2002), suggesting that the EOM are probably less dependent on glycogen as a metabolic fuel than other skeletal muscles. It is also possible
that the EOM rely on constant transport of blood-borne glucose and fatty acids
through their extensive microvascular network (Kjellgren et al. 2004). Overall, the
pattern is consistent with the EOM relying to a large extent on mitochondria as the
main source of energy under all conditions. One example is the use of lactate as a
substrate for its aerobic metabolism (Andrade and McMullen 2006). In limb skeletal muscles lactate is usually the end product of glycolysis and is associated with
muscle fatigue. In the EOM, the presence of lactate dehydrogenase B allows the
oxidation of lactate back to pyruvate for entry to the Krebs cycle; therefore, lactate
can sustain EOM activity and slow the progression of fatigue (Fig. 3.10).
The EOM contain high levels of both oxidative and glycolytic enzymes. An analysis of serially sectioned and histochemically stained EOM myobers demonstrated
that, except for the myobers expressing MyHC-slow tonic, all bers express both
succinic dehydrogenase and a-glycerophosphate dehydrogenase (Asmussen et al.
2008). This demonstrates that single EOM myobers combine high levels of both
oxidative and glycolytic pathways, in stark contrast to limb skeletal muscle. When
each enzyme was plotted against myober area or whether the ber was fast or
slow, a continuum of bers emerged, with only the slow tonic-positive myobers in
a group by themselves. Again it appears that the ber type system used in limb and
body skeletal muscles does not t the picture in EOM.
44
L.K. McLoon et al.
Fig. 3.10 Use of lactate in

EOM. (a) Proposed ow of
substrates in an EOM ber.
Blood glucose enters
glycolysis as glucose-6phosphate (glucose-6-P).
Glycogen content is low and
glycogenolysis is greatly
down-regulated. The lactate
dehydrogenase (LDH)
reaction ows in the direction
of lactate oxidation to
pyruvate, which enters the
mitochondrial Krebs cycle.
(b) Electron micrograph
illustrating the high
mitochondrial content of an
EOM ber
Extraocular muscle fiber

Glycogen
Glucose
Glucose-6-P
Glycolysis
LDH
Pyruvate
Lactate
Krebs cycle
OxPhos
Mitochondria
3.8
Myonuclear Turnover and Regeneration
Another unusual property of adult EOM is its ability to remodel portions of its
myobers throughout life. Using bromodeoxyuridine labeling and immunohistochemical techniques, it was shown that the EOM retain a population of activated
satellite cells (McLoon and Wirtschafter 2003), and these cells replicate and appear
45
to fuse into existing myobers (McLoon and Wirtschafter 2002; McLoon et al.
2004). This same process occurs in laryngeal muscles (Goding et al. 2005), suggesting that this may be a general feature of craniofacial muscles.
The ramications of the continual turnover of myonuclei in single EOM myobers
are unclear. It is has been known for a long time that the EOM are resistant to injury
and often react differently to various intramuscular drug treatments when compared
to limb skeletal muscle. Botulinum toxin A, which in limb skeletal muscles causes
muscle atrophy, results in no long-term changes in EOM myober cross-sectional
area (Spencer and McNeer 1987; Croes et al. 2007). While some MyHC isoform
shifting has been described (Stirn Kranjc et al. 2001), basically there are few changes
in EOM compared to limb skeletal muscle after botulinum toxin injections.
Conversely, the EOM also exhibit robust and rapid regenerative responses after
various perturbations. Acutely after botulinum toxin A injections the EOM exhibit a
rapid and signicant increase in myogenic precursor cells for weeks after injection,
while there is only an abortive regenerative response in similarly treated leg muscle
(Ugalde et al. 2005). The same rapid regenerative response occurs after experimental EOM surgical recession (Christiansen et al. 2010) or resection (Christiansen and
McLoon 2006). A similarly robust response to denervation occurs in other craniofacial muscles, for example the lateral and posterior cricoarytenoid laryngeal muscles,
after experimental section of the recurrent laryngeal nerve (Shinners et al. 2006).
In some way this process must be important for the maintenance of normal function
in the EOM, as examination of surgically resected muscles from patients with strabismus have shown signicant alterations in the numbers of activated satellite cells
within these muscles compared to normal control EOM (Antunes-Foschini et al.
2006, 2008). Current studies suggest that there is a population of myogenic precursor cells in the EOM that may be responsible for this elevated ability to adapt and
remodel (Kallestad et al. 2011). Future work will focus on dening these regenerative cell populations, and the potential role they play in EOM muscle adaptability
and the relative sparing of the EOM in aging and skeletal muscle pathology.
There are several hypotheses for what controls this on-going process of myober
remodeling in normal adult EOM. In an in vitro experiment, it was shown that the
EOM precursor cells depend on their specic cranial motor neurons for survival;
they do not survive in the presence of spinal motor neurons (Porter and Hauser
1993). This suggests that specic trophic factors are critical for the maintenance of
mature EOM. Analysis of gene expression differences between EOM and leg muscle
reveals that neurotrophic factors such as insulin-like growth factor (IGF-1) as well
as neurotrophic factor receptors such broblast growth factor-receptor I are upregulated in EOM (Fischer et al. 2002). The up-regulation of IGF-1 receptor compared to leg skeletal muscle has been demonstrated immunohistochemically
(Anderson et al. 2006), and western blot demonstration of the up-regulation of IGF-1
protein in EOM compared to leg skeletal muscle conrmed and extended the earlier
gene expression proling studies (Feng and von Bartheld 2011). Much more work
needs to be done in this area, but from the studies thus far, it appears that, compared
to non-cranial skeletal muscles, the EOM and their corresponding motor neurons
maintain up-regulated levels of neurotrophic molecules.
46
3.9
L.K. McLoon et al.
Summary
In summary, many unique characteristics set the EOM apart from non-cranial skeletal
muscles. These differences start with the early genetic signaling that controls EOM
formation from the non-segmented cranial mesoderm and continue with the maintenance of EOM-specic characteristics by up-regulated expression of specic
groups of neurotrophic factors compared to limb muscles. The EOM are continuously active, even in primary gaze. This constancy in the maintenance of contractile
force must play a role in the molecular and anatomical individuality of the EOM.
The suggestion that the EOM may indeed be a distinct allotype is supported by the
myriad differences between the EOM and non-cranial skeletal muscle, including
the complexity of co-expression patterns of myosin heavy chain isoforms and other
contractile elements, the differences in metabolic pathways used by the EOM, and
their ability to remodel throughout life. These properties play a critical role in determining the unique functional capabilities of these muscles physiologically (see Das
2012, Chap. 4) as well as their propensity for and sparing from various skeletal
muscle diseases (see Pedrosa-Domellf 2012, Chap. 5). The ability to control the
direction of gaze, coordinate eye movements with position of the head and body in
space, and follow and track moving objects is critical to being able to navigate in the
world. This complexity must be needed to ensure that we maintain exquisite control
over eye position and eye movements in three-dimensional space.
Acknowledgements Supported by NIH grant EY015313, the Minnesota Lions and Lionessess,
and an unrestricted grant to the Department of Ophthalmology from Research to Prevent
Blindness Inc.
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Zhou Y, Cheng G, Dieter L, Hjalt TA, Andrade FH, Stahl JS, Kaminski HJ (2009) An altered phenotype in a conditional knockout of Pitx2 in extraocular muscle. Invest Ophthalmol Vis Sci
50:45314541
Zhou Y, Liu D, Kaminski HJ (2010) Myosin heavy chain expression in mouse extraocular muscle:
more complex than expected. Invest Ophthalmol Vis Sci 51:63556363
Chapter 4
Motor Control of Extraocular Muscle

Vallabh E. Das
4.1
Introduction
Six pairs of extraocular muscles (EOMs) are innervated by three pairs of cranial
nerves whose cell bodies lie in three cranial nerve nuclei on each side of the brain,
namely the oculomotor, trochlear, and abducens nuclei. Early studies of the oculomotor system examined neuronal responses of extraocular motoneurons within
these motor nuclei and developed a framework for understanding the motor control
of EOM (Fuchs and Luschei 1970; Keller and Robinson 1971). Perhaps one of the
most signicant and elegant outcomes of some of these studies was the proposal for
a nal common pathway for eye movements (Robinson 1968, 1981). Thus,
according to the oculomotor nal common pathway theory, motoneuron innervation
of EOM was independent of the type of eye movement that was being executed.
While this framework still has validity in understanding the neural control of eye
movements, there have been new developments in the last couple of decades that
has brought about renewed interest in the oculomotor periphery and cast doubt on
the so-called nal common pathway. The goals of this chapter are to review ocular
biomechanics and motor control of EOM while highlighting new developments and
identifying issues that are yet unresolved. We have conned our discussion to the
motor neurons and their effector organ, the eye. Central control of eye movements
is outside the scope of this chapter.
V.E. Das, Ph.D. (*)

College of Optometry, University of Houston, Houston, TX 77204, USA
e-mail: vdas@optometry.uh.edu
51
52
V.E. Das
Fig. 4.1 Initial studies modeled the oculomotor plant as multiple Voigt elements in series. The left
panel shows two such Voigt elements hooked up in series. Each Voigt is made up of an elastic element (K ) and a viscous element (R). Each Voigt element contributes a single time-constant exponential decay response following release from displacement. The actual response then is a sum of
exponential decay curves due to each Voigt element. The right panel shows a simulation of the
decay of eye position following eye-pull as sum of two exponential decay curves of time-constant
20 and 200 ms
4.2
Biomechanical Characteristics of the Eye
The globe, connective tissue, and EOM together form the oculomotor plant.1 In a
seminal eye-pull study to examine mechanical properties of the plant, Robinson
held the eye at an eccentric horizontal location and then suddenly released the eye
while monitoring the trajectory of the movement back to central gaze (Robinson
1964). A rst important outcome of this study was that the inertia due to the globe
was of little importance in constructing a mathematical model of the plant. Following
the experimental observation that the eye took a path that could be approximated as
an exponential decay function, Robinson suggested that the passive properties of
the oculomotor plant could be modeled as a series of viscoelastic elements (Voigt
elementsFig. 4.1). The elasticity was primarily due to the spring-like properties of
the EOM itself and the viscosity was due to the orbital connective tissue. There has
been some controversy on the number of Voigt elements and the values of the decay
time constants due to these elements. Initial studies, all based on similar eye-pull
1
The term plant comes from engineering terminology for something that is controlled.
4 Motor Control of Extraocular Muscle
53
methodology, suggested that the decay following eye-pull could be approximated

by 12 time constants (i.e., 12 Voigt elements), although the values of the time
constants were variable (Robinson 1964; Collins 1971; Pola and Robinson 1978;
Seidman et al. 1995; Stahl and Simpson 1995). More recent studies have determined
that the number of time constants is at least 4 and perhaps more (Sklavos et al. 2005,
2006; Anderson et al. 2009).
Most of the studies described above have primarily examined behavior when
muscle activation is constant (release after sustained eye-pull). Clearly this is not a
normal situation. It has been determined that activation of the muscle produces
additional nonlinearities in plant behavior (Anderson et al. 2009). Another approximation made by the eye-pull studies is to lump the EOM and the orbital connective
tissue into one element. It turns out that the passive properties of the muscle itself
are quite complicated and nonlinear and could be represented by connecting in parallel an elastic element, a viscous element, and seven other Maxwell elements where
each Maxwell element is a series combination of an elastic and viscous element
(Quaia et al. 2009a, b, 2010).
Clearly, the examination of the oculomotor plant such as that described in this
section only scratches the surface of the potential complexity of the system. There
are several questions that beg to be answered including: (1) How do the different
muscle ber types (see Chap. 3 for details on structure and function of EOM) t into
this framework? Do the different ber types have similar passive properties or could
the complexity of plant models be a function of different passive properties of each
ber type? (2) Are passive properties different during development? In other words
might the mechanical structure of the system be especially susceptible to disruption
during development potentially leading to strabismus? (3) To a large extent, the
neural drive to the plant appears to compensate for the inherent nonlinearities in the
plant as evidenced by the stereotypical nature of eye movements such as saccades.
However, it is not clear if this issue is adequately investigated because the nonlinearities might play a signicant role in secondary and tertiary position of the eye
and perhaps more importantly in disease conditions such as strabismus. (4) What
happens to passive properties after intervention such as strabismus correction surgery? (5) If passive properties change due to development, disease, aging, etc., does
the motor innervation adapt to compensate for the change?
4.2.1
Implications of Extraocular Muscle Pulleys

on Ocular Biomechanics
EOMs were once conceptualized as strings that originated at the orbital apex and
terminated at the tendinous insertion onto the globe. However, Miller made the critical observation that muscle paths of rectus EOMs were remarkably stable despite
large eccentric xation (Miller and Robins 1987; Miller 1989). This suggested that
the origin of the EOM was not at the orbital apex, but at a more anterior location
closer to the globe. Later studies by Demer and colleagues have shown that the
54
V.E. Das
Fig. 4.2 Schematic view of a

cross-section through the eye
showing the extraocular
muscle pulleys of the lateral
and medial recti.
(Reproduced from Demer
2006)
EOM passes through connective tissue sleeves coupled to the orbit that functions as
pulleys (Demer et al. 1995, 2000; Clark et al. 1997, 2000). Thus, it appears that the
EOM pulley is the actual functional origin of the muscle path and is primarily
responsible for preventing sideslip of the EOM (Miller et al. 1993). It is important
to note that the pulley is not a single identiable structure in the orbit. Rather it is a
distributed structure made up of a dense network of collagen, elastin, and smooth
muscle (Miller et al. 2003) that interconnects with a complex network of connective
tissue within the orbit (Koornneef 1977). Studies suggest that the orbital layer bers
of the EOM terminate at the pulleys and it is only the EOM global layer bers that
pass through and insert onto the globe (Oh et al. 2001; Kono et al. 2002) (Fig. 4.2)
Here we concern ourselves on the possible inuence of pulleys on ocular motility and their implications for neural control of eye movements. The primary benet
of the pulley system as far as ocular motor control is concerned appears to be implementation of Listings Law (Demer 2004). Briey, eye movements have three
degrees of freedomhorizontal, vertical, and torsional. However, Donders law and
Listings law mandate that the torsional position of the eye is constrained for any
combination of horizontal and vertical orientations, thus effectively reducing the
number of degrees of freedom to two (Haustein 1989; Quaia and Optican 1998).
Prior to the discovery of the existence of EOM pulleys, implementation of Listings
law was presumed to be neural (Crawford and Vilis 1992; Tweed et al. 1999;
Angelaki and Hess 2004). This led to predictions of rather complicated patterns of
neural innervation of EOMs during eye movements to secondary and tertiary positions. Following the discovery of EOM pulleys, Demer put forth an elegant hypothesis
of how proper positioning of the rectus pulleys could effectively provide a mechanical
55
implementation of Listings law (Demer 2004). Subsequent neurophysiological and

electrical stimulation studies in the abducens nerve by Angelaki and colleagues
showed that there was indeed no neural implementation of Listings law in the brain
and therefore Listings Law must be implemented mechanically (Ghasia and
Angelaki 2005; Klier et al. 2006, 2011). Although it appears that the pulleys can
obviate the necessity for central control of torsion required by Listings law, the
brain needs to provide control signals for torsion that deviates from Listings law
such as during convergence, the vestibulo-ocular reex, and head-free gaze shifts
(Crawford et al. 1999; Demer et al. 2003).
The initial studies by Miller and colleagues suggested that the pulley structures
stabilized muscle paths in the posterior orbit (Miller et al. 1993). The functional
signicance of preventing muscle sideslip is that the EOM force vector remains
constrained. In the event of rectus muscle sideslip, perhaps due to pulley malposition, the rectus EOM force vector could be misdirected into the orthogonal plane
resulting in problems of binocular coordination such as A or V patterns of strabismus (Oh et al. 2002). Demer suggests that many of the cases of strabismus could in
fact be of biomechanical origin due to pulley problems (Demer 2001, 2004).
However, other studies in monkeys with a developmental strabismus induced by
sensory methods have clearly demonstrated a neural origin for strabismus and a
pivotal neural role in maintaining the state of strabismus including the A and V patterns (Das and Mustari 2007; Das 2011; Joshi and Das 2011). An example is provided in Fig. 4.3. Corroborating these reports have been studies that examined
muscle anatomy of monkeys with sensory strabismus that determined that the pulley structure is in fact normal (Narasimhan et al. 2007). Thus, it appears that the
etiology could be important in understanding the role that EOM pulleys and
motoneuron control of EOM might play in determining eye alignment or eye movement properties in disease states.
4.2.2
Modern Approaches to Modeling of the Plant
The nonlinear properties of the oculomotor plant tissue make it difcult to formulate
models using conventional linear control systems theory and lumped elements (see
Fig. 4.1). Lumped element models tend to oversimplify the complexity of the EOM
and other plant tissue. A few laboratories have attempted to create plant models
using modern approaches. The rst such attempt was that by Miller (Orbit 1.8 software, Eidactics Inc.). The Orbit software is a sophisticated biomechanical model of
the eye plant that allows the user to modify many parameters including strength of
innervation of each muscle, muscle stiffness and contractility, pulley stiffness, pulley locations, etc. The primary use proposed for this software is to simulate expected
outcomes from strabismus surgeries (Demer et al. 1996; Clark et al. 1998a, b).
Although more sophisticated than control systems models, one disadvantage of this
model is that it only simulates static eye positions, not dynamic eye movements. An
alternative to Orbit 1.8 is the SEE++ software developed by Haslwanter, Buchberger,
56
V.E. Das
Fig. 4.3 Top panelcomparative cross-section MRIs of a normal subject and a patient with
incomitant pattern strabismus. The lateral rectus of the patient is shifted inferiorly in supraduction
(adapted from Oh et al. 2002). This sideslip of the rectus muscle could be the source for pattern
strabismus in this patient. Bottom panelsRecording from a medial rectus motoneuron in a monkey with sensory-induced strabismus. As expected, during horizontal smooth-pursuit, this rightburst-tonic (BT) neuron is modulated in correlation with movement of the left eye. During vertical
pursuit with the right eye viewing (right column), there is an inappropriate horizontal component
in the left eye that is the dynamic equivalent to an A-pattern strabismus. The motoneuron shows
activity that is correlated with this horizontal component suggesting that A patterns in sensoryinduced monkeys are due to central innervation (adapted from Joshi and Das 2011). Right eye
red; left eyeblue. Positive values indicate rightward or upward eye positions and negative values
indicate leftward or downward eye positions
57
Fig. 4.4 Advanced model of oculomotor plant that can simulate dynamic eye movements (adapted
from Wei et al. 2010). Previous generations of similar software such as Orbit 1.8 can only simulate
static eye position. Panel (a) shows the structure used to develop the model and the gaze trajectory
of the eye for a simulated saccade. Each muscle is modeled as a strand with unique properties as
described by Wei and colleagues. In addition, dynamic pulleys are incorporated in the model. Panel
(b) shows the model simulating a 20 deg saccade based on neural input derived from actual data
and colleagues that is primarily for use on PC computers (Orbit works only on a
Macintosh) (Haslwanter et al. 2005; Hoerantner et al. 2007; Brandner et al. 2011).
Another attempt at developing a sophisticated model using a slightly different
approach was by Schutte et al. (2006). This nite element analysis (FEA) model has
the advantage of being able to model nonlinear tissue interactions. However, currently, the FEA model also only simulates static eye positions and may be limited by
some computational limitations inherent to FEA. The most recent attempt at using
advanced methods for modeling the plant is by Pai and colleagues at the University
of British Columbia (Wei and Pai 2008; Wei et al. 2010). An innovation in this
model is that the individual muscle elements are programmed as strands which
can represent even a single ber, if required. Because these strands can be strung
together, different levels of sophistication can be achieved. In addition, these investigators have also incorporated simulation of dynamic eye movements (Fig. 4.4).
In addition to being useful to predict outcomes of strabismus surgeries, these
advanced models can help to improve our understanding of ocular biomechanics.
For example, it is often hard to predict the biomechanical contributions of the cyclovertical muscles when the eye is in tertiary positions and using a fully structured
distributed model (rather than lumped elements) can provide a much better understanding of how the different elements of the complex system work together. Of
course, predictions of mathematical models are only as good as the data that are
used to develop these models in the rst place. As new information about the complex properties of the oculomotor plant tissue come to light (Schoemaker et al.
2006; Yoo et al. 2011), the models are likely to be more accurate and thus develop
more predictive power when used to study disease states.
58
4.3
V.E. Das
Motor Control of Conjugate Horizontal Eye Movements
Coordinated and conjugate eye movements in the horizontal plane require simultaneous
contraction of the ipsilateral eye lateral rectus and the contralateral eye medial rectus and simultaneous relaxation of the contralateral eye lateral rectus and the ipsilateral eye medial rectus muscles. The coordinated contraction and relaxation of the
four horizontal recti is mediated by innervation from the abducens and oculomotor
nerves and is facilitated by the hard-wired interconnections between the abducens
and oculomotor nuclei. Most of our understanding of motoneuron control of eye
movements comes from studies of the horizontal system. Although principles of
operation are the same, the cyclo-vertical system is necessarily more complicated
because the brain must control four pairs of EOM.
4.3.1
Neurons in the Abducens Nucleus
4.3.1.1
Neuroanatomy
Excellent reviews of the neuroanatomy of the cranial motor nerves and the extraocular nuclei can be found elsewhere (Sharpe and Wong 2005; Buttner-Ennever 2006).
Here we give a brief summary to provide a suitable context for the discussion of the
response properties of extraocular motoneurons during different kinds of eye movements. Due to its critical role in binocular coordination, the abducens nucleus is
sometimes called the center of horizontal gaze (Leigh and Zee 2006). The abducens
nucleus is a spherical-shaped structure that is located just below the oor of the
fourth ventricle and at the junction of the pons and medulla. Based on neuroanatomical tracing, the abducens nucleus is now recognized to have four principal
populations of motoneuronstwitch and non-twitch abducens motoneurons,
abducens internuclear neurons, and occulus-targeting neurons. The occulustargeting neurons belong to the cell groups of the paramedian tracts and probably
supply the cerebellum with a copy of the command signal (Langer et al. 1985). They
are not directly responsible for generating an eye movement. The abducens motoneurons (lateral rectus motoneurons) may be of the twitch or non-twitch sub-type
depending on the type of muscle ber that they innervate. Thus, the twitch abducens
motoneurons mostly innervate the singly-innervated bers or twitch bers in the lateral rectus muscle and the non-twitch motoneurons mostly innervate the multiplyinnervated bers in the lateral rectus (Buttner-Ennever et al. 2001). Although such a
categorization is potentially interesting, there is yet no neurophysiological evidence
that differentiates twitch and non-twitch motoneurons. The abducens motoneurons
innervate the ipsilateral lateral rectus via the abducens nerve (CNVI). Thus, these
neurons are directly responsible for abduction of the ipsilateral eye. The other population of neurons in the abducens nucleus that are critical for control of horizontal
gaze are the abducens internuclear neurons. The axons of the abducens internuclear
neurons cross the midline at the level of the abducens nucleus and then ascend via
59
Fig. 4.5 Schematic showing

anatomical connections
between abducens and
oculomotor nuclei that result
in the generation of
coordinated movements of
the right and left eyes. Note
that the abducens nucleus
contains abducens
motoneurons (green) and
abducens internuclear
neurons (black). CN VI
cranial nerve VI, abducens
nerve; CN III cranial nerve
III, oculomotor nerve; MLF
medial longitudinal
fasciculus; LR lateral rectus;
MR medial rectus
the medial longitudinal fasciculus to synapse onto medial rectus motoneurons in the
contralateral oculomotor nucleus which in turn innervates the medial rectus muscle
ipsilateral to the oculomotor nucleus via the oculomotor nerve (CNIII) (ButtnerEnnever and Akert 1981). This pattern of interconnection between the abducens and
oculomotor nucleus is illustrated in Fig. 4.5. Therefore, excitation of one abducens
nucleus and inhibition of the contralateral abducens nucleus due to pre-motor signals results in the almost simultaneous contraction of the ipsilateral eye lateral rectus muscle and contralateral eye medial rectus muscle and relaxation of the
contralateral eye lateral rectus muscle and ipsilateral eye medial rectus muscle,
thereby producing a coordinated and conjugate eye movement. This, in its essence,
is the anatomical basis for generating conjugate eye movements wherein the two
eyes are controlled as one by a single pre-motor conjugate command. From a neuroanatomical standpoint, there are no major differences between the abducens
motoneurons and the abducens internuclear neurons (McCrea et al. 1986). It may be
that the internuclear neurons are slightly smaller than the motoneurons and that they
have axon collaterals while the motoneurons do not. Comparison of the neural
response characteristics of motoneurons and internuclear neurons is provided later.
4.3.1.2
Implication of Anatomical Connection Between Abducens

and Oculomotor Nuclei
The anatomical connection between the abducens and oculomotor nucleus is clearly
critical for binocular coordination of eye movements in the horizontal plane.
Although perhaps not as easily perceived, these neural interconnections also play
60
V.E. Das
Fig. 4.6 Schematic showing how the anatomical connections between the abducens and oculomotor
nuclei can result in a comitant strabismus with either eye viewing. Legend is same as in Fig. 4.5.
Figure on left shows esotropic misalignment due to a weak lateral rectus of the right eye. Figure on
right shows an esotropic misalignment due to an increased innervation of the medial rectus of the
left eye. During right eye viewing, increased activity in the right abducens is necessary to increase
innervation to the weak right eye lateral rectus
an important role in setting the state of eye misalignment in strabismus and in

understanding outcomes following strabismus correction surgery. Thus, this anatomical arrangement is the reason a single weak muscle can result in an apparent
eye misalignment (strabismus) with either eye viewing. Consider the situation in
Fig. 4.6 (left panel) where the lateral rectus of the right eye is weak. When the normal left eye is viewing the target (right eye is covered), the contraction of the right
eye lateral rectus is less than that of the right eye medial rectus resulting in adduction of the covered right eye and an appearance of a right esotropia. Now consider
the situation when the weak right eye is forced to xate (Fig. 4.6, right panel). In
order to balance forces in the right eye medial and lateral rectus muscles, the brain
must increase the innervation to the weak lateral rectus muscle in the right eye. This
can be achieved by increasing ring rates of neurons in the right abducens nucleus.
By the anatomical scheme shown in Fig. 4.6, an increase in activity in the right
abducens nucleus will not only increase activity in the right abducens motoneurons,
but will also increase activity of the right abducens internuclear neurons. Therefore,
it follows that there is an increased activity (excitation) of the contralateral (left)
medial rectus motoneurons and therefore an increased innervation of the left eye
medial rectus relative to the left eye lateral rectus, resulting in adduction of the left
eye. Thus, there is appearance of esotropia with either eye viewing, although the
underlying decit is inherent to one muscle. It is worth pointing out that an equivalent argument can be constructed wherein there is a decreased innervation applied
to an intact antagonist muscle to compensate for the weak muscle when the weak
61
eye is forced to xate. The predictions would be exactly equivalent, and an eye
misalignment would be expected with either eye viewing. In reality, the situation
shown in Fig. 4.6 is probably only hypothetical in congenital forms of strabismus,
especially if the etiology is sensory. In these cases, it is rather unlikely that underaction or overaction of a single muscle results in eye misalignment (Das 2008).
It is likely that more than one or perhaps all muscles are affected in strabismus.
Alternately, it may be that the patterns of innervation are themselves disrupted
resulting in unbalanced forces in the medial and lateral recti of an eye (Das and
Mustari 2007; Joshi and Das 2011). Whatever the underlying cause, the anatomical
pathways interconnecting the abducens and oculomotor nuclei will assure that there
is symmetry in behavior.
This anatomical scheme also explains how strabismus angle can be reduced by
resection/recession surgery on a single muscle. Consider the situation when an
esotropia is observed in a patient without apparent weakness of any particular muscle. When the right eye is xating on a target, the left eye is adducted and vice-versa.
One possible surgical intervention is to strengthen the lateral rectus muscle of the
left eye (resection surgery). Thus, when the right eye is viewing a target, the treated
left eye is not as adducted as in the pre-surgical condition. Now when the treated left
eye is forced to xate, the brain could decrease innervation to the surgically strengthened left eye lateral muscle (by decreasing ring rates in the left abducens nucleus)
in order to balance the force exerted by the antagonist left eye medial rectus. It follows that the decrease in activity in the left abducens nucleus also causes a decrease
in activity of the right oculomotor nucleus by the internuclear pathway. Therefore,
when the left eye is forced to xate, there is an equivalent decrease in contraction of
the right eye medial rectus and an apparent decrease in the esotropia observed in the
right eye. In reality, surgeons may opt to perform strabismus correction surgery on
more than one muscle since there are physical limits to how much a muscle can be
either recessed or resected.
4.3.1.3 Abducens Neuron Neurophysiology

Several studies have examined ring rate properties of neurons in the abducens
nucleus. Abducens neurons (and also oculomotor neurons) are generally described
as showing burst-tonic responses during eye movements. Thus, they show a burst or
a pulse of activity, proportional to eye velocity, which is necessary to compensate
for the viscous properties of orbital tissue. They also show tonic or a step of activity,
proportional to eye position, thereby preventing elastic restoring forces due to EOM
from bringing the eye back to the center of the orbit following an eye movement.
Therefore, the simplest model that relates neural response of abducens nucleus neurons to eye movements takes the following form
FR(t t ) = K * E (t ) + R * E (t ) + B
(4.1)
62
V.E. Das
FR: ring rate

Dt: neural latency
E: Eye position at time t
E: Eye velocity at time t
K: conjugate position sensitivity
R: conjugate velocity sensitivity
B: constant term that signies neuronal response when xating straight ahead
Across the various studies, the estimate for average position sensitivity of
abducens neurons is approximately 45 spikes/second/degree (spks/s/deg), the estimate for average velocity sensitivity is approximately 0.41.0 spks/s/deg, and the
estimate for constant term B is approximately 100150 spks/s. Neural latency is
around 10 ms. The threshold, which is the eye position at which the neuronal ring
goes to zero, can be estimated to be B/K.
While the pulse-step model of (4.1) remains a popular representation of motoneuron responses, it is not the most precise. Biomechanical models suggest that the eye
plant is modeled with 24 time constants. If the neural drive to the plant is to compensate for plant dynamics (viscoelastic properties) and generate rapid and precise
saccadic movements (as we know that it can), then we expect that the response
characteristics of abducens neurons to be more complex, i.e., include higher order
terms (Robinson 1964). Keller rst suggested that adding an acceleration term to
(4.1) (U*E) would provide a better representation of neuronal discharge (Keller
1973). Later Goldstein examined neuronal discharge during the post-saccadic interval and suggested adding a new term (post-saccadic slideC*FR) that would
account for the gradual transition from the saccadic pulse to the post-saccadic step
(Goldstein 1983). In a relatively recent study, Sylvestre and Cullen re-examined
abducens neuron discharge during saccadic and slow eye movements (Sylvestre and
Cullen 1999). They attempted to t motoneuron responses to several different models (variations of equation (4.1)) that included higher order and nonlinear terms.
They found that using a rst-order pulse-step model (4.1) was sufcient to explain
most of the motoneuron discharge. They also conrmed that addition of an acceleration term and a slide term signicantly improved model ts, especially during
saccadic eye movements. Equation (4.2) shows the model representation that these
authors suggested best represented motoneuron discharge
FR(t ) = K * E (t ) + R * E (t ) + U * E (t ) C * FR (t ) + B
(4.2)
Figure 4.7 shows an example of motoneuron discharge during a saccadic eye movement (top panel) and the contribution of the individual terms of (4.2) (bottom panel)
towards the nal response. While the pulse (velocity) and step (position) terms are the
most important components of the response, the slide term is critical for the slow postsaccadic decay of the neural response. One point of interest that Sylvestre and Cullen
identied in their study was that model coefcients estimated during rapid eye movements such as saccades were different from model coefcients estimated from slow
eye movements such as smooth-pursuit or the vestibulo-ocular reex. Further, the
estimated coefcients showed some variability depending on the peak velocity of
sinusoidal smooth-pursuit. Other studies have also shown a similar nonlinearity in the
Fig. 4.7 The top two panels show a sample saccadic eye movement and the eye velocity associated
with the saccade. The third panel shows burst-tonic activity of a motoneuron that drives the rightward saccade. Included are model ts with only position and velocity terms (4.1) and with position, velocity, acceleration, and slide terms (4.2). Although the rst-order pulse-step model t of
(4.1) results in quite a good representation of motoneuron response, the pulse-slide-step model is
a better representation of motoneuron response. Bottom panelContributions of individual terms
of the pulse-slide-step model towards the nal motoneuron response
64
V.E. Das
responses of abducens neurons (Fuchs et al. 1988). A straightforward explanation

may be that we have not yet arrived at the correct combination of higher order and
nonlinear eye-terms (variations of (4.1) and (4.2) for example) that would provide
a single unied model representation of motoneuron discharge (Sklavos et al. 2005).
Another possibility, promoted by Sylvestre and Cullen (1999), is that the dynamics of
the antagonist muscle may be different during fast and slow eye movements. Thus,
during a fast eye movement, motoneurons innervating the antagonist muscle are completely shut-off and so the movement is determined by the active agonist muscle
only working against the passive properties of the antagonist muscle. On the other
hand, during slow eye movements, the system works in push-pull manner with both
muscles actively innervated.
A few studies have tried to examine whether the response properties of the abducens
internuclear neurons differed from that of the lateral rectus motoneurons (abducens
motoneurons) in the abducens nucleus (Delgado-Garcia et al. 1986a, b; Fuchs et al.
1988). Using antidromic activation methods, Fuchs and colleagues unequivocally
identied internuclear neurons in the abducens nucleus of the monkey. Although both
abducens internuclear neurons and lateral rectus motoneurons showed burst-tonic
responses that are qualitatively similar, there were some important quantitative differences in their response characteristics. While motoneurons appear to show a recruitment order (the eye position sensitivity, K, increased with increasing threshold),
internuclear neurons were mostly already recruited even for thresholds of 20 deg in
the off-direction, and there was no apparent relationship between threshold and position sensitivity. Further, if the velocity sensitivity is plotted as a function of eye
position threshold, then motoneurons and internuclear neurons appear to form two
distinct clusters. The abducens internuclear neurons tend to be clustered with higher
sensitivities at lower thresholds (see Fig. 4.8 in Fuchs et al. 1988). Some studies have
used this indirect strategy to classify abducens neurons into lateral rectus motoneurons and abducens internuclear neurons (Sylvestre and Cullen 1999, 2002).
4.3.2
Neurons in the Oculomotor Nucleus
4.3.2.1
Neuroanatomy
The oculomotor nucleus is a midline nucleus that extends rostrally to the posterior
commissure and caudally to the trochlear nucleus at the ponto-mesencephalic junction. Dorso-ventrally, it is just ventral to the peri-aqueductal gray matter. Neurons
from each oculomotor nucleus innervate one of four EOMs as summarized in
Table 4.1. The topographic organization of neuronal subdivisions was rst established by Warwick (1953), and later revised by Buttner-Ennever and colleagues
(Warwick 1953; Buttner-Ennever et al. 2001). In this revised scheme, the innervation of EOM is organized in a rostro-caudal manner with the inferior rectus subdivision being the most rostral followed caudally by the MR, IO, and SR divisions
(Buttner-Ennever et al. 2001).
65
Fig. 4.8 Distribution of

A-group, B-group, and
C-group cells of the medial
rectus (MR) subdivision in
the oculomotor nucleus of the
monkey. The S-group is the
equivalent of the C-group
cells for the superior rectus
and inferior oblique
subgroups. Adapted from
Buttner-Ennever (2006)
Table 4.1 Patterns of innervation of EOM and their primary and secondary actions
Muscle
Innervation
Primary action
Secondary action
Medial rectus (MR)
Oculomotor (ipsi)
Adduction
Lateral rectus (LR)

Abducens (ipsi)
Abduction
Superior rectus (SR)

Oculomotor (contra)
Elevation
Intorsion
Inferior rectus (IR)
Oculomotor (ipsi)
Depression
Extorsion
Superior oblique (SO)
Trochlear (contra)
Intorsion
Depression
Inferior oblique (IO)
Oculomotor (ipsi)
Extorsion
Elevation
In addition to the topographic organization of neurons according to the muscle

innervated, it is now recognized that there are at least three neuronal types within
each medial rectus subdivision, the so-called A-group, B-group, and C-group
neurons. All our information about these motoneuronal groups has come from anatomical studies (Buttner-Ennever and Akert 1981; Spencer and Porter 1981). No
studies as of yet have identied unique physiological characteristics of the A, B,
or C-group cells. However, the information available from anatomical studies is
potentially interesting. First, the location of the A, B, and C groups is distinct. While
the A- and B-group cells are located within the nucleus, the C-groups cells tend to
cluster at the boundary of the nucleus (see Fig. 4.8). Even more interesting are the
patterns of afferent and efferent projections of these cells. While the A-group and
B-group cells receive projections from pre-motor areas serving all types of eye
movements, the C-group cells do not receive afferent projections from saccadic or
VOR pre-motor areas (Ugolini et al. 2006). In addition, while the A- and B-group
cells project to the singly-innervated twitch bers within the mid belly of the EOM,
the C-group cells innervate the multiply-innervated non-twitch bers at the distal
66
V.E. Das
end (Buttner-Ennever et al. 2001). Such a differentiation in the pattern of afferent

and efferent projections of the C-group cells has led to the suggestion that perhaps,
the C-group multiply-innervated non-twitch ber pathway could be preferentially
involved in driving slow eye movements including gaze holding (Ugolini et al.
2006). However, an argument against this hypothesis is that fast myosins are found
through the length of the muscle and so it is unlikely that the so-called slow nontwitch bers contribute only to slow eye movements (McLoon et al. 2011). Further
investigation in the form of neurophysiological data is needed to understand whether
the C-group is functionally distinct from A- and B-group cells.
4.3.2.2
Neurophysiology
The response characteristics of medial rectus motoneurons in the oculomotor

nucleus are similar to those in the abducens nucleus and do not require specialized
description. They show a stereotypical burst-tonic response where the burst is proportional to the eye velocity and the tonic level of activity is proportional to eye
position in the orbit. Neurons in the left oculomotor nucleus project to the left eye
medial rectus muscle and drive rightward eye movements, and neurons in the right
oculomotor nucleus project to the right eye medial rectus and drive leftward eye
movements. Across the various studies, the average conjugate position sensitivity is
approximately 4 spks/s/deg, the average conjugate velocity sensitivity ranges
0.51 spks/s/deg, and the constant term B is around 100 spks/s.
In addition to the motoneurons that innervate EOM, the oculomotor nucleus also
contains oculomotor internuclear neurons that mostly innervate the contralateral
abducens nucleus (Langer et al. 1986). The function of the oculomotor internuclear
neurons is not clear. It was rst thought that the oculomotor internuclear neurons
could be the pathway that provided the abducens nucleus with a vergence signal but
a neurophysiological study that identied the oculomotor internuclear neurons
using antidromic activation methods did not nd any differences between the
response characteristics of the oculomotor internuclear neurons and other medial
rectus motoneurons in the oculomotor nucleus (Clendaniel and Mays 1994).
4.4
Motor Control of Cyclovertical Eye Movements
The superior rectus, inferior rectus, superior oblique, and inferior oblique muscles
control cyclovertical (vertical and torsional) eye movements. Neurons in the oculomotor nucleus innervate the ipsilateral inferior rectus and inferior oblique muscles
and the contralateral superior rectus muscle. Neurons in the trochlear nucleus innervate the contralateral superior oblique muscle. Each rectus muscle has a primary
vertical and secondary torsional action, and each oblique muscle has a primary torsional and secondary vertical action as shown in Table 4.1. Unlike in the horizontal
system, the secondary actions of the cyclovertical muscles are signicant and vary
67
Fig. 4.9 Geometric

arrangement of superior
rectus and superior oblique
muscles. This arrangement
results in the signicant
primary vertical or torsional
and secondary torsional or
vertical actions of the
cyclovertical muscles
with horizontal position of the eye (Robinson 1982). This is largely a product of the
geometrical arrangement of the eye in the orbit and EOM insertion points (Fig. 4.9).
Thus, the vertical recti are approximately 23 deg temporal in each eye and the
obliques are approximately 51 deg nasal in each eye. Therefore, if the eye is turned
out toward the temple (abduction), the obliques have more torsional action, and the
vertical recti have more vertical action. If the eye is turned in towards the nose
(adduction), the obliques have more vertical action, and the vertical recti have more
torsional action.
Just like the horizontal system, the cyclovertical system is organized into agonistantagonist pairs. Thus, the superior rectus and inferior rectus of each eye form
an agonistantagonist pair and the superior oblique and the inferior oblique of the
same eye form another agonistantagonist pair. In addition, the four cyclovertical
muscles in each eye are also arranged in yoked muscle pairs that help to ensure that
binocular alignment and binocular coordination is maintained in the vertical and
torsional planes. For example, the superior rectus of one eye and the inferior oblique
of the other eye form a yoked muscle pair. Simultaneous excitation of both these
muscles will result in a coordinated elevation and same-direction torsion of both
eyes. Similarly, the inferior rectus of one eye and the superior oblique of the other
eye form a yoked muscle pair because simultaneous excitation of both sets of muscles results in a coordinated depression and same-direction torsion of both eyes.
Cyclovertical alignment must also be maintained during head tilt. In this condition,
the yoked muscle pairs are the superior rectus and superior oblique of the lower eye
(i.e., ear nearest shoulder upon head tilt) and the inferior rectus and inferior oblique
of the higher eye (i.e., ear farthest from shoulder upon head tilt). The pairing of
these muscles results in an incyclotorsion of the lower eye and excyclotorsion of the
upper eye with minimal vertical change in either eye. The pattern of anatomical
connection from the oculomotor and trochlear nuclei to cyclovertical muscles guarantees that pre-motor excitation of the oculomotor and trochlear nuclei on the same
side of the brain results in a torsional movement of both eyes with little vertical
component. Note that the simultaneous excitation of the yoked muscles must be
68
V.E. Das
controlled by appropriate pre-motor input to the oculomotor and trochlear nuclei

(Moschovakis et al. 1990).
The properties of cyclovertical motoneurons in the oculomotor and trochlear
nuclei are perhaps not as widely studied as the horizontal motoneurons in the
abducens and oculomotor nuclei. Essentially, they also exhibit burst-tonic behavior
like horizontal motoneurons (King et al. 1981). King and colleagues determined
that the average position sensitivity (K) was 4.2 spks/s/deg, and the average velocity
sensitivity was 0.6 spks/s/deg. The average threshold was 25 deg in the off-direction
of the cells. Mays and colleagues examined the response characteristics of trochlear
motoneurons during vergence eye movements and found that activity in trochlear
motoneurons was correlated with the excyclotorsion observed during vergence
(Mays et al. 1991).
4.5
Motoneuron Responses During Vergence Movements
The responses of motoneurons and pre-motor neurons during vergence eye movements and combined saccade-vergence eye movements have received particular
interest in the last two decades because of the new insights into binocular control
achieved by studies that involve tasks combining conjugate and vergence eye movements. During a purely vergence eye movement, both the medial recti must contract,
and both lateral recti must relax. In a Hering framework, the control of vergence is
mediated by neural structures that are different from those driving conjugate eye
movements. According to this hypothesis, for eye movements that include both a
conjugate and vergence component, the summation of conjugate and vergence drive
occurs at the level of motoneurons. In a Helmholtz framework, pre-motor commands encode movements of an individual eye. While initial investigation suggested that the Hering hypothesis was valid, weight of current evidence appears to
have shifted towards a more Helmholtz-like monocular framework (Chen et al.
2011; Cullen and Van Horn 2011). It appears that during combined saccade-vergence movements (disconjugate saccades), monocular control gets each eye rapidly
onto the target while a slow vergence (binocular signal) eye movement helps to
ne-tune the position of the eyes. The reader may get additional information from
several excellent reviews on this topic (Mays 1998; King and Zhou 2000; Cullen
and Van Horn 2011). Studies that have recorded activity of abducens neurons and
medial rectus motoneurons during vergence eye movements have shown that indeed
motoneuronal activity is modulated during both conjugate and vergence eye movements (Keller and Robinson 1972; Mays and Porter 1984).
A complication that arose from studies of motoneuron activity during vergence
was the nding that average sensitivity of the population of abducens neurons during a vergence eye movement was less than the average sensitivity of the same
population during a conjugate movement (Mays and Porter 1984). In other words,
the reduction in ring rate of lateral rectus motoneurons for a convergence movement to a particular position in the orbit was smaller than the reduction in ring rate
69
observed for a conjugate eye movement to the same orbital position. This meant that
the lateral rectus muscle was innervated more strongly in convergence than for conjugate gaze, although the eye is at the same orbital position. In order to balance the
increased lateral rectus innervation during vergence, the medial rectus must also be
innervated more strongly (i.e., increased ring in oculomotor neurons) during convergence to a particular orbital position than for conjugate movement to the same
orbital position. This was found to be mostly true (Miller et al. 2011). These observations lead to the prediction of co-contraction of the medial and lateral muscles
during vergence due to the increased forces in convergence compared to conjugate
eye movements. However, in two studies that used implanted strain gauges directly
onto the rectus muscles, no increased force in the medial and lateral rectus was
observed during convergence (Miller et al. 2002, 2011).2
So as of now, the missing force remains an unsolved paradox. There is therefore a disconnect between the predictions from the recordings of motoneurons in
the abducens and oculomotor nuclei and the force measurements at the muscle.
These ndings have led some to propose abandoning the nal common path
hypothesis since the path for vergence and conjugate eye movements do not appear
to be the same (Miller 2003; Miller et al. 2011). It may be that the answer lies in
the complexity of the muscle structure. Other than the points mentioned already
about the different ber types and the different motoneuronal subtypes, it is also
known that there are complex serial and parallel connections between muscle
bers, and at the molecular level, there is a lot of variation in expression of myosins
along the muscle bers (McLoon and Wirtschafter 2003; McLoon et al. 2004,
2011). There is also evidence for substantial muscle remodeling over time. Any of
these factors could affect the relationship between motoneuron ring and the force
generated by the motor unit. As suggested by Miller et al. (2011), one resolution to
the paradox would be if neurons that have large differences in the conjugate and
vergence sensitivities do not contribute much towards an eye movement due to
innervation of an inherently weak muscle ber. Additional investigation into both
muscle structure and innervation of individual muscle bers is necessary to resolve
this rather thorny issue.
2
Studies from labs that examined motoneuron responses during combined saccade-vergence
movements have shown that many abducens motoneurons and medial rectus motoneurons surprisingly encode a binocular signal (i.e., encode movements of either eye) although they might be
expected to only encode movements of the eye that they project to. For the purposes of this chapter,
it should be noted that the nding of unequal sensitivities for vergence and conjugate eye movements is exactly equivalent to the nding of binocular encoding in motoneuronal activity by these
other studies. The reason that the two ndings are equivalent is that a simple linear mathematical
transformation can transform a conjugate/vergence representation of motoneuronal responses into
a right eye/left eye representation (King and Zhou 2002; Sylvestre and Cullen 2002).
Conjugate = (right eye + left eye)/2
Vergence = Left eye right eye
Right eye = Conjugate vergence/2
Left eye = Conjugate + vergence/2
70
4.6
V.E. Das
Summary
The oculomotor system is perhaps unique in that this motor control system is driving
a plant with little to no inertia. Further, the load is unchanging unlike in hand motor
control, for example, where the plant load can change if the subject picks up an
object of any weight. However, since poor vision is not well tolerated, there are
other stringent requirements for neural control of the oculomotor periphery including precise calibration, fast response times, and high speeds of muscle contraction.
All of this is somehow achieved with a great deal of precision and accuracy by the
neural control of six pairs of EOMs. Although the framework of neural control was
laid out as early as in the 1960s and 1970s, it is apparent now that this framework is
not completely accurate in certain conditions (disjunctive eye movements for example). Anatomical and biomechanical studies of muscle structure in recent years have
outpaced neurophysiological evaluation of how this complex system is controlled.
Perhaps the most important issues yet to be resolved would be to identify whether
the different ber types contribute differently to eye movements and to identify
whether their neural control from motoneurons is also distinct. Not only are these
questions important from the point of view of understanding oculomotor control,
but they are extremely important in understanding disease conditions such as strabismus and nystagmus.
Acknowledgments This work was supported by NIH grant EY015312. I wish to thank Dr. Anand
Joshi and the editors for critically reading the manuscript and providing helpful comments.
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Yoo L, Reed J, Shin A, Kung J, Gimzewski JK, Poukens V, Goldberg RA, Mancini R, Taban M,
Moy R, Demer JL (2011) Characterization of ocular tissues using microindentation and hertzian viscoelastic models. Invest Ophthalmol Vis Sci 52(6):34753482
Chapter 5
Extraocular Muscles Response

to Neuromuscular Diseases and Specific
Pathologies
Fatima Pedrosa Domellf
5.1
Introduction
The response of the extraocular muscles (EOMs) to neuromuscular diseases generally

differs signicantly from that of the other muscles in the body. The EOMs may be
early or preferentially affected in diseases such as myasthenia gravis, oculopharyngeal muscular dystrophy (OPMD), and Miller Fisher syndrome (MFS), but in contrast they remain notoriously unaffected in the muscular dystrophies originating
from defects in the dystrophinglycoprotein complex (DGC). Accumulating evidence points towards a special response of the EOMs in amyotrophic lateral sclerosis (ALS), also distinct from that of the other striated muscles in the body. From a
clinical point of view, it is important to realize that even very small disturbances of
ocular motility have a great impact on visual function and quality of life. We rely
upon perfect coordination of eye movements to align both foveas properly and send
a single coherent image to the brain, and the EOMs are the effector organ for ocular
motility.
Muscle is among the most plastic tissues in the body, having very high capacity
to adapt in specic ways to different types of exercise, disuse, strain, and hormones.
The muscles of the body vary widely in overall size (e.g., the muscles of the thigh
vs. the small muscles in the hand), architectural organization of their muscle bers
(e.g., parallel bers in the biceps brachii, convergent bers in the deltoid), and ber
type composition (e.g., predominantly slow twitch contracting and fatigue resistant
in the soleus, fast contracting, and fatigable in the tibialis anterior) reecting adaptation to their particular tasks in their anatomical context. The EOMs are extreme
in their specialization, as they are very small, have an array of ber types that is
F. Pedrosa Domellf, M.D., Ph.D. (*)

Department of Ophthalmology, Ume University, Ume, Sweden
e-mail: fatima.pedrosa-domellof@ophthal.umu.se
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F. Pedrosa Domellf
76
completely distinct from those occurring in all other muscles and combine both
high contraction velocity and fatigue resistance at once, a feature not seen in any
other muscles. The EOMs differ fundamentally from the remaining skeletal muscles
and have therefore been classied as a separate muscle allotype, a class of muscle
distinct from the limb and trunk muscles, on one hand, and from the masticatory
muscles, on the other hand, and which also represent a separate class/allotype. The
distinctness of the EOMs as a separate muscle allotype is reected in their unique
structural and physiological properties, their developmental origin and their gene
expression prole (Sadeh 2004; Fischer et al. 2005; Spencer and Porter 2006;
McLoon 2011). The unique properties of the EOMs are thought to reect evolutionary adaptation to produce the precise and highly coordinated movements of the eye.
However, these unique properties have also rendered the EOMs more resistant or
more prone to certain diseases. Our understanding of the mechanisms underlying
the particular responses of the EOMs to disease is very fragmentary but such knowledge has the potential to provide important clues for the development of new therapies in the future.
5.2
Miller Fisher Syndrome
MFS is a very rare condition, clinically characterized by ophthalmoplegia (paralysis

of eye movements), ataxia (limb incoordination), and arreexia (loss of normal tendon reexes) along with the occurrence of circulating autoantibodies against gangliosides, typically against GQ1b (Chiba et al. 1993, Willison and OHanlon 1999; Mori
et al. 2001; reviewed by Willison 2005). MFS is considered a milder form of GuillainBarre syndrome, a far more common paralytic acute inammatory demyelinating
polyneuropathy. The symptoms of MFS may last months but the disease generally has
a good prognosis with progressive recovery. Typically, MFS is preceded by a gastrointestinal, e.g., Campylobacter jejuni, or respiratory infection, e.g., Haemophilus
influenza, and through a mechanism of molecular mimicry, autoantibodies against self
gangliosides are raised, due to molecular similarities between the lipo-oligosaccharides on the bacteria and the gangliosides in the human peripheral nerves (Willison
2005). In short, data from both human and experimental models indicate that antibodies raised by the body to ght the initial bacterial infection are responsible for the
autoimmune injury that leads to peripheral nerve dysfunction. The injury occurs at the
neuromuscular junctions (NMJs), where the gangliosides are accessible outside of the
bloodnerve barrier, and involves a complement-mediated reaction (Chiba et al. 1993;
Wilison and OHanlon 1999, reviewed by Willison 2005).
Two particular features of the EOMs make them susceptible to MFS. The rst is
the particular composition of their NMJs, regarding relevant ganglioside epitopes
(Liu et al. 2009); the second is their extremely rich capillary supply, which likely
makes the availability of ganglioside autoantibodies much higher than in other muscles (Kjellgren et al. 2004). An immunohistochemical study (Liu et al. 2009)
revealed that the NMJs of the human EOMs are highly reactive to antibodies against
5 Extraocular Muscle Response to Neuromuscular Diseases
77
Fig. 5.1 Cross-sectioned human adult extraocular muscle showing specic binding of antibodies
against gangliosides GQ1b, GT1a, and GD1b (green) at neuromuscular junctions (NMJs) identied
with alpha-bungarotoxin (red )
GQ1b, GT1a, and GD1b gangliosides (Fig. 5.1), whereas the NMJs of limb muscles
do not bind these antibodies (Fig. 5.2). In other words, in spite of the limitations
inherent to ganglioside identication with antibodies, data show clear differences in
epitope availability between the NMJs of EOMs and other skeletal muscles, strongly
suggesting that these differences may be the molecular basis for the particular susceptibility of the EOMs in MFS. This syndrome typically also includes ataxia and
arreexia, which have been proposed to be due to involvement of the muscle spindle
afferents. Immunohistochemical data also revealed that the nerve terminals in muscle spindles bind antibodies against GQ1b, GT1a, and GD1b gangliosides, strongly
suggesting that the proposed pathophysiology of MFS truly relies upon differences
in ganglioside epitope availability to circulating autoantibodies.
5.3
Myasthenia Gravis
Myasthenia gravis (MG) is another autoimmune disease involving the NMJs,

although it is not specic for the EOMs and is regarded as a chronic condition
(reviewed by Drachman 1994; Kusner et al. 2006). Autoantibodies directed at nicotinic acetylcholine receptors, produced in response to an unknown trigger and leading to a deciency of acetylcholine receptors at the NMJ, are a known underlying
78
F. Pedrosa Domellf
Fig. 5.2 NMJs of human adult limb muscle do not bind antibodies against gangliosides GQ1b,
GT1a, and GD1b, in contrast to the extraocular muscles
cause of myasthenia gravis in approximately 85% of patients (Romi et al. 2005).

Consequently, the nal step in signal transmission from the nerve to the muscle is
hampered and translates clinically into fatigable muscle weakness. However, these
autoantibodies are not always present in MG and false positives are found in other
autoimmune diseases, such as rheumatoid arthritis. Autoantibodies against other
muscle proteins such as muscle-specic kinase (MuSK), titin, rapsyn, or ryanodine
may also be present in patients with myasthenia symptoms that are seronegative for
acetylcholine receptors (Romi et al. 2005). Recently, matrix metalloproteinases 2,
3, and 9 have also been implicated in the pathogenesis of myasthenia gravis, independently of the presence or absence of acetylcholine receptor antibodies (Helgeland
et al. 2011). MG affects patients of all ages, with a peak in the second and third
decades for females and in the sixth and seventh decades for males, and it is associated with thymus pathology in up to two-third of the patients and with thyroid
dysfunction in up to 10% of the cases.
79
The EOMs and the levator palpebrae are typically the rst muscles to be affected
in MG, 5080% of the patients presenting with double vision (diplopia) and ptosis,
that get worse along the day or with fatigue (Kaminski et al. 1990; Elrod and
Weinberg 2004; Romi et al. 2005). A classical sign is the worsening of the ptosis
following sustained upgaze, a sign that helps in the differential diagnosis of other
pupil-sparing disorders affecting ocular motility. The disease may be limited to the
EOMs and levator palpebrae, the so-called ocular myasthenia, or it may spread to
the other muscles, the so-called generalized form. The most feared complication
with time is a myasthenic crisis, an acute exacerbation of muscle weakness, e.g.,
after an infection, leading to respiratory failure. However, adequately treated with
acetylcholine inhibitors and different regimens of immunosuppression, the vast
majority of patients lives a normal life and has no major complications (Drachman
2008; Drachman et al. 2008).
The pathological hallmark of MG is the loss of synaptic folds and their acetylcholine receptors, which apparently result from a complement-mediated autoantibody lesion localized to the NMJ. It has been proposed (Kaminski et al. 2002) that
differences in gene expression levels of elements of the complement cascade (Porter
et al. 2001) make the EOMs more susceptible to MG. However, a difference in the
levels of gene expression of the elements of the complement cascade could not be
conrmed on the human EOMs vs. limb muscles (Fischer et al. 2005). Furthermore,
it remains unknown whether the levator palpebrae differs from the other muscles
regarding the complement cascade. The EOMs differ from the other muscles by
having very high ring frequencies and a low so-called safety-factor, a measure of
the overcapacity of the endplate potential. These two features may partly be the
reason why the EOMs are functionally affected earlier by the loss of acetylcholine
receptors. Further studies are needed to shed light on the triggering factors and on
the causes of the wide heterogeneity of the disease.
5.4
Mitochondrial Disorders and Chronic Progressive

External Ophthalmoplegia
The EOMs are typically affected in mitochondrial disorders with a myopathy

component, the most common of them being chronic progressive external ophthalmoplegia (CPEO). A wide spectrum of clinical conditions resulting from anomalies
of the respiratory chain and leading to impaired oxidative phosphorylation is collectively referred to as mitochondrial disorders (Zeviani and Di Donato 2004).
These disorders have very diverse clinical implications and may show high phenotypic variability between generations and complex patterns of inheritance, as both
nuclear and mitochondrial DNA (mtDNA) encode the elements of the respiratory
chain and the key enzymes needed for mtDNA replication and expression as well as
RNA translation within the mitochondria (Oldfors and Tulinius 2003; Zeviani and
Di Donato 2004). The frequency of pathogenic mtDNA mutations that potentially
can cause disease in the offspring of female carriers has been estimated to be
approximately 1:200 in an unselected European population (Elliott et al. 2008).
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F. Pedrosa Domellf
However, because of the frequent co-existence of both wild-type and mutant mtDNA
in the same cell, most mtDNA mutations only affect cellular function and become
clinically relevant when the proportion of mutant mtDNA exceeds that of wild-type.
CPEO is clinically characterized by ptosis and increasing limitation of eye movements (ophthalmoplegia). The disease usually, but not necessarily, has a late onset
and the clinical course of the ptosis and of the ophthalmoplegia may diverge
signicantly. The insidious and generally rather symmetric progression of the EOM
weakness is gradually compensated by head movements, and diplopia or discomfort
due to limited eye motility may therefore be absent (Schoser and Pongratz 2006). In
contrast, the ptosis is asymmetric in most cases. Although the CPEO typically dominates the clinical picture, other signs of mitochondrial disease such as muscle
weakness related to exercise and neurologic involvement should not be overlooked
and will strengthen the diagnosis. Thyroid-associated orbitopathy, myasthenia
gravis, and oculopharyngeal muscle dystrophy are part of the differential diagnosis
of CPEO.
A wide range of mutations has been reported to cause CPEO: large-scale mtDNA
rearrangements, single nucleotide mutations in transfer RNA genes as well as
anomalies of mtDNA maintenance genes which are encoded by the nuclear genome.
Altogether approximately 15% of the patients having an autosomal dominant or
recessive pattern of inheritance (Oldfors and Tulinius 2003; Zeviani and Di Donato
2004; Kolberg et al. 2005; Schoser and Pongratz 2006; Greaves et al. 2010).
Kearns-Sayre syndrome combines early onset progressive external ophthalmoplegia, retinopathy, stunted growth, muscle weakness, cardiac pathology, and cerebellar ataxia. Progressive external ophthalmoplegia is also seen in MELAS, another
mitochondrial myopathy with encephalopathy, lactate acidosis and stroke-like episodes. In MELAS, pigmentary retinopathy and short stature may also be present.
PEO is also present in other, more rare mitochondrial disorders, some of which are
considered separate syndromes such as MERF (myoclonic epilepsy and myopathy
with ragged-red bers), MNGIE (mitochondrial neurogastrointestinal encephalopathy), SANDO (sensory ataxic neuropathy, dysarthria and ophthalmoparesis),
and NARP (neuropathy, ataxia and retinitis pigmentosa, for references see Schoser
and Pongratz 2006).
The muscle bers in the EOMs are extremely rich in mitochondria, and they
have high oxidative enzyme activity, having particular metabolic proles adapted to
the constant activity needed for eye movements (Fischer et al. 2005; Patel et al.
2009; Garcia-Cazarin et al. 2010). These may in part explain the particular susceptibility of the EOMs to mitochondrial disorders, but there is very little data on the
particular changes that occur in these muscles in these diseases. Progressive loss of
cytochrome c oxidase (COX, a mitochondrial enzyme marker whose loss indicates
dysfunction) has been noted in the muscle bers of the aging human EOMs (MullerHocker et al. 1992). A recent study shows that these COX-negative muscle bers that
accumulate exponentially in the aging human EOMs have high levels of mtDNA deletions, suggesting an accelerated aging process in the EOMs compared to skeletal muscle or other post-mitotic tissues (Yu-Wai-Man et al. 2010). In a well-characterized
cohort of 13 CPEO patients, 11 surgical samples taken from the levator palpebrae
(LP) and from two EOMs had more COX-decient muscle bers than the respective
81
skeletal muscle biopsies. Furthermore, lower proportions of deleted mtDNA resulted

in COX-decient bers in the LP/EOMs, compared to the other muscles (Greaves
et al. 2010).
5.5
Oculopharyngeal Muscular Dystrophy
OPMD is characterized by the onset of ptosis followed by progressive dysphagia

due to involvement of the pharyngeal muscles, as well as weakness and wasting of
the tongue and masticatory muscles in patients in their fth or sixth decade (Brais
2003). Involvement of the EOMs with restricted ocular movements occurs later in
the course of the disease but it does not lead to a complete external ophthalmoplegia. Other muscles of the body such as the diaphragm and pelvic and shoulder girdle
muscles may also become affected. Dysphagia may lead to nutritional and aspiration problems and requires proper clinical management.
OPMD is usually autosomal dominant, although recessive forms and sporadic
cases also exist (reviewed by Brais 2003). The underlying genetic defect consists of
short (GCG)813 expansions on the polyadenylate-binding nuclear protein gene 1
(PABPN1). Mutated PABPN1 protein, together with heat shock proteins and ubiquitin, forms typical tubulolamentous intra-nuclear inclusions that are exclusively
present in the nuclei of muscle bers (Tom et al. 1997; Croquet et al. 1983).
However, the mechanisms behind the mutations and how the mutated protein affects
the muscle cells are only partially understood. It has been proposed that the turnover
of myonuclei seen in the muscle bers of the EOMs may also occur in other craniofacial muscles and provide the basis for the earlier involvement of the eye and
pharyngeal muscles in OPMD (Wirtschafter et al. 2004).
5.6 Thyroid Disease

Approximately 3050% of the patients with Graves disease (Brent 2008) develop
clinically apparent thyroid-associated ophthalmopathy (TAO), also known as
thyroid eye disease (TED), but patients with no clinical symptoms or signs of eye
involvement may also show orbitopathy when adequate imaging techniques are
used (Lennerstrand et al. 2007). Risk factors for the development of TAO include
cigarette smoking, post-treatment hypothyroidism, and radioiodine treatment, as
well as high serum levels of thyrotropin receptor antibody (Thornton et al. 2007;
Eckstein et al. 2006; Ag and Smith 2008; Bartalena et al. 2008; Trisk 2009;
Trisk et al. 2009).
An array of changes in the orbital tissues leads to the clinical picture of TAO.
Initially, the symptoms are related to inammation and swelling and are dominated
by progressing discomfort, tearing, conjunctival injection, and edema. Eyelid retraction gives these patients a typical appearance and contributes to the worsening of
lacrimation and discomfort. Eyelid retraction may become permanent due to
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F. Pedrosa Domellf
adhesions between adjacent palpebral and orbital structures. In a subgroup of

patients, the progressive increase in orbital tissue volume pushes the eye forward, a
condition termed exophthalmos or proptosis. Increased orbital volume imposes
mechanical constraints for the action of the EOMs. However, the most feared aspect
of TAO is compression of the optic nerve due to increased intraorbital pressure, as
it is may compromise vision irreversibly.
Diplopia has been reported to occur in approximately 20% of the patients who
develop TAO. Blurred vision, which may have different etiologies including discretely disturbed eye motility, occurs in approximately 10% of patients with TAO
(Bartley et al. 1996). The involvement of the EOMs in TAO may vary, from rather
discrete and not readily apparent from a clinical examination, to extensive brotic
restriction of eye movements. Imaging techniques such as CT and MRI are very
helpful for identifying and quantifying the extent of EOM involvement, whereas
velocity measurements of saccadic eye movements have, thus far, provided controversial results and are not easy to use in a clinical setting (Trisk 2009).
At the tissue level, the changes behind TAO include expansion of orbital connective and fat tissue, inltration of orbital tissues, including the EOMs, with mononuclear cells and hyaluronan, and, in the long run, brosis and impaired eye motility
(Khoo and Bahn 2007). The orbital broblasts are regarded as major players in
these processes, particularly regarding adipogenesis, and data indicate that they are
the primary targets in the orbit for the circulating autoantibodies against thyrotropin
receptor. Autoantibodies against insulin-like growth factor-1 (IGF-1) also play an
important role in recruitment and activation of T-cells and stimulation of hyaluronan deposition. Deposition of hyaluronan in between muscle bers and in fatty
connective tissue leads to increased volume of the EOMs and orbital contents but
the process underlying TAO also includes inammation and damage of the EOMs,
reected by the presence of detectable autoantibodies against these muscles (Khoo
and Bahn 2007).
5.7 Amyotrophic Lateral Sclerosis

ALS is a progressive, fatal, neurodegenerative syndrome affecting both the upper
and lower motor neurons and their supporting cells (Boille et al. 2006; Andersen
2006). It is clinically characterized by progressive loss of voluntary muscle function, leading to early death due to respiratory failure. The incidence of ALS increases
with age, and it typically affects people in the sixth decade or older. The disease
may have a bulbar onset in 2025% of the patients with initial symptoms of dysphagia and dysarthria. However, a systemic onset, usually in a limb muscle, is more
common; the cranially innervated muscles are also involved at later stages. Strikingly,
involvement of the EOMs is not a typical feature of ALS, although it does occur in
some cases, particularly in patients who survived longer periods due to assisted
ventilation (Leveille et al. 1982; Hayashi et al. 1987; Palmowski et al. 1995). Human
EOMs of donors who died of ALS without ventilator support show mild signs of
83
Fig. 5.3 Notice the impact of ALS on the limb muscles ((a) control, (b) ALS) with brosis and
muscle ber atrophy on the left side of (b) and extremely hypertrophic muscle bers with internal
nuclei (right side) as well as fatty replacement (white areas on the left). In contrast, in the same
patient, the EOMs are notably less affected at the end-stage of ALS. Notice however the wider
variation in muscle ber size and the increased space between muscle bers in (d). (ab): eosin
staining; (cd): NADH-activity staining
denervation and muscle ber overuse, with a wider range of muscle ber area and
altered composition of contractile and extracellular matrix (ECM) proteins (Ahmadi
et al. 2010; Liu et al. 2011). Wide variation in the extent of pathological changes
was seen between different donors and also between the EOMs of the same donor.
In all cases, the changes present in the EOMs were very mild when compared to the
devastating impact of ALS on the skeletal muscles of the same individuals at the
time of death (Fig. 5.3). We have therefore suggested that the EOMs are more resistant to the pathophysiological process underlying ALS. However, our understanding of the pathophysiology of ALS is rather limited, in spite of intensive research in
the eld (Boille et al. 2006). Approximately 90% of the cases of ALS are so-called
sporadic and of unknown pathogenesis. In the remaining cases, a familial pattern of
inheritance may be present or become apparent later on, and in 1020% of these
patients, mutations in the SOD1 gene are present. Mutated SOD1 is thought to
cause ALS by a gain of toxic function, as the absence of SOD1 activity in animal
models does not cause ALS. The interplay of genetics, environment, and aging in
the pathophysiology of ALS is gaining increasing importance (Andersen 2006).
Furthermore, recent data indicate that metabolic changes in skeletal muscle likely
play an important role in the early pathogenesis of ALS (Dupuis and Loefer 2009).
Defects in energy metabolism such as hypermetabolism and hyperlipidemia are
regarded as negative factors contributing to the pathogenesis of ALS. Convincing
data show that motor neuron death starts at the NMJ and proceeds towards the
spinal cord (Fischer et al. 2004). In two elegant proof of concept papers, it has been
F. Pedrosa Domellf
84
shown that (1) metabolic changes in the muscle ber are capable of initiating
dismantling of the NMJ (Dupuis et al. 2009, 2011) and (2) skeletal muscle-restricted
expression of human SOD1 causes motor neuron degeneration and an ALS-like
syndrome in transgenic animal models (Wong and Martin 2010). In other words, the
view on ALS is changing focus from the motor neurons and their supporting cells
centrally to the muscle and the NMJ. The human EOMs differ signicantly from the
other muscles in the body with respect to their metabolic prole and pathways,
structural components, developmental, and regeneration markers, by a total of 338
genes (Fischer et al. 2005); therefore, some of their intrinsic properties may make
them more resistant to the underlying process behind ALS. Most strikingly, the
EOMs are capable of maintaining a normal laminin composition in their NMJs, in
contrast to the limb muscles from matched ALS patients (Liu et al. 2011). The latter
is particularly important because the ECM may regulate the availability of different
growth and trophic factors, and maintained specialization of the basement membrane is crucial for proper synaptic function. We propose therefore that the EOMs
are a useful model to study ALS as they may provide insights on strategic adaptation for longer motor neuron survival or for better preservation of muscle function
which may be important for the development of new therapies for ALS.
5.8
Duchenne and Related Muscle Dystrophies
The selective sparing in muscular dystrophies caused by defects in the dystrophin/dystroglycan complex (DGC) is by far the most intriguing property of the
EOMs given that these are devastating diseases of childhood that lead to severe
handicap and early death. An understanding of the molecular basis for the selective sparing of the EOMs in these muscle dystrophies holds the promise of therapeutic advances for this group of diseases. This has been an active research area,
although the identication of specic structural adaptations of the EOMs has
remained rather elusive (reviewed by Andrade et al. 2000).
A number of genetic defects affecting almost any of the proteins involved in the
molecular link formed by the ECM on the surface of muscle bers, across the cell
membrane, and the subsarcolemmal cytoskeleton are known to cause muscle dystrophies (Emery 2002), Duchenne muscular dystrophy (DMD) being the most wellknown of all. In Duchenne and Becker muscular dystrophy, the genetic defect
affects dystrophin (Hoffman et al. 1987; Koenig et al. 1988), a cytoskeletal molecule
found in a subsarcolemmal location and a key element of the so-called DGC. The
DGC spans the cell membrane and comprises, among others, dystroglycans, sarcoglycans, syntrophins, and dystrobrevins, and it connects to actin on the cytoskeletal
side and to laminin 211 (merosin) on the ECM side. The DGC has a fundamental
function providing the mechanical stabilization of the sarcolemma needed for muscle ber integrity and force transmission, and it is also important for cell signaling
(reviewed by Ervasti and Sonnemann 2008). Examples of muscle dystrophies
85
caused by defects in genes related to the DGC are some forms of limb-girdle muscular
dystrophy, which are due to defects in the different sarcoglycans (Bonnemann et al.
1995; Lim et al. 1995) and congenital muscle dystrophies (reviewed by Muntoni and
Voit 2004) caused by defects involving the laminin alpha-2 chain, also known as
merosin-decient congenital muscular dystrophy (Helbling-Leclerc et al. 1995),
alpha-7-integrin (Hayashi et al. 1998), or collagen VI genes.
The EOMs are clinically and histologically spared in DMD and in animal models
of muscle dystrophies due to mutations in dystrophin, the laminin alpha-2 chain,
and sarcoglycans (for references see Andrade et al. 2000). The laminin chain composition of the human EOMs differs from that of skeletal muscle bers. The EOMs
co-express laminin alpha-4, alpha-5, and beta-2 chains, in addition to alpha-2 and
beta-1 chains present in all skeletal muscle bers (Kjellgren et al. 2004). The
co-expression of additional laminin chains is most likely a specic mechanism that
protects the human EOMs in merosin-decient congenital muscle dystrophy.
Supporting this hypothesis, the EOMs of the dy3k/dy3k mice, which completely
lack the laminin alpha-2 chain, remain unaffected, and co-express the additional
laminin chains, in contrast to the affected limb muscles (Nystrom et al. 2006).
Possible general factors of importance for the selective sparing of the EOMs in
muscular dystrophy may be the very small diameter of muscle bers and the very
small loads that these bers work against. Differences in calcium homeostasis may
also be a relevant factor, as the EOMs have a superior capacity to handle calcium
and calcium overload is a part of the pathogenic process in these diseases. However,
an increased regenerative capacity may be the single most relevant property for the
selective sparing of the EOMs in DMD (Kallestad et al. 2011). The gene expression
proles of the EOMs differ from those of limb muscle by increased expression of
genes related to regeneration, growth, and development (Porter et al. 2001; Fischer
et al. 2005). Experiments using incorporation of bromodeoxyuridine (brdU) indicate that the EOMs have signicant activation of muscle precursor cells and addition of myonuclei to the muscle bers, even in the absence of disease (McLoon
et al. 2004, 2007). A recent study identied a subpopulation of muscle cell precursors with special properties that are present at higher numbers in the EOMs from
both mdx and mdx/utrophin/ mouse models of DMD, compared to their limb muscles, strongly suggesting an important role for successful regeneration in the sparing of the EOMs (Kallestad et al. 2011).
5.9
Summary
In summary, the EOMs display a complex disease prole when compared with limb
skeletal muscles. Their propensity for, or sparing from, various forms of muscle
pathology are under intensive study in many laboratories. Hopefully, uncovering the
mechanisms for EOM sparing or involvement in specic muscle disease entities
will help direct translational research towards new therapies for treatment.
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F. Pedrosa Domellf
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Part IV
Masticatory Muscles
Chapter 6
Masticatory Muscle Structure and Function

Mark Lewis, Nigel Hunt, and Rishma Shah
6.1
Introduction
The muscle group referred to as the muscles of mastication includes the temporalis,
the medial and lateral pterygoid, and the masseter muscles on both sides of the face
and jaws. These voluntary skeletal muscles are derived from the paraxial mesoderm
of the rst branchial arch whilst their connective tissue components are derived
from mesenchymal cells of neural crest origin. They are innervated by the mandibular division of the fth (trigeminal) cranial nerve (CNV). Precision in the control of
jaw position and movement of the mandible is provided by the human mandibular
locomotor system. It is important to remember that this control of both jaw position
and function varies considerably throughout the life of an individual, principally to
support the activities of providing nutrition, speaking, and swallowing. For example,
in the newborn infant very ne movements of the jaw are associated with the important tongue activity necessary for breast or bottle-feeding. Subsequently, as the
deciduous teeth erupt and later as the permanent teeth erupt, these changes in dentition are associated with periods of rapid growth of the individual in general, and
therefore the need to create increased biting and chewing forces is developed. There
may be altered demands in relation to the ravages of such conditions as dental caries
and periodontal disease with the possibility that teeth may need to be extracted or
M. Lewis, Ph.D. (*)

School of Sport, Exercise and Health, Loughborough University, Loughborough,
Leicestershire, UK and UCL Eastman Dental Institute, London, UK
e-mail: mlewis@eastman.ucl.ac.uk
N. Hunt, Ph.D., MOrth., R.C.S. R. Shah, Ph.D., MOrth., R.C.S.
UCL Eastman Dental Institute, 256 Grays Inn Road, London WC1X8LD, UK
91
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lost leading to prosthetic replacement. The different embryological origin and innervation
of these muscles compared to somatic skeletal muscle coupled with their changing
and unique functions have led to the possibility of structural specialisation within
the muscles of mastication. Of the muscles in this group, the masseter muscle has
undergone most investigation particularly in relation to its ease of access compared
to the other muscles of the group.
6.2 Anatomy
The temporalis muscle is a fan-shaped muscle arising from the whole of the temporal
fossa except for that part formed by the zygomatic bone together with the deep
surface of the temporal fascia (Fig. 6.1). The anterior and posterior bres converge
to attach, via a tendon, to the medial surface, the apex, and the anterior and posterior
borders of the coronoid process and the anterior border of the ramus of the mandible
nearly as far forward as the last molar tooth. The anterior bres act to elevate the
mandible whilst the posterior bres are principally involved in drawing the mandible back after protrusion of the jaw but also provide a backward pull during closing
of the jaw. Electromyographic investigations suggest the muscle is active during
forced elevation of the mandible but not in slow elevation.
The medial pterygoid muscle arises as two heads: the supercial head from the
bone around the maxillary tuberosity, and a deep head from the medial surface of
the lateral pterygoid plate. The muscle bres pass downwards, backwards and laterally to insert into the deep surface of the angle of the mandible. The medial pterygoid works in combination with the masseter and anterior bres of temporalis to
Fig. 6.1 The muscles of mastication. The masseter, temporalis, and medial pterygoid muscles are
responsible for jaw closure, whereas the lateral pterygoid muscle is associated with jaw opening
and facilitates lateral and protrusive mandibular movements
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elevate the mandible, whilst simultaneous contraction of both the medial and lateral
pterygoids of both sides of the jaws protrudes the lower jaw. However, when the
medial and lateral pterygoid muscles contract on one side only the mandible rotates
and protrudes to the opposite side as occurs in chewing movements.
The lateral pterygoid muscle also has two heads: the superior head that arises
from the infratemporal surface of the greater wing of the sphenoid bone, and an
inferior head from the lateral surface of the pterygoid plate of the maxilla. The bres
from both heads converge as they pass posteriorly and laterally to be inserted into a
small depression on the anterior surface of the neck of the mandibular condyle and
the anterior aspect of the articular disc of the temporomandibular joint. Contraction
of the lateral pterygoid muscles draws the mandibular condyle downwards and forwards onto the articular eminence as occurs during opening of the mouth. As noted
above, working together, the medial and lateral pterygoid muscles are involved in
many of the complex movements of the mandible as occur during suckling and
mastication.
The masseter muscle is a quadrilateral-shaped muscle composed of three superimposed layers, which blend together anteriorly. The supercial layer is the largest
and arises as a thick aponeurosis from the zygomatic process of the maxilla and the
anterior two-thirds of the lower border of the zygomatic arch. The bres pass downwards and backwards to be inserted into the angle region and the lower half of the
lateral surface of the ramus of the mandible. The middle bres arise from the deep
surface of the anterior two-thirds of the zygomatic arch and the lower border of the
posterior third and are inserted into the middle of the ramus of the mandible. The
deep bres arise from the deep surface of the zygomatic arch and are inserted into
the upper part of the ramus and coronoid process of the mandible.
The principal action of the masseter muscle is to elevate the mandible with a
small effect in lateral and protrusive movements and minimal activity in the rest
position. The relative involvement of the three different bre layers during functional
movements has been fully elicited through electromyographic studies (Vitti and
Basmajian 1977).
The size, volume, thickness, cross-sectional area and the direction and orientation of the masseter muscle have been measured using different types of magnetic
resonance imaging (MRI) (van Spronsen et al. 1992), computerised tomography
(CT scan) (Kitai et al. 2002), and bilateral ultrasonography (US) (Kiliaridis and
Kalebo 1991; Trawitzki et al. 2006). The masseter muscle has been reported as
short, thin, of low volume, and having a small cross-sectional area in orthodontic
Class III, prognathic (Ariji et al. 2000; Kitai et al. 2002; Trawitzki et al. 2006) and
long face patients (Kiliaridis and Kalebo 1991; van Spronsen et al. 1992) when
compared to patients with ideal antero-posterior and vertical facial balance and proportions. Multi-disciplinary treatment of prognathic patients can increase the thickness of the masseter; however, this is never to the levels seen in patients with
normal or ideal facial form (Trawitzki et al. 2006). When compared to other facial
patterns, long face individuals showed the thinnest, whilst short face patients exhibited the thickest masseter muscle volume compared to average face subjects
(Satiroglu et al. 2005; van Spronsen 2010) (Fig. 6.2).
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Fig. 6.2 MRI scans indicating the greater thickness of masseter muscle in a short face (SF) and a
thinner muscle in a long face (LF) compared to an individual with normal (Nor) vertical facial
morphology (reproduced with permission of P.R. van Spronsen)
Furthermore, the orientation of the masseter muscle bres in prognathic patients

compared to controls was found to be in a more forward direction, forming an
obtuse angle with the Frankfort horizontal plane (Ariji et al. 2000; Kitai et al. 2002).
It has been suggested that the more upright the direction of the masseter muscle
bres (as in short face patients) in relation to the Frankfort horizontal or functional
occlusal planes, the greater the occlusal forces (Kitai et al. 2002).
Other studies have assessed the relationship between the volume of the masseter
muscle and specic craniofacial skeletal parameters. The results have indicated a
positive correlation between masseter muscle volume and the ramus height (Kubota
et al. 1998), posterior face height (Benington et al. 1999), and the cross-sectional
area of the zygomatic arch (Kitai et al. 2002), whilst a negative correlation was
observed in relation to mandibular inclination and gonial angle (Kubota et al. 1998;
Benington et al. 1999). No relationship was found between masseter muscle volume
and cranial width (Kitai et al. 2002). Furthermore, general anterior and posterior
craniofacial vertical dimensions were more related to masseter muscle volume than
cross-sectional area (Boom et al. 2008).
6.3
Fibre Typing
The actinmyosin relationship is key to skeletal muscle contraction (Barany 1967;

Barany et al. 1967). The sarcomeric myosin lament is one of the most important
elements of the contractile mechanism, consisting of two myosin heavy chains
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(MyHC) and four myosin light chains (MyLC), which may be further subdivided
into essential (alkali) light chains and regulatory (phosphorylatable) light chains
(Lowey and Risby 1971). The role of the MyLCs in human skeletal muscle has yet
to be claried, but it is the MyHCs that are responsible for forcevelocity characteristics of myobres, although other factors inuence them (e.g., neural input and
architecture). The MyHC isoform present in a given myobre is an important factor
for the classication of its physiological properties (Barany 1967; Barany et al.
1967; Brooke and Kaiser 1970; Weiss and Leinwand 1996).
Eleven MyHC isoforms have been identied in mammalian skeletal muscle with
b/I, IIA, IIB and IID/X as the main isoforms in adult skeletal muscle. MyHC-b/I
represents the slow contracting MyHC, with MyHC-b designated to cardiac muscle
(Weiss and Leinwand 1996) and MyHC-I referring to skeletal muscle. The group of
MyHC-II isoforms produce fast contraction velocities with characteristic shortening speeds relative to one another where IIB > IIX/D > IIA. It has been demonstrated
in knockout mice that MyHC-IIB and IIX/D are necessary for the normal function
of adult skeletal muscle, and the absence of these MyHCs leads to the presentation
of distinctive phenotypes (Acakpo-Satchivi et al. 1997). With respect to human
skeletal muscle, the presence or absence of MyHC-IIB is still unanswered.
Histochemical studies have identied type IIB bres as a major constituent of fast
muscle, but Pereira et al. (1997) and others (Ennion et al. 1995) have shown that the
isoform is a homologue of MyHC-IIX found in rat and rabbit. Thus, absolute
clarication is still required. Slow bres are better adapted for isometric contractions,
developing the same force as fast bres, but with less ATP consumption. Thus, developing the maximum power with the most efciency at low velocity, slow bres are
found mainly in the postural muscles that are essentially fatigue-resistant. On the
contrary, fast bres (MyHC-II) develop maximum power with the greatest efciency
at high velocity and are best suited to short-lasting, faster, and more powerful movements, such as those effected by sprinters (Yoshioka et al. 2007) and during
mastication.
Masticatory MyHC: Interestingly, the craniofacial muscles express other isoforms,
including a very fast masticatory MyHC (MyHCIIM) present in the jaw-closing
muscles of non-human primates and carnivores (Rowlerson et al. 1981, 1983).
Studies into the jaw-closing muscles of humans and rabbits show they also express
a-cardiac myosin, normally found in heart muscle, and the a-cardiac MyHCpositive bres in rabbit have slower shortening velocities than MyHC-IIA (Sciote
and Kentish 1996).
Embryonic and neonatal MyHCs (MyHC-emb and MyHC-neo) are typically
expressed during embryonic myogenesis (Periasamy et al. 1984; Schiafno et al.
1986; Bouvagnet et al. 1987), within regenerating (Schiafno et al. 1986; Sartore
et al. 1982; Matsuda et al. 1983) or denervated (Schiafno et al. 1988) adult skeletal
muscle, and the extraocular muscles (Wieczorek et al. 1985; Sartore et al. 1987).
The persistent expression of the developmental MyHC isoforms within the adult
human masseter shows a good deal of heterogeneity (Butler-Browne et al. 1988;
Sciote et al. 1994; Stal et al. 1994).
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Other MyHC isoforms: Additionally, extraocular MyHC (MyHC-EOM) has been

found in the extraocular (Sartore et al. 1987) and laryngeal muscles (DelGaudio
et al. 1995). The fast contracting MyHC-a-cardiac is expressed in cardiac muscle;
however, it has been found occasionally in skeletal muscle, including masseter
(Suchak et al. 2009).
The MyHC and related gene expression within the main jaw-opening muscles
has been studied extensively in humans (Vignon et al. 1980) and other mammalian
species (Rowlerson et al. 1983). The jaw-opening mechanism is not particularly
different amongst the species, hence the predominant bres are fast, with relatively
fewer type I bres. Eriksson et al. (1982) have reported human digastric muscles
contain approximately 29 % type I bres, with the remainder type II. There are
appreciable differences in the kinetics of jaw closing which are controlled by the
expression of specic bre types within individual muscle compartments and
between the different jaw-closing muscles. Human jaw-closing muscles contain
1090 % type I bres and no type IIM (masticatory) bres (Sciote and Morris 2000),
which are found in primate jaw-closing muscles (Rowlerson et al. 1983). The different insertions of these jaw-closing muscles will produce different functionality: for
example, the insertion of the temporalis muscle nearer to the occlusal plane in
carnivores enables more rapid jaw closure (Sciote and Morris 2000).
Moreover, differences are evident between human jaw-closing and limb muscles
such that healthy limb skeletal muscles are composed of a mosaic of type I and II
bres, with the type II bres displaying a relatively larger diameter. The myobres
tend to be homogeneous for a specic MyHC; however, combinations may co-exist
within the same myobre (Sciote and Morris 2000). In contrast, human jaw-closing
muscles tend to have equal proportions of type I and II bres, but the type II bres
tend to be of a smaller diameter (Ringqvist 1973a, b). Equally, the human masseter
muscle displays a number of phenotypes specic to individual factors within any
given jaw. Hunt et al. (2006) demonstrated variation in both the relative size and
proportion of type II bres in masseter muscle in relation to vertical facial morphology. Individuals displaying a long face deformity have smaller and fewer type II
bres whereas the type II bres were both larger and present in greater proportion
in individuals with reduced vertical facial dimensions. Muscle phenotypes may also
be modied by such things as the presenting dental occlusion (Sciote et al. 1994).
As previously mentioned, the different muscle compartments within individual
muscles may house different bre types, and it has been suggested that the anterior
supercial aspect of the masseter muscle contains the largest variability in bre
types within this group of muscles (Serratrice et al. 1976).
Individuals with craniofacial abnormalities may have differing expression of the
MyHC genes and their associated proteins, which are related to the presenting facial
abnormality. For example, a negative correlation has been noted between patients
who have an increased vertical facial form and upregulation of the MYH1 gene
representing the fast MyHC-IIX isoform (Suchak et al. 2009). Following surgical
correction, e.g., orthognathic surgery, bre type transitions are observed that resemble
those seen in regeneration (Lee et al. 2000). A number of investigations have
documented that the predominantly type I (slow) MyHC expressed in those with
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increased vertical facial proportions shifts to a greater proportion of type IIA (fast)
MyHC after jaw surgery (Harzer et al. 2007; Maricic et al. 2008; Oukhai et al.
2011). The functional adaptability of the masticatory muscles seems to be key to the
future surgical stability of severe craniofacial deformities.
6.4
Biochemistry
Cellcell and cellextracellular matrix (ECM) interactions lead to the upregulation

of specic transcription factors and genes essential in the normal development and
maintenance of skeletal muscle (Maley et al. 1995; Melo et al. 1996; Grounds et al.
1998). The three-dimensional ECM consists of the interstitial connective tissue and
basement membrane in intimate contact with satellite cells and myobres.
The basement membrane, regulating cell polarity and separating tissue types, is
composed of mainly collagen IV, laminin, entactin, and heparan sulphate proteoglycans (HSPGs) (Sanes et al. 1986), whereas the interstitial ECM between myobres
is composed of mainly collagen I, bronectin, and HSPGs (Cornelison 2008).
Collagen provides tensile strength and the proteoglycans (PGs) create space for the
tissue and allow for diffusion; additionally, the ECM behaves as a storage depot for
cytokines and growth factors. The main ECM components form four groups
collagenous glycoproteins, non-collagenous glycoproteins, proteoglycans, and elastin
(Lewis et al. 2001). The ECM differs between muscle groups, and all members play
an essential, co-ordinated, often synergistic role in functionality. The binding of
growth factors and their proteolytic fragments in the ECM has been demonstrated to
exert a number of important inuences, such as direct mitogenic effects (Foster et al.
1987). Importantly, the majority of biologically active ECM molecules exhibit multiple active binding sites with the capacity to bind different ligands and bring about
different activities. Structural integrity of the muscle tissue is crucial to normal function, and the ECM, with its vast array of molecules, lends itself well to this role.
The adhesion molecules present on myogenic precursor cells (MPCs) consist of
ve groups, of which three, the ADAMs (a disintegrin and metalloproteinase
domain), cadherins (M-, N- and R-Cadherin), and immunoglobulin superfamily
(e.g., neural cell adhesion molecule 1 (NCAM-1) and vascular cell adhesion molecule 1 [VCAM-1]), are involved in control of direct cellcell adhesion (Lewis et al.
2001). The dystrophindystroglycan complex and integrins, on the other hand, play
an important role in cellECM adhesion. The matrix metalloproteinases (MMPs),
secreted into the ECM as latent proenzymes, are essential to ECM maintenance
for example, the gelatinases (MMP-2 and -9) degrade the major components of the
ECM, namely collagen IV and laminin (Lewis et al. 2001). Activation occurs by
proteolysis and is inhibited in a 1:1 manner by the tissue inhibitors of the metalloproteinases (TIMPs) (Birkedal-Hansen 1995) with any disturbances in the
MMP:TIMP ratio manifesting clinically as disturbances in wound healing (Carmeli
et al. 2004; Guillen-Marti et al. 2009). The molecules support muscle regeneration
by the MPCs in disease and injury.
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Studies suggest MMP-2 is secreted by MPCs and the interstitial broblasts

(Kherif et al. 1999) and is expressed in healthy skeletal muscle where it is localised
to the perivascular regions, nerves and neuromuscular junctions (NMJs) (Lewis
et al. 2001). MMP-9, a product of inammatory cells (Lewis et al. 2000; Schoser
et al. 2002), is not expressed in normal adult non-cranial skeletal muscles, but it is
upregulated after muscle injury or disease, where it is located next to the blood
vessels, nerves, and NMJs (Kherif et al. 1999). Interestingly, it is also expressed
within myobres in healthy human craniofacial muscle (Singh et al. 2000). The
differences in location between the craniofacial and somite-derived muscles could
be the consequence of their different developmental origins. Specically within the
human masseter muscle, TIMP-1 appears to be consistently expressed. The very
low levels of TIMP-2, MMP-2 and MMP-9 expression support the low level of
ECM turnover in the craniofacial musculature (Tippett et al. 2008). The gelatinases
facilitate MPC migration during development (Chin and Werb 1997) and regeneration, and their important role has been claried by in vitro (Allen et al. 2003) and
in vivo (El Fahime et al. 2000) studies whereby overexpression facilitated substantially greater migration and blocking activity was sufcient to prevent MPC migration. MMP-9 expression within the craniofacial muscles increases just prior to MPC
fusion. In contrast, MMP-2 mRNA and protein expression occur during all stages of
MPC differentiation (Kherif et al. 1999; Lewis et al. 2000; Carmeli et al. 2004).
Studies have also suggested a synergistic role of growth factors on MMP expression
(Allen et al. 2003).
6.5
Regeneration and Adaptation
Satellite cells are present as mitotically quiescent, undifferentiated mononuclear

cells located between the sarcolemma of individual muscle bres and their associated basal lamina sheaths (Mauro 1961; Muir et al. 1965). These cells are a normal
constituent of all vertebrate skeletal muscle, regardless of age, bre type and location (Schultz 1976), and comprise 210 % of the nuclei associated with any particular bre (Bischoff and Heintz 1994). Of the total number of nuclei in mature muscle,
satellite cells make up 15 % (Allbrook 1981; Alameddine et al. 1989). Interestingly,
satellite cells are in greater number within oxidative muscles as compared to glycolytic muscles, regardless of species (Gibson and Schultz 1983; Schultz 1989). The
size of the population is, in part, regulated directly or indirectly by innervation as
well as the muscle functional state (Schultz et al. 1984). The bre type distribution
of the regenerated myobres takes on the characteristics of the host muscle bed.
Hence, it follows that innervation, recruitment pattern, and ultimate bre type may
be important determinants of satellite cell distribution. The distribution along individual bres is relatively even with the exception of the motor endplate regions
where cell density is increased (Wokke et al. 1989). Several reasons have been
suggested for this, including preservation of the NMJ and synthesis of molecules
important for the structure or function of motor endplates (Wokke et al. 1989).
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It has been found that the ratio of satellite cell nuclei to total nuclei number
varies between masticatory and somatic muscle groups with the latter demonstrating a higher ratio (Renault et al. 2002). This is despite the presence of a greater
mean number of nuclei per bre within the masseter muscle. Importantly, the ratio
of satellite cells decreases in both groups with age; however, it has been suggested
that generally the masseter muscle regenerates less effectively following a traumatic injury than somatic muscle (Pavlath et al. 1998). The contrast in regenerative
capability may be explained by the different embryological origins of craniofacial
and somatic skeletal muscle and variations within the myoblast populations.
Numerous animal models have been used to examine the structural and
functional characteristics of regenerating skeletal muscle (Carlson and Gutmann
1975a, b; Faulkner et al. 1980). Regardless of the nature, severity, and extent of the
injury, the process of muscle regeneration is comparable, although the outcome and
timetable of the reparative process may vary (Lee et al. 2000). Some in vivo studies
have used differential labelling of satellite cells and myonuclei with 3H-thymidine
to demonstrate the satellite cell as the sole source of new MPCs (Schmalbruch
1976). Recent studies have demonstrated that the population of satellite cells in
muscles is quite heterogeneous, both molecularly and functionally (Collins et al.
2005; Biressi and Rando 2010; Rossi et al. 2010). In response to injury, satellite
cells become activated and proliferate to form a pool of MPCs (Lee et al. 2000).
Some of the MPCs differentiate to provide a source of nuclei to damaged myobres
or alternatively fuse together to form new multinucleated myobres (Moss and
LeBlond 1971; Snow 1978; Campion 1984), whereas some daughter cells replenish the
satellite cell population (Barofo et al. 1995, 1996; Yoshida et al. 1998; Beauchamp
et al. 1999). The migration of MPCs through the basal lamina of myobres both
within (Phillips et al. 1990) and between (Watt et al. 1994) skeletal muscles and
formation of the connective tissue network by the proliferating MPCs is key to successful repair and regeneration (Hughes and Blau 1990; Li and Huard 2002; Hill
et al. 2003).
Satellite cells were originally thought to be of somitic origin: classic quail-chick
chimera experiments revealed the association of satellite cell nuclei derived from
implanted quail somite with host chick myobres (Armand et al. 1983). However,
more recent studies have suggested a non-somitic origin of satellite cells (Ferrari
et al. 1998; De Angelis et al. 1999; Hawke and Garry 2001; Asakura and Rudnicki
2002; LaBarge and Blau 2002; Polesskaya et al. 2003). For craniofacial muscles,
these cells are derived from the same source of craniofacial mesenchyme as the
muscles themselves (Harel et al. 2009). Further, it has been proposed that MPCs
may still retain the plasticity to transcend the lineage boundary when exposed to
certain in vitro and in vivo environmental cues (Jackson et al. 1999; Lee et al. 2000;
Geiger et al. 2002; Wada et al. 2002; Cao et al. 2003; Zheng et al. 2007), although
some evidence exists that they may arise from circulating blood-borne or other stem
cell populations. Another source of stem cells (muscle-derived stem cells, MDSCs)
is present in adult skeletal muscle with the ability to give rise to different cell types,
including MPCs (Royer et al. 2002; Tamaki et al. 2002; Wada et al. 2002). Further
studies need to be undertaken to determine whether these cells truly are satellite cell
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M. Lewis et al.
progenitors, a subpopulation of satellite cells, or an independent progenitor cell

population that is resident in the extracellular niche of skeletal muscle (McKinneyFreeman et al. 2002). Signicantly, the potential to produce different tissues from
muscle-derived cells opens up another dimension for novel therapies, such as tissue
engineering (Qu-Petersen et al. 2002).
Growth factors play a role in skeletal muscle development and growth. In particular,
insulin-like growth factors I and II (IGF-I and -II) play an important role in the
general growth and development of different tissues. The effects of IGFs, which are
under negative feedback, are initiated upon binding to cell surface receptors, which
are abundant in skeletal muscle (Livingston et al. 1988), and modulated through
interactions with secreted IGF binding proteins (IGFBPs), of which there are six
members (Stewart and Rotwein 1996). IGFBPs are secreted from cells that also
secrete IGFs (Ernst et al. 1992), and it has been speculated that IGFBP-4 may be
necessary for in vivo enhancement of human skeletal muscle (Brimah et al. 2004).
IGF-I appears to be essential for correct embryonic development in animal models,
as demonstrated by the underdeveloped muscle tissue and perinatal death of mice
homozygous for either a mutation of the IGF-I gene or IGF-I receptors (IGF-1Rs)
(Liu et al. 1993; Powell-Braxton et al. 1993).
It is likely that the growth hormone (GH)IGF axis plays a major part in mediating the growth and differentiation of skeletal muscle. The direct action of GH is
unclear (Halevy et al. 1996), despite establishing the presence of the GH receptor
mRNA in skeletal muscle. Data from recent studies in GH receptor knock-out mice
and established cell cultures have suggested that GH is not necessary for the control
of skeletal muscle during the embryonic and perinatal stages, but important for
postnatal myobre growth involving the fusion of MPCs to nascent myotubes, as
well as the positive specication of type I bres (Sotiropoulos et al. 2006). These
growth-enhancing actions of GH are facilitated by circulating or autocrineparacrine
production of IGF-1 (Le Roith and Zick 2001). Indeed, numerous studies have shown
increased IGF-1 mRNA within skeletal muscle tissue and MPC cell lines in response
to GH exposure (Florini et al. 1996). There are three IGF-1 splice variants, IGF1Ea, IGF-1Eb and IGF-1Ec. Due to its upregulation in exercised and regenerating
human skeletal muscles, IGF-1Ec is also referred to as mechanogrowth factor
(MGF) (Yang et al. 1996). IGF-1 is produced by MPCs within regenerating muscles
(Hawke and Garry 2001), which promote MPC cell survival (Stewart and Rotwein
1996; Napier et al. 1999), proliferation (Florini et al. 1996; Yang and Goldspink
2002; Ates et al. 2007), differentiation (Galvin et al. 2003), and hypertrophy (Baker
et al. 1993; Florini et al. 1996; Matsumoto et al. 2006; Quinn et al. 2007), responses
that are temporally separate in MPCs (Allen and Boxhorn 1989; Florini et al. 1991).
It has been demonstrated that MGF is upregulated after the surgical correction of
craniofacial abnormalities, thus indicating its role in regeneration and potential
adaptation in these specialised muscles (Maricic et al. 2008).
Maximal stimulation of proliferation and the highest percentage of fusion of rat
satellite cells in vitro are produced by a combination of FGF and IGF-I (Allen and
Boxhorn 1989); however, differentiation with minimal proliferation can be achieved
with IGF-I alone. Proliferation is brought about by the activation of MAP kinases
101
(Coolican et al. 1997), whilst differentiation is achieved by increasing levels of

mRNA for myogenin, the MRF most directly associated with terminal myogenesis
(Florini et al. 1991), and activation of the phosphoinositol 3-kinase/Akt/70-kDa S6
protein kinase pathway (Coolican et al. 1997). In exercised muscle/compensatory
hypertrophy, IGF-I exerts its effects by increasing protein (sarcomere) formation
(Adams and Haddad 1996; Adams and McCue 1998). Notably, the age-related
changes of sarcopenia and muscular dystrophy were negated in mice expressing
muscle-specic IGF-1 (Musaro et al. 2001; Barton et al. 2002).
The micro-environmental cues provided by tissue-specic ECM components are
essential in determining the fate of stem cells and their progeny, and this has been
discussed previously. The stem cell niche itself protects the quiescent cells from
these inuences; however, upon escaping the niche, cells are not only directed by
the ECM components, but also by non-myogenic cells within the tissues. The nonmyogenic cells that play an important role in skeletal muscle development, maintenance, regeneration, and often chronic pathological conditions include platelets,
polymorphonuclear leukocytes (PMLs), macrophages, and broblasts.
Inammatory cells, in particular macrophages, play a role in tissue homeostasis
whereby upon injury they can undertake phagocytosis (Robertson et al. 1993), antigen presentation, and provide support through the delivery of mitogens and cell
contact-mediated survival signals (Nathan 1987; Cantini et al. 2002). PMLs accumulate within minutes at an injury site and by cytokine release can promote attraction and activation of other inammatory cells. The role for leukocytes is based on
the observation that quiescent satellite cells express VCAM-1 and inltrating leukocytes express the specic co-receptor VLA-4 (integrin a4b1). Thus, cellcell interactions may initiate genetic responses that promote regeneration.
Skeletal muscle injury leads to the inux of newly recruited macrophages by 24 h,
which are responsible for the active removal of necrotic tissue and successful muscle
regeneration (Grounds 1987, 1991; Robertson et al. 1993; Bischoff 1997). It has
been demonstrated that human MPCs, released after micro- and macro-injury, can
selectively and specically attract monocytes through the release of a variety of
chemokines (e.g., vascular endothelial growth factor [VEGF]) (Rissanen et al. 2002).
Incidentally, the chemotactic inuence was highest in newly activated MPCs, aided
by close proximity to muscle capillaries (Schmalbruch and Hellhammer 1977),
which then declined towards the time of late differentiation and the formation of
multinucleated myotubes (Chazaud et al. 2003). Others have also shown greater
in vitro MPC proliferation in the presence of primary rat monocytes (Cantini et al.
1995), and superior primary rat and human MPC proliferation and myotube formation in the presence of macrophage-conditioned medium, as compared to a negative
control (Cantini et al. 2002). Additionally, in vivo administration of the macrophageconditioned medium substantially improved regeneration with respect to speed and
volume within rat muscles subjected to tissue ablation (Cantini et al. 2002).
As the monocytes differentiate into macrophages, reciprocal interaction with
MPCs amplies the release of macrophage chemoattractants for additional monocytes and MPCs (Chazaud et al. 2003). It has been implied that the growth factors
released by macrophages (IGF-I and -II, HGF, FGFs, platelet-derived growth factor
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M. Lewis et al.
BB (PDGFBB), epidermal growth factor [EGF], IL-6 (Robertson et al. 1993; Hawke
and Garry 2001)) and involvement with cell adhesion molecules may not only rescue MPCs from apoptosis, but also play similar roles for erythroblasts and neuronal
cells (Meucci et al. 2000; Chazaud et al. 2003).
Within skeletal muscle, broblasts are surrounded by the peri- and endomysium
and are attached to the ECM via integrins (Mackey et al. 2008) enabling the cells to
register and respond to any mechanical stimuli transmitted through the ECM: this
ability has been suggested to be essential for correct broblast functioning (SarasaRenedo and Chiquet 2005). The endomysial collagen is primarily produced by
broblasts, and it has been demonstrated in vitro that broblasts produce factors
that may modify MPC response (Sinanan et al. 2008).
In summary, the muscles of mastication, and especially the masseter muscle, differ
from non-cranial muscles in several important ways. Firstly, the range and variation
of MyHC protein isoforms, and in particular, the persistence of developmental isoforms which can be considered part of the normal adult MyHC isoform population.
Secondly, the presence and location of certain metalloproteinases, especially MMP-9,
adjacent to myobres in normal, healthy craniofacial muscle tissue is seen as
opposed to its presence only in response to disease or injury, and thirdly, differences
exist in the regenerative capability with a suggestion that the masseter muscle may
be less effective at this process compared to somite-derived muscle.
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Chapter 7
Motor Control of Masticatory Muscles

Barry J. Sessle, Limor Avivi-Arber, and Gregory M. Murray
7.1
Introduction
This chapter focuses on the brainstem and higher brain center mechanisms involved
in the execution, initiation, reex regulation, and sensorimotor coordination of the
masticatory musculature. A brief overview is given of masticatory musculoskeletal
biomechanics, but other chapters may be consulted for general aspects of biomechanics related to motor control and for the structural and functional features of
this musculature and its motor units and muscle bers and sensory innervation.
Mastication is a complex motor function that involves the simultaneous bilateral
coordinated activation and/or inactivation of the jaw, tongue and face muscles. Jaw
opening occurs by downward traction of the mandible by the anterior bellies of the
digastric muscles and the mylohyoid muscles and anterior traction of the condyles
by the lateral pterygoid muscles. Jaw closing occurs by activation of the masseter,
temporalis, and medial pterygoid muscles. Jaw protrusion requires activation of
the lateral pterygoid, the anterior bers of the temporalis and the supercial
masseter muscles, and jaw retrusion is brought about by activation of the posterior
bers of the temporalis muscles. During mastication, the tongue muscles (e.g.,
genioglossustongue protrusion; hyoglossustongue depression; styloglossus
tongue retrusion; palatoglossustongue elevation) assist in maneuvering the food
bolus from side to side, and the lip muscles (e.g., orbicularis orisperioral sphincter,
B.J. Sessle (*) L. Avivi-Arber

University of Toronto, 124 Edward Street, Toronto, ON, Canada M5G 1G6
e-mail: barry.sessle@utoronto.ca
G.M. Murray
University of Sydney, Sydney, Australia
111
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zygomaticus majorelevation and retraction of the modiolus) and cheek muscles

(buccinatorsretraction of the modiolus), along with the tongue muscles, assist in
maintaining the food bolus within the mouth on the occlusal table (Dubner et al.
1978; Lang 1995; Miles et al. 2004).
There are unique features of the orofacial motor system that distinguish it from
the spinal motor systems. Moreover, many orofacial movements involve muscles
innervated by several cranial nerves. In view of this and the large number of muscles involved, intricate bilateral motor control is essential to ensure coordinated
and appropriate motor patterning is carried out. This is especially the case for those
motor functions involving the masticatory muscles. Yet, most of the literature on
motor control focuses on limb motor control. Reviews of the topic often completely neglect the motor control mechanisms necessary for masticatory and other
orofacial movements, many of which necessitate complex processing to provide
for the exquisite motor control that is required for these muscles that serve important and diverse functions, some of which are vital for sustaining the life of the
organism.
Each masticatory muscle may be guided in the various motor functions in which
it participates by brainstem motor outputs inuenced by higher brain centers.
Guidance also derives from sensory inputs to its motoneurons that derive from a
large array of different types of receptors. Many of these features are similar to
those in the spinal motor system, but some are associated with tissues unique to the
orofacial region (e.g., tooth, cornea, taste receptors). Some of the muscles are multipennate (e.g., masseter, medial pterygoid) and functionally heterogeneous, and
thus the different compartments of these muscles may contribute differentially to
the various motor functions carried out by each of these muscles, as noted in the
next section.
7.2
Masticatory Musculoskeletal Biomechanics
Musculoskeletal biomechanics as applied to the masticatory system comprise

mechanics of the masticatory muscles themselves (i.e., muscle anatomy including
their attachments and angulations, internal muscle architecture, and activation
patterns) and mechanics of the teeth (including the periodontal ligament), bones and
joints (i.e., material and structural properties) that shape the amount, direction,
force, and rate of the complex orofacial movements. A detailed understanding of the
musculoskeletal biomechanics of this system is important not just for the understanding of the effects of anatomical changes (e.g., tooth modications, reconstructions, implants, surgery) on motor function but also for the diagnosis and management
of musculoskeletal disorders such as temporomandibular disorders (TMD). The following only briey reviews some aspects of musculoskeletal biomechanics as
applied to the human masticatory system. The reader is also referred to more detailed
and comprehensive descriptions (Hannam 1994; Herring 2007; Hannam et al. 2008;
Curtis 2011).
7.2.1
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Masticatory Muscles Mechanics
The generation of mandibular movement is brought about by active jaw muscle

tensions and passive soft tissue tensions. The anatomy of the jaw muscles is extraordinarily complex (e.g., Hannam 1994; Hannam et al. 2008). The motor units within
the masseter, temporalis, and medial pterygoid muscles (the jaw-closing muscles)
are arranged in a highly complex manner within each muscle. For example, masseter
muscle bers on the whole do not run from the zygomatic arch to the ramus but
rather there are small compartments of short bers divided by aponeurotic sheaths
and arranged in a so-called pennate (compartment) manner (Fig. 7.1). Therefore,
when motor units on one side of a compartment contract, forces can be generated at
an angle (the pennation angle) to the long axis of the muscle, with a force vector
(i.e., magnitude and direction of force) at an angle to the force vector that would be
generated if muscle bers passed directly from the zygomatic arch to the ramus
without pennation. These complexities of muscle-ber architecture, together with
selective activation of certain motor units within the muscle, provide a wide range
of directions with which forces can be applied to the jaw and thereby contribute to
the enormous range and sophistication of jaw movements that are possible. When
generating a particular movement of the jaw, the sensorimotor cortical regions that
drive voluntary movements are not organized in terms of specic muscles to activate.
Rather, they send a command signal to activate those motor units, in whatever muscles are available, that are biomechanically best suited to generate the force vector
(i.e., magnitude and direction of force) required for that particular jaw movement
(e.g., Widmer et al. 2003).
7.2.2
Masticatory Motor Function Mechanics
The active and passive tensions mentioned above generate a range of jaw motions
and stresses, strains and forces throughout the various components (e.g., teeth, temporomandibular joints [TMJs], bone) of the masticatory system. Anatomical and
functional studies in experimental animals and humans have documented some of
these variables (e.g., Herring 2007). Because some of these approaches are highly
invasive, mathematical modeling has been used to clarify structurefunction relationships. These models can range from relatively simple 2D static analyses that
tend to focus on peak bite force, to more complex 3D models based on rigid body
mechanics, rigid body meaning that the jaws undergo no deformation. Some models
are becoming very sophisticated (Hannam et al. 2008; Curtis 2011). For example,
Artisynth (http://www.magic.ubc.ca/artisynth/pmwiki.php; Hannam et al. 2008) is
a 3D biomechanical computer simulation that models the vocal tract and upper
airway and is capable of articulatory speech synthesis. The accuracy with which
these models reect normal function, however, is dependent on the sophistication
and range of variables (e.g., muscle size, muscle site, muscle angulation, muscle
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Fig. 7.1 (a) Location of the attachment of the multi-axis force transducer and the axes orientation
relative to the head. (b) Anatomical representation of the jaw-opening muscles (anterior digastric)
and jaw-closing muscles (temporalis, masseter, and medial pterygoid). Masseter muscle compartments can be seen from the lateral and medial views, and the location of the ne-wire recording
sites for each compartment are depicted (adapted from Widmer et al. 2003) (Reprinted with permission from Springer)
115
activity, ligament position, visco-elasticity, skeletal anatomy) that are incorporated

into the models. Once developed, these models can be used to predict force distributions, for example in the TMJ, and rigid body motion. This is an example of forward
dynamics. These models can also be used to study the effects of perturbations to the
system, testing the effect of implants, surgery, prosthetic reconstructions, and the
like. The greater the number of input variables that are based on valid experimental
data, particularly from humans, the more reliable and valid these models will be in
predicting forces at various locations, such as teeth, joints, and effects of perturbations to the system. Musculoskeletal problems also can be solved by inverse dynamics which use body motions and external forces to calculate the muscle forces.
7.3 Types of Motor Functions

Mastication is a semiautomatic orofacial movement under the control of a brainstem
central pattern generator (CPG) that can be modulated by descending inuences
from higher brain centers and also reexively inuenced by inputs from orofacial
somatosensory receptors (Fig. 7.2). Voluntary movements, such as voluntary jaw
opening or voluntary jaw protrusion, are driven by higher centers such as the
primary motor cortex (MI) and the cortical masticatory area (CMA) that can themselves also be modulated by somatosensory inputs to the cortex and brainstem motor
output circuits. Reexes are movements whereby an afferent input to the central
nervous system (CNS) can evoke a reex jaw movement, e.g., biting on a hard
particle during chewing can protectively evoke a jaw-opening response.
Cerebral Cortex
Somatosensory and Motor Areas
Planning, initiation and

modulation of voluntary and
involuntary movements;
Sensory-motor integration;
Motor learning
Thalamus
Basal
ganglia
Sensory-motor
integration;
motor learning
Cerebellum
Other subcortical areas
(e.g., red nucleus, reticular
formation)
Muscle
contraction
Sensory
receptors
Brain stem
Central
Pattern
Generators
Motor V,VII,XII
Involuntary movements
Initiation and modulation of
semiautomatic movements
Sensory V/
Mesencephalic
Fig. 7.2 The principal inputs and outputs to/from face MI and face SI. There are extensive interconnections (excitatory and/or inhibitory) between cortical and subcortical regions, and commissural bers are responsible for bilateral coordination. The Central Pattern Generators provide the
programmed motor output to muscles participating in chewing (the Chewing Center) and swallowing (the Swallow Center). (Adapted from Avivi-Arber et al. 2011b) (Reprinted with permission from Elsevier)
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B.J. Sessle et al.
Most of the masticatory motor functions are cyclic in nature, that is, they are regularly recurring movements. These cyclic jaw movements and other associated facial
and tongue movements that characterize chewing are generated by muscles that are
driven by a program that resides in the brainstem CPGs and which itself can be
modulated by afferent inputs acting through brainstem reex circuits or higher brain
centers. During chewing, there are a wide range of directions and magnitudes of bite
forces between opposing upper and lower teeth and a similarly wide range of directions and magnitudes of forces from the tongue, lips, and cheeks that can be exerted
on the food bolus. This complexity demands highly coordinated processes that, for
example, on the one hand allow for light forces to explore and ascertain the texture
of a foodstuff and on the other hand allow for the generation of the large forces necessary for biting through tough foodstuffs while avoiding self-injury (Lund 1991;
Woda et al. 2006). Thus, there is the need for sophisticated neural circuits that allow
for integration bilaterally of these diverse and complex motor functions and for coordination with other motor functions such as respiration and swallowing. Virtually all
of these functions are not purely motor but indeed are sensorimotor, since they
depend upon or utilize sensory inputs or feedback to initiate or guide them.
Chewing is a motor function learned after birth, distinct from swallowing which
develops in utero. Most mammals are born as suckling and swallowing animals, but
as the infant matures, the rhythmic jaw movements become increasingly under central
control and more sophisticated, engaging to a greater degree other muscle groups that
allow for more renement and the emergence of chewing behavior in the full sense of
the word. The postnatal eruption of the teeth provides important sensory inputs from
periodontal receptors that also assist in the development of masticatory control.
7.4
Neural Processes
There are several features that distinguish orofacial motor functions and their underlying mechanisms from spinal sensorimotor processes and movements (see Sessle
2009). In addition to the number of muscles that may often require bilateral muscle
activities, these distinguishing features include the arrangement of the various sensory
nuclei and motor nuclei into distinct neuronal pools in the brainstem, and unique
aspects of the peripheral and central mechanisms (see below). The orofacial region
receives its sensory and motor nerve supplies from the brainstem. The major sensory
nuclei include the trigeminal (CNV) brainstem sensory nuclear complex (VBSNC)
that receives most of the general somatosensory afferent input from the orofacial
tissues, and the solitary tract nucleus (NTS) that receives visceral afferents (e.g., those
supplying lingual taste buds, and laryngeal and pharyngeal taste buds and mechanoreceptors). The main cranial nerve motor nuclei include the CNV motor nucleus
(Motor CNV) that provides the motor innervation of most jaw muscles, the CNVII
motor nucleus supplying the muscles of facial expression, CNXII motor nucleus
supplying the intrinsic and extrinsic tongue muscles, and the nucleus ambiguus
(CNIX and CNX) that mainly supplies muscles of the palate, larynx, and pharynx.
These brainstem sensorimotor circuits are controlled by other brainstem systems
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(e.g., CPGs) as well as by descending inuences from other subcortical and cortical
areas. The following considers these peripheral and central processes in turn.
7.4.1
Peripheral Mechanisms
The receptors and the afferent inputs involved in motor control of muscles including
the masticatory muscles have largely been covered in other chapters dealing with
spinal sensory or motor functions or specically with orofacial functions and will
not be considered in detail here. The orofacial tissues are characterized by a high
innervation density of exteroceptive, proprioceptive, and nociceptive primary afferent bers, most of which occur in CNV and have their primary afferent cell bodies
in the trigeminal ganglion (CNV ganglion) and project into the brainstem. In addition to perceptual information, they provide the CNS with crucial peripheral
feedback and feedforward information needed for the ne control of rapid and
complex orofacial motor functions (for review, see Dubner et al. 1978; Miles et al.
2004; Lund et al. 2009; Sessle 2009). Jaw-closing muscles have muscle spindles
providing inputs about muscle stretch and length. Of particular importance are the
specialized nerve endings within the skin, mucosa, joints, and periodontium that
act as mechanoreceptors sensitive to deformation of underlying muscles during orofacial movements or of the periodontal ligament during tooth movement thereby
acting as proprioceptors providing information regarding the position and movements of the orofacial muscles and joints. This feature may be particularly important for the control of facial and jaw-opening muscles that in contrast to the other
skeletal muscles, including the jaw-closing muscles, have few or no muscle spindles
(for review, see Dubner et al. 1978; Miles et al. 2004; Paxinos 2004). It is noteworthy that the primary afferent cell bodies of those jaw muscles that do have spindles
(i.e., jaw-closing muscles) occur not in the CNV ganglion but in the CNV mesencephalic nucleus (MesV) within the CNS.
The orofacial region is further characterized by specialized chemoreceptive endings in taste buds that can also affect the patterns of mastication (Neyraud et al.
2005). Small-diameter, slow-conducting primary afferents (e.g., A-delta, C-bers)
with free nerve endings acting as nociceptors or lower-threshold thermoreceptors
also exist within the orofacial tissues and carry into the brainstem nociceptive and
thermosensitive afferent information used for motor control as well as perceptual
processes (for review, see Dubner et al. 1978; Miles et al. 2004; Paxinos 2004).
7.4.2
Brainstem Reflex Processes
As noted above, there are other important sensory and cranial nerve motor nuclei
and these include the NTS, and the CNVII and CNXII motor nuclei and the nucleus
ambiguus. Furthermore, in addition to the VBSNC and NTS, there are other important interneuronal sites such as the inter-trigeminal nucleus, the supra-trigeminal
nucleus, and components of the medial and especially lateral reticular formation that
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lie immediately adjacent to the VBSNC and the NTS. These sites provide some of
the neural circuitry and processing that form the basis for the central programs
(central pattern generators, CPGs) so crucial in the initiation and control of complex
functions such as chewing and swallowing. These regions also provide a neural
substrate allowing for the initiation or modulation of brainstem reexes by receiving and integrating afferent inputs from various orofacial tissues and from other
brainstem or suprabulbar areas, such as afferent inputs, descending controls, and
conscious state. As well as these afferent inputs being capable of evoking brainstem-based reex responses, afferent signals are also relayed from the brainstem to
higher brain centers involved in sensorimotor control of the muscles (Dubner et al.
1978; Murray et al. 2001; Sessle et al. 2005).
7.4.2.1
Brainstem Reflexes
The motoneurons supplying the masticatory muscles receive reex afferent inputs from
free nerve endings as well as the specialized receptors in the orofacial tissues. Thus, the
masticatory neuromuscular system can be inuenced reexively by the somatosensory
inputs into the brainstem from receptors that signal pain, touch, joint position, muscle
stretch or tension, and the like. Through their connections with the previously mentioned interneuronal circuits, these afferent inputs can activate or inhibit the cranial
nerve motoneurons supplying the masticatory musculature. Brainstem circuits also
underlie the autonomic reex changes in heart rate, blood pressure, breathing, and salivation and in more complex behaviors that can be evoked by non-noxious or noxious
stimulation of orofacial tissues. On the basis of these various types of responses, several human behavioral paradigms have been developed in order to study the effects of
orofacial stimuli in humans; these include changes in autonomic functions (e.g., heart
rate, salivation), muscle reexes, and facial expression.
Given the large number of muscles in the orofacial region, and the diversity of
receptors and afferent inputs, the number of reexes is also vast. This applies to the
masticatory muscles as well. For example, mechanical stimulation of the jaw-closing
muscles can result in several jaw reex responses that involve brainstem circuits and
are modulated by afferent and descending inuences. Jaw muscle stretch evokes
myotatic stretch reexes through activation of jaw muscle spindle afferents (Dubner
et al. 1978; Lund and Olsson 1983). As indicated above, the primary afferent cell
bodies of these spindle afferents are located in MesV, and impulses in their central
axons can monosynaptically activate jaw-closing motoneurons in Motor CNV.
Synapses occur on these primary afferent cell bodies, and they and their central
axons have intriguing electrophysiological and neurochemical features that have
recently been reviewed (Lund et al. 2009). The jaw-opening reex and the reex
effects of stimulation of periodontal receptors around the root of the tooth are two
examples of other well-studied jaw reexes. A brief excitatory reex in the jaw
muscles may be elicited under certain conditions, but an inhibitory reex involving
one or more so-called silent periods in the jaw-closing muscles has received
particular attention over the years. This inhibitory reex is usually thought to provide
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a protective or regulatory function, for example bite force, during jaw-closing

movements, and its occurrence and/or duration has been proposed, with little
scientic rigor, as a useful diagnostic tool in certain orofacial pain or motor disorders. However, it is subject to considerable variation because of several interacting
factors. Furthermore, inhibitory periods in the jaw-closing muscles can be induced
by stimulation of different types of receptors in various orofacial tissues other than
periodontal tissues. Reex excitatory or inhibitory effects can also be elicited in
tongue, facial, and other muscles in the orofacial region (Dubner et al. 1978;
Aramideh and De Visser 2002). The jaw reex effects of noxious stimulation of
orofacial tissues have received considerable attention particularly in the last two
decades. Brief high-intensity stimulation can elicit a transient jaw-opening reex, or
transient inhibitory effects in jaw-closing muscles, as noted above. However, the
application of algesic chemicals (e.g., hypertonic saline, capsaicin, glutamate, mustard oil) to the TMJ, muscle, or other orofacial tissues of anesthetized animals can
result in prolonged increases in electromyographic (EMG) activity of both the jawopening and jaw-closing muscles. These effects involve activation of neurons in
subnucleus caudalis or in other components, for example subnucleus oralis of the
VBSNC, as well as several chemical mediators and receptor mechanisms (e.g.,
NMDA, opioids, GABA) in Motor CNV and the interneuronal sites involved (see
Sessle 2006). It has been suggested that the co-contraction of the masticatory muscles may be the mechanism for a splinting effect that has the effect of limiting jaw
movements in pathophysiological conditions affecting deep tissues such as the TMJ
and muscles. Despite these important observations in experimental animals, there is
no consensus on whether the EMG activity of these muscles decreases, increases or
remains unchanged during experimentally induced or clinical orofacial pain in
humans. Inuences from brainstem and higher brain centers involved in stress,
emotion, alertness, sleep, and wakefulness are possible factors that may account for
the disparity in experimental and clinical pain data. Thus, the issue of how pain
interacts with the neuromuscular system is not entirely clear, and some hypotheses
have been proposed to account for the motor effects of pain that are seen clinically.
The Vicious Cycle Theory proposes that pain can lead to muscle hyperactivity and
vice versa, whereas the Pain Adaptation Model proposes that changes in agonist and
antagonist jaw muscles allow the masticatory system to adjust to or adapt to the
painful condition. Most of the limited scientic evidence available favors the latter
concept, but some limits and inconsistencies have been noted not only in the orofacial sensorimotor system (Murray and Peck 2007) but also in the spinal motor
system (for review, van Dieen et al. 2003). In addition, nociceptive activity can
inuence higher brain centers involved in motor control, such as the sensorimotor
cortex, and thereby inuence masticatory muscle function.
7.4.3
Descending Influences
Descending modulatory (i.e., excitatory or inhibitory) inuences from various

cortical and subcortical structures as well as segmental modulatory inuences
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(Dubner et al. 1978; Sessle 2006, 2009) have profound effects on many of the
neurons in the VBSNC or NTS that relay to thalamus or other brain regions
(Fig. 7.2). Because many of these neurons also contribute as interneurons to reex
and other behavioral responses evoked by stimulation of orofacial tissues, responses
can also be regulated by these modulatory inuences on the interneurons or in some
cases, on the motoneurons themselves that are part of the reex circuits. These
descending modulatory inuences include those from the amygdala and other parts
of the limbic system, the lateral hypothalamus, the lateral habenular nucleus, the
basal ganglia, the anterior pretectal nucleus, the red nucleus, the cerebellum, the
sensorimotor cerebral cortex, the cortical premotor and supplementary motor areas
(SMAs), and the cortical masticatory and swallowing areas. It is through these
descending excitatory or inhibitory inuences that the higher brain centers can exert
control over the brainstem processes and activities of motoneurons supplying not
only the masticatory but also all the orofacial musculature, and thereby initiate,
guide or regulate orofacial motor functions. The next sections examine in more
detail these higher brain center inuences and processes.
7.4.4
Subcortical Processes
Several areas in the CNS exert modulatory inuences on motor behavior via direct or
indirect projections to cranial nerve motoneuron pools. The numerous connections
between these areas mean that the neural circuitry involved in the CNS control of
motor function is extensive and complex. Only limited study has been made on these
pathways as they apply to orofacial motor control as compared to limb motor control.
In the case of the brainstem, the descending inputs as well as the afferent inputs
from peripheral receptors access the reex interneurons that project to and modulate
motoneurons in the cranial nerve motor nuclei. Several of these regions also act in
concert to form the neural circuitry of the CPGs for chewing, swallowing, and other
analogous complex motor behaviors (Lund 1991; Jean 2001; Lund et al. 2009).
Most research attention has focused on the CPGs underlying swallowing and especially mastication. For the latter, this CPG (the chewing center) can generate
chewing-like movements independent of orofacial sensory inputs. Nonetheless,
studies in humans and animals indicate that it can utilize these inputs, especially
those from periodontal mechanoreceptors and jaw muscle spindles, in concert with
other brain regions accessing it, to provide for modication and guidance of masticatory movements (Fig. 7.2). The CPG-dependent stereotyped movements typical
of chewing can be varied, and function in an integrated manner with movements of
the cheeks and tongue to allow for repositioning of the food bolus and for alterations
in masticatory force, velocity and jaw displacement as the food is crushed and
manipulated. These features explain how several factors, for example the number of
teeth, food composition and hardness, and bite force, can inuence the masticatory
process and provide for the appropriate reduction of food to a size suitable for swallowing. As part of this process, the CPG can also modulate sensory inputs, such that
121
central control can mask out undesirable perturbations and reexes that might
disrupt the ongoing masticatory process, yet also allow nociceptive reex inputs to
access the masticatory motoneurons and thereby provide protection of the masticatory apparatus. One common example of this process in operation is the interruption
of chewing by the jaw-opening reex elicited by a noxious stimulus such as a sh
bone piercing the oral mucosa. In the case of the CPG for swallowing (the swallow
center), it appears to involve neurons within and adjacent to the NTS. Collectively,
the output of these neurons provides the time-locked, patterned drive to the different
motoneuron pools supplying the muscles that participate in swallowing. While the
swallow CPG neurons are triggered into action by sensory inputs, the CPG is nonetheless relatively insensitive to sensory feedback or descending controls once the
swallow has started. It thus contrasts with chewing which is sensitive to both sensory inputs and CNS controls (Dubner et al. 1978; Jean 2001).
Several higher brain centers directly or indirectly access motoneurons via the
various brainstem interneuronal groups, including the CPGs (for review, see Dubner
et al. 1978; Lund 1991; Sessle 2006, 2009). Many cerebral cortical output pathways
project indirectly to the brainstem via various components of the basal ganglia and
substantia nigra, as well as directly to the brainstem. Orofacial motor decits can
arise after lesions of some of these components. Recordings in basal ganglia neurons (e.g., in putamen and globus pallidus) show activity during orofacial movements such as chewing, and many of these neurons may receive orofacial sensory
inputs. The importance of these structures to orofacial motor control is underscored
by pharmacological studies. For example, there is evidence that abnormal motor
functions, such as those seen in oral dyskinesia and sleep bruxism, may be partly
due to an imbalance in dopamine (by drugs that alter dopamine actions, such as
amphetamines and cocaine) that changes basal ganglia functional activity. As in the
subcortical processes involved in limb motor control, several other neurochemicals,
subcortical structures, and interconnecting circuits are involved in orofacial motor
control. They include acetylcholine, GABA, glutamine, serotonin, vasopressin, catecholamines, and opioids. Brain structures include the hypothalamus, amygdala,
subthalamic nucleus, red nucleus, anterior pretectal nucleus, superior colliculus,
periaqueductal grey, and cerebellum.
7.4.5
Cerebral Cortical Processes
Several areas in the cerebral cortex exert descending inuences on brainstem and
other subcortical regions. Studies utilizing transcranial magnetic stimulation (TMS)
or imaging (e.g., fMRI, PET) in humans have revealed that movements involving
the masticatory muscles may be associated with activation of several cortical areas,
including the face primary motor cortex (face MI), face primary somatosensory area
(face SI), premotor cortex, SMA, CMA, anterior cingulate gyrus and insula (Martin
2009; Avivi-Arber et al. 2011b). Different cortical areas and different patterns of
activation are associated with different types of movements (e.g., chewing vs.
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B.J. Sessle et al.
Fig. 7.3 An example of a face MI neuron that red rhythmically during the jaw-opening phase of
chewing by an awake monkey. (a) Neurons activity in relation to a single masticatory trial. (b)
Neurons activity in relation to 11 masticatory trials aligned to the point of maximum jaw closing
(vertical line in the gure) during the food-preparatory phase. The traces showing movements of the
mandible and the EMG activity of the masseter, genioglossus, and anterior digastric muscles are
derived from averaged data. (c) A neurons phasic activity in relation to 33 rhythmic chewing cycles
aligned to the point of maximum jaw opening (vertical line in the gure) during the rhythmic-chewing
phase, but shown in prolonged time scale. (d) Neurons swallow-related activity by aligning seven
chewing trials to the point of the GG-dened swallow onset (the vertical line shown in (d)). Inset:
the orofacial mechanoreceptive eld of the neuron and the tongue movement direction (arrow)
evoked by ICMS (threshold T for movement, 30 mA) applied at the neuronal recording (adapted
from Yao et al. 2002). (Reprinted with permission from The American Physiological Society)
swallowing vs. clenching or tapping the teeth together), in part reecting whether the
movement does or does not involve evoked sensory inputs that project to and activate the cortical area(s). Intracortical microstimulation (ICMS) and neural recording studies in monkeys and subprimates (e.g., rats) have revealed consistent ndings
(Murray et al. 2001; Yao et al. 2002; Avivi-Arber et al. 2010; Figs. 7.3 and 7.4).
Thus, ICMS can evoke specic movements from specic cortical sites, and the
123
Fig. 7.4 (a, b) Surface views of the cortical sites from which jaw and tongue muscle activities
were evoked by ICMS (60 mA) at AP planes 2.5, 3.0, 3.5 and 4.0 mm anterior to bregma and within
the left cortex of a rat that 1 week earlier had its incisor extracted and a rat that 1 week earlier had
undergone sham extraction. Scale bar = 1 mm. (c) Number of sites from which ICMS (60 mA)
within the left and right face MI and face SI could evoke EMG activity in the left and right anterior
digastric muscles. The left and right anterior digastric muscles had a signicantly larger number of
ICMS sites within the contralateral face MI (ANOVA, Bonferroni: P < 0.0001). Within the left face
MI, the number of right anterior digastric sites was signicantly larger in rats of the extraction
group than in rats of the sham-extraction and naive groups (*ANOVA: P < 0.0004, Bonferroni:
P < 0.0015 and 0.0016, respectively) (AP anterior-posterior; LAD left anterior digastric; RAD right
anterior digastric; MI primary motor cortex; R right face MI; L left face MI; ICMS intracortical
microstimulation) (adapted from Avivi-Arber et al. 2010). (Reprinted with permission from John
Wiley and Sons)
pattern of some of these evoked movements, for example mastication, may vary
between sites. Furthermore, the ICMS studies have demonstrated that each orofacial muscle or movement is represented multiple times within face MI, indicating
124
B.J. Sessle et al.
that each output zone of face MI controls one of the many contextual functions in
which a muscle participates. This multiple representation includes ipsilateral and/or
contralateral elemental movements, for example jaw-opening, tongue protrusion, or
facial twitch, as well as complex activities such as chewing and swallowing which
can be evoked by ICMS not only from the deep and principal parts of the classical
CMA, lateral to face MI, but also from within face MI and even within the face SI
in the monkey, rabbit, and cat. Furthermore, selective cold block or ablation of each
of these regions can disrupt chewing and swallowing to varying degrees, indicating
that each may be involved differentially in the production and patterning of chewing
and swallowing. This includes the coordination of the tongue, facial, and jaw movements that is necessary for the proper ingestion and transport of food or liquid
(Hiraba et al. 1997, 2007; Murray et al. 2001; Lund et al. 2009; Sessle 2009).
It is also noteworthy that ICMS-evoked orofacial movements have been observed
for the SMA, an area which, like premotor cortex, has been implicated in the preparation for movement. However, little information is available on the role of this region
in orofacial motor control except for recent studies indicating that premotor cortex as
well as other cortical areas (e.g., parietal cortex) may be involved in the preparation
and planning for ingestion, visuomotor control, and perhaps even in cognitive functions related to the understanding and communication of ingestive motor actions,
facial recognition, and other complex behaviors involving the orofacial region.
Ablation or cold block of the monkeys face MI or SI also disrupts the animals
ability to perform a learned tongue task (Murray et al. 2001; Sessle et al. 2007; AviviArber et al. 2011b) and lesioning of the cats SI, MI or masticatory cortex disrupts
masticatory movements (Hiraba and Sato 2005a, b). Interestingly, face MI or SI ablation or block causes much less disruption of a biting task. This is consistent with
ICMS ndings and single neuron recordings showing a very limited representation
of jaw closing in face MI. Single neuron recordings in monkeys or subprimates also
have revealed that many face MI and SI neurons discharge in relation to chewing or
swallowing (e.g., Fig. 7.3). However, most also discharge in association with more
elemental movements, with some being active in relation to jaw movements, especially jaw opening, and many others being active in relation to tongue movements.
These ndings are consistent with the above ICMS ndings. Although single neuron
recordings in face MI also have revealed that some neurons are active during preparation for movement, many more neurons in premotor areas appear to show this
feature. This is consistent with other studies that have placed more emphasis on
cortical and subcortical regions in addition to MI in mechanisms involved in
motor planning and preparation (Murray et al. 2001; Sessle et al. 2007; Avivi-Arber
et al. 2011b).
The neuronal recording and ablation ndings outlined above have underscored
the importance of the somatosensory cortex as well as the motor cortex in the ne
motor control of orofacial movements. The face SI can inuence orofacial movements by its projections to face MI and other cortical areas and to subcortical regions
such as the VBSNC, NTS, reticular formation, and the cranial nerve motor nuclei
(Murray et al. 2001; Sessle et al. 2007; Avivi-Arber et al. 2011b). The face SI has a
somatotopically arranged array of somatosensory inputs which are predominantly
125
from facial skin and intraoral structures but may also include some inputs from deep
tissues, such as muscles. The face MI and CMA also receive somatosensory inputs.
While limb MI neurons receive inputs primarily from deep tissues, face MI neurons
receive inputs especially from supercial tissues of the face, mouth, and jaws, such
as skin, mucosa, and teeth (Hatanaka et al. 2005; Henry and Catania 2006; Kaas
et al. 2006; Iyengar et al. 2007). Although most face MI neurons receive somatosensory inputs from the same orofacial areas within which movement is evoked by
ICMS applied to the same neuronal recording site receiving the somatosensory
inputs, a substantial number of face MI neurons receive somatosensory inputs from
distant orofacial regions that have no close spatial relation with the ICMS-evoked
movement area. In addition, a well-described feature of neurons not only in face SI,
but also face MI and CMA, is that these neurons receive bilateral inputs from the
orofacial tissues. This organization of somatosensory inputs to face MI is probably
related to the need for extensive somatosensory feedback from wide bilateral peripheral orofacial areas for the ne control, coordination, and modulation of the bilateral
orofacial muscle activities during orofacial movements (Murray et al. 2001). These
bilateral inputs may be used by CMA, for example, to help guide masticatoryrelated movements. Face MI may also utilize its orofacial afferent inputs for generating and regulating orofacial movements in order to rene ongoing cortical motor
activity and shape the appropriate motor response. For example, this is seen in the
control of voluntary orofacial movements such as the manipulation of the food
bolus after it is placed in the mouth, since many face MI neurons are active during
the food preparatory phase. Sensory inputs from the orofacial regions presumably
are utilized by these MI neurons for this purpose. Pain may also inuence masticatory muscle function by actions on the sensorimotor cortex as will be discussed in
the following section.
Face MI and SI rely on orofacial afferent inputs to guide, correct, and control
movement by the use of sensory cues prior to movement and by using sensory
information generated during movement. These processes may involve intracortical
processing, cortical gating, and transfer of somatosensory information, as well as
corticofugal projections to subcortical sites that modulate and select somatosensory
information ascending through subcortical relay neurons in the brainstem, such as
VBSNC, NTS, and thalamus. These inputs also play critical roles in motor learning
and in the motor adjustments or adaptations that take place after a change in the
peripheral environment. This brings us to a consideration of neuroplasticity, especially as it applies to the cortical mechanisms of orofacial motor control.
7.5
Cortical Neuroplasticity and Control

of Masticatory Muscles
Neuroplasticity is the capacity of the nervous system in general to alter its structure
(e.g., synaptogenesis, dendritic branching) and function (e.g., excitability, longterm depression or potentiation) throughout life (Ebner 2005; Barnes and Finnerty
126
B.J. Sessle et al.
2010; Plowman et al. 2010). Neuroplasticity induced by altered afferent inputs has
been well documented in the VBSNC in relation to the central processing of tactile
and nociceptive information from the orofacial region (Sessle 2006). Numerous
studies also have shown that both SI and MI undergo neuroplastic changes following manipulations of afferent inputs or in association with learning of novel motor
skills. While nearly all these studies have focused on SI and MI representing the
limbs and the facial vibrissae in rodents, as well as subcortical regions such as the
basal ganglia and thalamus, there is some recent evidence that comparable neuroplastic changes may occur in face SI and face MI representing the oral tissues
(Avivi-Arber et al. 2010, 2011b). For example, dental extraction can lead to a loss
of dental representation and an enhanced representation of adjacent orofacial structures within face SI of the mole rat (Henry et al. 2005). Alteration of the dental
occlusion by trimming or extraction can be associated with modications of the jaw
and tongue motor representation within face MI and face SI (Fig. 7.4) (Sessle et al.
2007; Avivi-Arber et al. 2010, 2011a). Lingual nerve transection has been associated with a signicantly decreased MI representation of tongue protrusion after 12
weeks, and after 34 weeks with a signicantly increased tongue-protrusion representation (Adachi et al. 2007). Noteworthy is that extraction of a rat mandibular
incisor results in an increased representation of jaw-opening muscle along with
increased overlapping representations of the jaw-opening and tongue-protrusive
muscles within face MI and face SI (Fig. 7.4) (Avivi-Arber et al. 2010). An increased
overlapping of motor representations within the limb MI is one of the most consistent ndings associated with limb motor skill training, and is considered crucial for
coordinating movements involved in the acquisition of novel limb motor skills (see
Nudo et al. 1996). Modication to the dental occlusion in humans and rodents
induced by dental extraction or trimming affects muscle activities and patterns of
jaw movements during mastication (Hannam et al. 1977; Miehe et al. 1999). In
addition, adaptation to an altered pattern of mastication would require repetition of
novel motor movements somewhat analogous to learning a novel motor skill. Thus,
it is possible that the reorganization of motor representations within face MI and
face SI, including co-activation of jaw and tongue muscles, plays a role in motor
adaptation to an altered oral state.
Indeed, recent studies in monkeys and humans suggest a role for face MI neuroplasticity in orofacial motor skill acquisition. In rats, tongue force training has been
associated with decreased thresholds of ICMS-evoked tongue motor response but
with no signicant change in the tongue motor representation within face MI
(Guggenmos et al. 2009). In awake monkeys, training in a novel tongue-protrusion
task results in a signicantly increased proportion of ICMS sites representing tongueprotrusion movement, a decreased proportion of ICMS sites representing lateral
tongue movement, and signicantly increased proportions of neurons in MI and SI
showing tongue protrusion-related activity and lingual mechanosensory inputs
(Sessle et al. 2007). It is interesting to note that analogous changes were not apparent in the CMA/swallow cortical areas, suggesting a differential expression of taskrelated neuroplasticity within different cortical areas that are involved in the control
of orofacial motor functions. Analogous studies in humans using TMS have shown
127
that training in a novel tongue-protrusion task results in a signicantly improved

successful task performance in 1 week, but even as quickly as within 15 min. This
has been associated with a signicantly increased tongue motor representation and/
or decreased threshold of TMS-evoked tongue responses within the face MI
(Svensson et al. 2006; Boudreau et al. 2007; Zhang et al. 2010). While tongue MI
changes may reect changes in motor experience consistent with the concept of
use-dependent neuroplasticity (Nudo et al. 1996), the close correlation between
successful tongue task performance and the rapid onset of tongue MI neuroplasticity suggests that the tongue MI changes are necessary for achieving the improved
motor performance of the learned novel task consistent with the principle of use it
and improve it (Kleim and Jones 2008).
Many dental procedures can be associated with postoperative acute pain that
sometimes develops into a chronic pain condition. Clinical practice indicates that
pain conditions can modify patients orofacial motor behaviors and jeopardize their
motor performance (Svensson et al. 2004; Sessle 2006, 2010; Sessle et al. 2008).
While acute pain is commonly known to evoke protective brainstem reex circuits,
intraoral pain induced by injection of the algesic glutamate into the tongue in rats
and application of capsaicin to the tongue in healthy humans has been associated
with decreased face MI excitability (Boudreau et al. 2007; Adachi et al. 2008), consistent with the Pain Adaptation Model, whereby decreased face MI excitability
and limitation of movements serve as a protective mechanism of the orofacial tissues/muscles (Lund et al. 1991; Murray and Peck 2007). Chronic pain conditions,
such as TMD in humans, have been associated with face SI and face MI neuroplasticity (Moayedi et al. 2011; Weissman-Fogel et al. 2011). However, it is not clear
whether the cortical changes predispose subjects to develop chronic pain or whether
they are adaptive, or maladaptive, responses to the pain condition. Neuroplasticity
within SI and MI also is associated with behavioral maladaptation and sensorimotor
dysfunctions such as embouchure dystonia in woodwind and brass musicians, or
dysphagia, dysarthria, or impaired mastication following CNS injuries such as stroke
(Sessle et al. 2007; Martin 2009; Haslinger et al. 2010).
7.6
Conclusions
In summary, the ndings reviewed in this chapter underscore the crucial role played
by face sensorimotor cortex in sensorimotor integration and control of the masticatory muscles and its remarkable capacity for neuroplasticity. Neurophysiological
changes occur within the face SI and face MI when the oral environment is altered,
and raise the possibility that such cortical changes reect adaptive mechanisms that
may be crucial in determining how well a person adapts to oral alterations, such as
dentures, implants, pain, and/or nerve damage. Yet, the cortical plasticity also may
reect changes that can lead to the susceptibility of healthy subjects to develop a
variety of chronic sensorimotor dysfunctional conditions. They also suggest that
there may be cortical templates for a variety of familiar, learned orofacial motor
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B.J. Sessle et al.
activities. Speech is one such activity involving the masticatory muscles. While its
consideration is beyond the scope of this chapter, cortical mechanisms are clearly
crucial to the ne control and coordination of the various muscles, including masticatory muscles, participating in voice production and articulation of speech sounds,
both when a child is learning to speak and once speech has been learned. In addition, since alteration in somatosensory inputs to the CNS has been associated with
neuroplasticity within other cortical and subcortical regions (e.g., brainstem)
involved in the control of masticatory muscles (Kis et al. 2004; Sessle 2006), it is
possible that some of the neuroplastic changes observed within face MI and face SI
are secondary to changes manifested within the other cortical or subcortical
regions.
Acknowledgements Studies of the authors were supported by: grant DE04786 of the US National
Institute of Dental and Craniofacial Research; CIHR grant MT-4918, the Australian Dental
Research Foundation, Inc.; and NHMRC of Australia, grant #512309. BJS is the recipient of a
Canada Research Chair.
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Chapter 8
Masticatory Muscle Response to Neuromuscular

Diseases and Specific Pathologies
Sadie L. Hebert, Christy L. Willoughby, Francisco H. Andrade,
and Linda K. McLoon
8.1
Introduction
The masticatory muscles are a complex bilateral set of four muscles (masseter,
temporalis, medial and lateral pterygoid muscles) that control movement of the
temporomandibular joint, between the maxillae and the only moveable bone in the
human skull, the mandible. These muscles are capable of fine-tuned gradients of
force and movement, as they are required for production of large forces often needed
in crushing of hard food items, and finer movements needed for chewing and human
speech production. As with other craniofacial muscles, the masticatory muscles
have unique phenotypes distinct from limb muscle due to their specialized function
and unique developmental origin. Their characteristics include small myofiber
cross-sectional area, fiber-type specific grouping (Eriksson and Thornell 1983), and
a wide range of myosins that allow for a spectrum of force and contraction speeds
(Stl et al. 1994; Korfage et al. 2000).
The masticatory muscles distinct development makes them susceptible to a host
of developmental anomalies. In contrast with other craniofacial muscles such as the
extraocular muscles and laryngeal muscles, the masticatory muscles are not as
robustly spared in many skeletal muscle diseases, with relatively complete sparing in
only two conditions that have thus far been reported: spinocerebellar ataxia (SCA)
S.L. Hebert, Ph.D. (*) C.L. Willoughby
Departments of Ophthalmology and Neuroscience, University of Minnesota,
e-mail: sjhebert@umn.edu
F.H. Andrade, Ph.D.
Department of Physiology, University of Kentucky, 800 Rose Street,
Lexington, KY 40536-0298, USA
L.K. McLoon, Ph.D.
131
S.L. Hebert et al.
132
type 3 and critical illness myopathy. However, these muscles do not seem as resistant
to pathology as other craniofacial muscles, such as Duchenne muscular dystrophy
(DMD) or amyotrophic lateral sclerosis (ALS). They are also vulnerable to functionspecific pathology. The high forces and impact produced during chewing make the
masticatory muscles prone to pathology related to these high stresses and impact.
Further, masticatory muscles are adaptable, and so their phenotype and pathology is
influenced by external factors such as stress, dentition, and diet, as well as to changes
in temporomandibular joint and respiratory function.
8.2
Developmental Anomalies
The masticatory muscles develop from cranial mesoderm of the first pharyngeal
arch. The core of each pharyngeal arch is comprised of mesodermal and neural crest
cells. Proper development of the masticatory muscles is dependent on the specific
migration and interaction between these two cell types. Syndromes of the first pharyngeal arch are typically caused by either improper migration or development of
mesodermal or cranial neural crest cells (Kapur et al. 2008; Passos-Bueno et al.
2009; Heude et al. 2011; Johnson et al. 2011).
Hemifacial microsomia, a syndrome of the first pharyngeal arch, encompasses a
wide variety of phenotypes including defects of the masticatory muscles, jaw, external ear, as well as microphthalmia. As a result, this syndrome is also referred to by
a multitude of namesGoldenharGorlin syndrome, first arch syndrome, lateral
facial dysplasia, unilateral craniofacial microsomia, otomandibular dysostosis,
oculoauriculovertebral dysplasia, auriculo-branchiogenic dysplasia, and oculoauriculovertebral spectrum. Patients with hemifacial microsomia may display defects
on one or both sides of the face.
The defects of the masticatory muscles differ widely across patients with hemifacial microsomia. The affected side(s) of the face in these patients can exhibit reduced
size or complete absence of the masticatory muscles. Typically, the masseter, temporalis, and medial and lateral pterygoids are hypoplastic and show reduced activity on
the affected side(s) though in some cases the masseter and temporalis are completely
absent (Moss and James 1984; Kapur et al. 2008; Heude et al. 2011). While the exact
cause of hemifacial microsomia is not currently known, it has been hypothesized to
be due to a defect in the cranial neural crest cells (Heude et al. 2011).
8.3
Sparing in Skeletal Muscle Disease
The masticatory muscles are completely spared in very few skeletal muscle diseases.
Masseter function is spared in some forms of SCA, but not in others. Patients with
SCA type 3 display a bilaterally normal masseter reflex response, while patients
with SCA type 2 have an abnormal masseter reflex (Garcia et al. 2009; AlvarezParadelo et al. 2011). The preferential sparing of masseter in certain subtypes of
8 Masticatory Muscle Response to Neuromuscular Diseases and Specific Pathologies
133
SCA indicates that masseter reflex could be a useful diagnostic tool in distinguishing between different subtypes of SCA.
Most cranial skeletal muscles are also spared or less affected in critical illness
myopathyan acute acquired myopathy in critically ill patients (Larsson 2008). The
limb and trunk muscles become extremely weak and undergo atrophy in critical illness myopathy, and 80% of the patients who develop this condition can display persistent quadriplegia and generalized weakness after a month-long ICU stay. Masseter,
along with other craniofacial muscles, is functionally and morphologically spared
(Aare et al. 2011). While the mechanism is unknown, the difference between the
retention of normal morphology and function in masseter muscle compared to the
significant decrease in muscle size and function limb muscle is quite striking.
Sparing of masticatory muscles in DMD and ALS presents a more complex picture, in contrast to the clearly demonstrable sparing in the extraocular and laryngeal
muscles. In ALS with primary lower motor neuron involvement, an electromyographic (EMG) study showed that a relatively high percentage of patients showed
evidence of motor unit potential (MUP) reinnervation in their masseter muscles
despite no clinical evidence of involvement (Preston et al. 1997). However, it was
also noted that evidence for active denervation in the masseter was seen only in a
few patients, while this was relatively common in the tongue muscles examined.
A similar story is seen in the analysis of masticatory muscles in DMD patients (see
below). It appears that in the continuum of muscle phenotypes, the masticatory
muscles are closer to the extraocular and laryngeal muscles than to limb muscles in
their morphologic and functional sparing in these two diseases, but they are not
completely and unequivocally spared from signs of degenerative changes.
8.4
8.4.1
Masticatory Muscle Specific Diseases/Conditions

Primary Pathology
The masticatory muscles as a group are susceptible to a greater number of skeletal

muscle diseases than extraocular or laryngeal muscles. The disease profile of these
muscles in DMD is illustrative of these differences. During the disease course of
DMD, both masseter and temporalis muscles show evidence of pathological
changes, with increased numbers of myofibers with centralized nuclei and some
increased fibrosis, although not as significant as that seen in limb muscles (Spassov
et al. 2010). Other studies have shown that compared to diaphragm or limb skeletal
muscle, the pathological changes in masseter are more limited (Muller et al. 2001).
In human DMD patients, however, it is clear that as the disease progresses there is
a significant loss in masticatory muscle force with resultant changes in orofacial
anatomy and function (Kiliaridis and Katsaros 1998; Botteron et al. 2009).
Other diseases of limb skeletal muscle directly involve the masticatory muscles
in the early stages of the disease. While the initial phase of myasthenia gravisinduced muscle weakness occurs in the extraocular muscles, the masticatory muscles show an early involvement in the course of the disease (Yarom et al. 2005).
S.L. Hebert et al.
134
This early development of weakness, particularly in jaw-closing muscles, can be

diagnostic of the presence of myasthenia gravis in human patients (Pal and Sanyal
2011). Comparative weakness in the strength of jaw-opening muscles was seen to
correlate with patients suffering from myositis (Pal and Sanyal 2011). These observations suggest that examination of masticatory muscle force changes could aid in
the diagnosis of muscle pathologic processes in many patients. Patients with bulbar
myasthenia gravis (characterized by weakness of craniofacial muscles innervated
by the lower brainstem) have poor masticatory performance (Weijnen et al. 2002).
Some patients with severe myasthenia gravis have to manually assist the lower jaws
during meals and may have significant weight loss.
A recent study examined orofacial function in Parkinsons disease patients, and
these patients all were seen to have impaired mastication and jaw-opening strength,
and these impairments worsened with disease progression (Bakke et al. 2011).
While other examples of disease involvement may exist, few studies examining the
specific involvement of the muscles of mastication have been performed.
8.4.2
Conditions Secondary to Other Craniofacial

and Systemic Problems
As discussed by Sessle et al. (see Chap. 7), the masticatory muscles generate high
forces during chewing, imposing mechanical stress on the teeth, and the maxillary
and mandibular bones, including the temporomandibular joint. In addition, diet,
stress, and other external factors can cause significant alterations in the masticatory
muscles. Masticatory muscle pain is a rather common symptom resulting from
systemic and local muscle disorders, both neurovascular (e.g., migraines) and neuropathic (e.g., trigeminal neuralgias), and typically is accompanied by other symptoms such as fatigability, stiffness, and weakness (Benoliel and Sharav 2010). One
common cause is bruxism, a condition characterized by involuntary grinding or
clenching of teeth. When it occurs at night, it is called sleep bruxism, and it is considered a sleep disorder. If bruxism is frequent and severe enough, it causes headache, localized masticatory muscle tenderness, temporomandibular pain, and
damaged teeth (Manfredini and Lobbezoo 2010). On the other hand, trismus is the
inability to fully open the mouth because of mechanical impediments (such as
temporomandibular joint damage or inflammation, or mandibular abscesses), drug
use, infections (tetanus is a classical example), or masticatory muscle diseases.
Oromandibular dystonia may cause painful bruxism and trismus; as with other focal
dystonias, it can be treated by botulinum toxin injections (Bhidayasiri et al. 2006).
8.4.3
Aging
As a group, craniofacial muscles are spared in aging as compared to limb muscle.

The extent to which masticatory muscles alter as they age is understudied, and
135
analysis is complicated by confounding factors in an aging population, including

decreased nutrition and altered hormones, and aging of joints and teeth (Hatch et al.
2001). Studies suggest that masticatory muscles undergo changes in myosin composition and synapse remodeling, but the extent to which this impacts the functioning of the muscles themselves is unclear.
The masticatory muscles have anatomically distinct regions, and age-related
changes are often region-specific. The superficial and posterior regions of masticatory muscles are primarily composed of fast myofibers in order to generate the
quick force needed when biting. The deep anterior aspects of the muscles contain
more slow-type motor units, which likely allow for fine control of muscle force for
chewing and biting behaviors. In the aging masticatory muscles, pronounced phenotypical changes occur which includes changes in fiber type and myosin heavy
chain (MyHC) isoform composition. These changes are muscle and region specific.
The masseter muscle has a large number of slow myofibers containing MyHC type 1.
With aging, myofibers expressing the fast MyHC isoforms increase in number with
a proportionate loss of myofibers expressing the slow MyHC isoform. This is interesting and contrasts with aging limb muscle, e.g., the biceps brachii, which shows a
shift towards a slower phenotype with aging (Monemi et al. 1999a, b). Further, aged
masseter muscle increases the expression of fetal MyHC and hybrid fibers which
co-express more than one MyHC isoform (Monemi et al. 1996, 1999a). In the pterygoids, a similar trend occurs. The pterygoids do not have many fibers that are solely
fast and express MyHC type IIA, but the number increases significantly in aging
muscle (Monemi et al. 2000). In addition to changes in MyHC isoform expression,
cross-sectional area of the masticatory muscles may also decrease with aging
(Newton et al. 1987; Monemi et al. 1999b). It is unknown if the changes in MyHC
isoform content are due to re-innervation by other motor neurons or due to changes
in the activity pattern of the original innervating motor neurons.
Animal studies have suggested that changes may occur in the innervation itself.
The nerve innervating the masseter in aged cats has decreased axon diameters and
disrupted myelin, which corresponds to a decreased velocity of action potentials
(Chase et al. 1992). Aged mice also show decreased axon diameter and nerve terminal areas (Elkerdany and Fahim 1993). Specific changes are seen in the neuromuscular junctions of aged mice, including nerve terminal area, perimeter, and length
decreases, while branching of the nerve increases. These changes suggest increased
degeneration and regeneration of the nerve terminals in aging masticatory muscles
in these rodents.
How the potential changes in nerve and myofiber phenotype potentially correlate
with changes in use of the masticatory muscles with aging is unclear. Many studies
have demonstrated that elderly adults do not lose masticatory function with age
(Hatch et al. 2001) and maintain adaptability of their muscles (Peyron et al. 2004).
Bite force decreases with aging (Bakke et al. 1990; Hatch et al. 2001), but could be
due to other components of the masticatory system. The literature is mixed on this
issue. For example, EMG activity changes in aged masticatory muscles. The transition from adult to elderly may show no (Peyron et al. 2004) or only a slight effect in
masticatory muscle EMG values (Ceclio et al. 2010). Other studies have shown
S.L. Hebert et al.
136
that EMG values in the masseter and temporalis may be lower in the elderly only
while chewing hard but not soft foods (Galo et al. 2007). When the contraction
characteristics of the aged anterior deep masseter muscle from aged rats were
directly assessed in vitro, no change in muscle weight nor optimal length for contraction was seen (Norton et al. 2001). Additionally, they found no change in isometric tetanic tension, contraction time, half-relaxation time, and twitch-to-tetanus
ratio. In comparison with the EMG data, this suggests that the masseter muscle may
retain robust function, and that EMG recordings may be complicated by the variance in the human population and other components of the masticatory system.
Further studies are needed to investigate the extent aging influences the properties of the masticatory muscles, as only a few labs utilize animal models to investigate potential mechanisms for aging related changes. Further research is needed to
clarify how aging may alter the properties of masticatory muscles, as well as delineate how other components of aging influence the muscles performance. Such
research could allow the development of new approaches to improve masticatory
function in aging populations.
8.5
Conclusions
As is clear from these studies, the masticatory muscles represent a unique set of
skeletal muscles. Their pattern of susceptibility or sparing in skeletal muscle
pathology is distinct from trunk and limb muscles, which may be due to their separate developmental origin and their unique phenotype and physiological role.
Pathology and treatment in other muscle groups cannot necessarily be generalized
to the masticatory muscles because of these phenotypic differences in function.
Continued study of diseases that might spare or involve the masticatory muscles is
essential to both enrich our general knowledge of skeletal muscle physiology, as
well as allow the maintenance of patient masticatory function in both disease and
aging in the future.
Acknowledgements Supported by grants T32DE007288 from NIDCR (SLH) and T32 AR007612
from NIAMSD (CLW).
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Part V
Laryngeal and Pharyngeal Muscles
Chapter 9
Structure and Function of the Laryngeal

and Pharyngeal Muscles
Lisa A. Vinney and Nadine P. Connor
The muscles of the pharynx and larynx subserve critical airway, deglutitive and
communication functions. The laryngeal muscles protect the lower airway from
invasion and allow voice production for the purposes of communication. The muscles of the pharynx serve deglutitive functions by creating appropriate pressures to
receive and propel a bolus and to shape the airway to modulate resonance during
voice and speech production. Thus, the laryngeal and pharyngeal muscles are critically important to survival and to communication. The structure and function of
these muscles are summarized in Table 9.1. A subset of these muscles will be discussed in this chapter as related to voice, swallowing, and airway functions.
Laryngeal and pharyngeal skeletal muscles, albeit similar at a conceptual level to
skeletal muscles found elsewhere in the body, have important structural and functional differences that will be described in this chapter. For example, there is evidence that some of the muscles listed in Table 9.1 may be structured to offer
biologically important, hard-wired neuromuscular redundancies, such as low innervation ratios and multiple innervations to provide a stable foundation for the critical
life-sustaining functions they subserve (Feinstein et al. 1955; Faaborg-Andersen
1957; Palmer 1989; Perie et al. 1997). The large body of knowledge found in the
literature concerning skeletal muscles in the limbs will not provide a specic understanding of the muscles of the pharynx and larynx. Unfortunately, laryngeal and
pharyngeal muscles have been relatively understudied until recently compared with
other muscles. Although there are glaring gaps in knowledge related to laryngeal
and pharyngeal muscles, currently available information points to their unique characteristics especially regarding muscle ber type, innervation, distribution of neuromuscular junctions (NMJs), and mitochondrial density. Thus, this chapter will
integrate the established information regarding the unique structure and function of
these muscle systems.
L.A. Vinney, M.S. N.P. Connor, Ph.D. (*)
Departments of Communicative Disorders and Surgery, University of Wisconsin-Madison,
600 Highland Avenue K4/711, Madison, WI 53792, USA
e-mail: connor@surgery.wisc.edu
141
142
L.A. Vinney and N.P. Connor
Table 9.1 Muscles of the larynx and pharynx

Muscles
Function
Larynx (extrinsic)
Suprahyoid muscles (above hyoid bone)
Digastric (anterior and posterior bellies)
Raises hyoid bone and pulls anteriorly or posteriorly; assists in depressing lower jaw when hyoid
is xed
Stylohyoid
Elevates hyoid bone and base of tongue
Geniohyoid
Elevates tongue and hyoid; draws both forward
when mandible is xed
Infrahyoid muscles (below hyoid bone)
Thyrohyoid
Elevates larynx by decreasing distance between
thyroid cartilage and hyoid bone via depression
of hyoid or elevation of thyroid
Sternohyoid
Depresses hyoid
Omohyoid (inferior and anterior bellies)
Depresses and pulls back on hyoid
Sternothyroid
Draws thyroid cartilage downward; may increase
pharyngeal size by drawing larynx down/
forward
Larynx (intrinsic)
Thyroarytenoid
Lateral cricoarytenoid
Posterior cricoarytenoid
Interarytenoids (transverse and oblique)
Cricothyroid
Pharynx
Superior constrictor
Middle constrictor
Inferior constrictor
Mylohyoid
Relaxes vocal folds and assists in glottic closure

when unopposed; will increase vocal fold
tension when opposed by other intrinsic muscles
Rotates muscular processes of arytenoids forward
and inward to adduct membranous portion of
vocal folds
Abducts vocal folds by pulling muscular processes
of the arytenoids posterolaterally
Adduct cartilaginous portion of vocal folds by
drawing arytenoids together
Increases distance from thyroid cartilage and vocal
processes of arytenoids to elongate and increase
longitudinal tension of vocal folds; generally
results in increased vocal pitch
Narrows pharyngeal cavity by anterior movement
of posterior pharyngeal wall and anterior and
inward movement of lateral pharyngeal wall;
sometimes thought of as a cluster of four
individual muscles including pterygopharyngeus, buccopharyngeus, mylopharyngeus, and
glossopharyngeus
Narrows pharyngeal cavity by anterior movement
of posterior pharyngeal wall and anterior and
inward movement of lateral pharyngeal wall
Narrows lower pharynx by anterior movement of
lower posterior pharyngeal wall and anterior and
inward movement of lateral pharyngeal wall;
contains thyropharyngeus and cricopharyngeus
Elevates hyoid and pulls it forward
(continued)
Structure and Function of the Laryngeal and Pharyngeal Muscles
Table 9.1 (continued)

Muscles
Cricopharyngeus
Thyropharyngeus
Levator veli palatini
Tensor veli palatine
Stylopharyngeus
Palatopharyngeus
Salpingopharyngeus
9.1
143
Function
Relaxes to allow esophageal opening and transfer of
food or liquid from hypopharynx to esophagus
Serves to propel food bolus downward during
swallowing
Elevates/retracts soft palate in order to seal off
nasopharynx from oropharynx; prevents nasal
regurgitation
Tenses/raises soft palate in order to seal off
nasopharynx from oropharynx; prevents nasal
regurgitation; assists in opening Eustachian tube
during swallowing and yawning
Elevates larynx; pulls pharyngeal wall laterally
resulting in widening of pharyngeal lumen
Pulls lateral pharyngeal wall up and in to narrow
and elevate pharynx; shuts off nasopharynx
Decreases pharyngeal width by elevating and
pulling lateral wall of pharynx posteriorly
Intrinsic Muscles of the Larynx
The intrinsic laryngeal muscles are vital to airway protection, breathing, and phonation.
These muscles can be classied by function into the adductor muscles and one
abductor (see Table 9.1). Each intrinsic muscle has specic functional properties
that allow it to produce the necessary laryngeal movements to serve airway and
phonatory functions. The intrinsic laryngeal muscles work in concert and display
specic movement patterns to allow for phonatory function, airway protection during
deglutition, and appropriate breathing patterns during both sleep and wakefulness.
9.1.1
Role of Intrinsic Laryngeal Muscles in Phonation
The intrinsic muscles of the larynx produce highly precise movements for phonation, breathing, and airway protection. The intrinsic laryngeal muscles are shown in
Fig. 9.1 in a canine larynx. The adductor muscles consist of the paired thyroarytenoid
muscles (TA), the paired lateral cricoarytenoid (LCA) muscles, the interarytenoid
muscles (IA), and the paired cricothyroid muscles (CT) that serves to elongate the
vocal folds in the elevation of vocal pitch. These muscles are generally rapidly contracting, but there is some variation in muscle ber types across the intrinsic muscles
that is discussed in greater detail below. The posterior cricoarytenoid muscle (PCA)
is an abductor. All of the intrinic muscles of the larynx, with the exception of the
cricothyroid muscle (CT) are innervated by the recurrent laryngeal nerve of the
144
Fig. 9.1 Posterior view of canine larynx showing interarytenoid (IA) and posterior cricoarytenoid
(PCA) muscles. Cricoid (CrC), thyroid (TC), and arytenoid (Ar) cartilages, aryepiglottic (AryF)
folds, epiglottis, and piriform sinuses (PS) are also shown. Photograph courtesy of Dr. Seth Dailey
vagus, the tenth cranial nerve (CNX). The CT is innervated by the external branch
of the superior laryngeal nerve that also originates from the vagus nerve.
The TA muscle makes up the main muscular component of the vocal folds and
contributes to vocal fold adduction and tension. The TA is found immediately deep
to the vibrating laryngeal mucosa of the vocal folds and makes up the bulk of the
vocal fold. Typical divisions of the TA muscles are into a more medial thyrovocalis
(or simply vocalis) muscle and a more lateral thyromuscularis muscle. Other synonymous nomenclature is medial or lateral thyroarytenoid muscles, respectively.
The TA muscle components attach to the laryngeal cartilages for which they are
named and provide tension within the vocal folds during phonation. This tension
affects vocal pitch and may oppose the action of the CT or complement it. Although
it is generally thought that the TA is innervated by the recurrent laryngeal nerve of
the vagus, additional innervation from the external division of the superior laryngeal
nerve was found in one canine study (Nasri et al. 1997). There appears to be more
study of the TA than other intrinsic laryngeal muscles, perhaps due to its important
role in voicing and ease of identication. However, relative to the studies of limb
muscles, the number of TA muscle studies is limited. In a Medline search we
conducted for literature containing a major subject heading of limb muscle
between the years 1980 and May 2011, we obtained 1,217 citations, whereas a
145
similar Medline search using the terms thyroaytenoid muscle for these years
yielded only 285 articles.
The LCA muscle is a vocal fold adductor and contains a large proportion of
rapidly contracting muscle bers in rat, canine, and human (Jung et al. 1999;
Shiotani et al. 1999a, b; Suzuki et al. 2002; Wu et al. 1998). Thus, the idea that
rapidly contracting bers may be necessary for airway protection is supported.
As noted previously, there has not been nearly the study of the LCA as there has
been of the TA (Nagai et al. 2005; Sanders et al. 1993; Shiotani and Flint 1998a;
Shiotani et al. 1999a, b; Jung et al. 1999; Suzuki et al. 2002; Wu et al. 1998).
The interarytenoid muscle (IA) contributes to the adduction of the vocal folds.
The innervation of the transverse and oblique bers of the IA is typically attributed
to the recurrent laryngeal nerve of the vagus. However, its innervations may be distinct from the other laryngeal adductors in that a study of the human larynx reported
that the IA had motor innervation from the internal branch of the superior laryngeal
nerve (Sanders and Mu 1998).
As the only muscle of abduction, the action of the PCA is to open the vocal folds,
and this action allows for inhalation. It is antagonistic to the TA, LCA, and IA
muscles. Studies have shown that, overall, muscle bers within the PCA muscle are
more slowly contracting than other intrinsic muscles of the larynx (Shiotani et al.
1999b). However, recent research in humans has conrmed that the PCA contains
two separate bellies (horizontal and vertical) with distinct histological characteristics (Asanau et al. 2011; Wu et al. 2000). The horizontal belly of the PCA reportedly
consists primarily of slowly contracting bers, whereas rapidly and slowly contracting bers are found in similar amounts in the vertical belly (Asanau et al. 2011). The
vertical belly of the PCA may modulate occasional adjustments in laryngeal tension
and stability during swallowing and voicing. On the other hand, the horizontal belly
likely allows for the permanent rhythmic activity of the PCA during the inspiratory phase of respiration (Asanau et al. 2011). The faster contracting vertical belly
of the PCA may also allow for swift abduction of the larynx to allow for rapid inhalation and the reversal of airway hunger.
The properties of the CT muscle allow for precise adjustments in vocal pitch.
When contracted, this muscle pulls downward on the anterior aspect of the thyroid
cartilage and serves to elongate the vocal folds and elevate pitch. There is the greatest electromyographic (EMG) activity in the CT when producing high pitch phonation, and little if any CT activity during extreme low-pitched phonation during vocal
fry (Shipp 1975). The term vocal fry refers to the perception of a low-pitched,
pulsating or rattling vocal quality that typically occurs below 70 Hz (Titze 1994).
9.1.2
Role of the Intrinsic Laryngeal Muscles in Breathing

and Swallowing
Muscles of the intrinsic larynx are active during breathing; however, the same
intrinsic muscle may exhibit different degrees of rapid or tonic (slow and sustained)
146
Fig. 9.2 Endoscopic images shown with simultaneous EMG information from one individuals
10 mL bolus swallow. A arytenoid adduction begins; B total arytenoid adduction; C open glottis
and forward tilt of arytenoid cartilages; D inversion of epiglottis just before whiteout; E just after
whiteout (open glottis); SM submental muscle; CP cricopharyngeus muscle; LP longitudinal
pharyngeal muscle; GG genioglossus muscle; SPC superior pharyngeal constrictor muscle; TA
thyroarytenoid muscle; PCA posterior cricoarytenoid muscle. Used with permission by the rst
author and publisher from Van Daele et al. (2005)
muscle contractions depending on whether inspiration or expiration is occurring

(for review, see Woodson 1999). For example, during wakefulness, the PCA is phasically active on inspiration and tonically active on expiration (Kuna et al. 1990).
The IA and TA muscles, on the other hand, are typically phasically active during
expiration and tonically active during inspiration (Kuna et al. 1988, 1991; Kuna and
Insalaco 1990). Thus, vocal fold position during quiet breathing in awake individuals results from the interaction of muscle antagonists (Kuna et al. 1990).
The activity of the TA muscle during wakefulness is particularly unique.
Specically, the TA appears to promote a degree of vocal fold adduction during
expiration and its action has been linked to resistance at the lungs and below the
epiglottis during expiration (Kuna et al. 1988). When expiration begins, TA activity
typically increases and then either levels off or gradually increases or decreases
depending on expiratory length. These changes in activation patterns are associated
with amount of expiratory airow and time of expiration. Longer expirations and
less airow occur at the end of the expiratory cycle when TA activations are high
(Kuna et al. 1988). The TA actively inuences an increase in expiratory durations
because it increases resistance at the glottis. This action can be thought of as a
laryngeal braking mechanism (Kuna et al. 1988).
Intrinsic muscles of the larynx are active during swallowing. As shown in
Fig. 9.2, combined EMG and endoscopy recordings have indicated that laryngeal
147
closure during deglutition generally patterns itself in the following order: (1) arytenoid
adduction in conjunction with PCA activity ceasing; (2) hyolaryngeal elevation;
(3) decline in cricopharyngeus muscle activity; (4) retraction of the tongue; (5) contraction and rise of the pharynx; (6) TA activity in conjunction with vocal fold
closure; and (7) suprahyoid muscle activity of the geniohyoid and mylohyoid (Van
Daele et al. 2005). Thus, actual vocal fold closure occurs over 500 ms after arytenoid
closure and, endoscopically, the vocal folds appear to be in a partially open position
just prior to whiteout of the laryngeal image on ber optic endoscopic evaluations
of swallowing (Van Daele et al. 2005). Given that the delay between swallow onset
and vocal fold closure can range from approximately 0.5 and 1 s (Van Daele et al.
2005), the TA must have the ability to close extremely rapidly just before bolus passage. The TAs fast contracting ber types may subserve this biological requirement. Clearly, the adduction of the vocal folds during swallowing is one of the
laryngeal muscles most important protective mechanisms. The other mechanisms
are the elevation of the larynx behind the base of the tongue and the depression of
the epiglottis to cover the airway, facilitated by muscles of the pharynx, discussed
later in this chapter. These protective functions are typically described as the primay
function of these muscles, with communicative functions being secondary.
9.1.3
Muscle Fiber Types and Mitochondria Characteristics

in the Intrinsic Laryngeal Muscles
Two characteristics that distinguish muscle bers are their shortening velocities and
the major pathway used for formulation of the bers energy supply (Widmaier et al.
2004). Shortening velocity, either fast or slow, is reected by composition of myosin
heavy chain (MyHC) properties within the muscle as well as the speed with which
ATP is broken down by ATPase. A single MyHC isoform may characterize a muscle
ber or a ber may co-express multiple isoforms. Slow bers (Type 1) are generally
fatigue resistant, while fast bers (Type 2) provide short surges of speed and strength
and are more prone to fatigue. Type 2 MyHCs can be further divided into Types 2A
and Type 2X in human limbs. Another fast ber type thought not to be found in large
mammals, specically primates, is Type 2B. The speed and power of Type 2B is
greatest, followed by Type 2X and then Type 2A (Powers and Howley 2004).
Different energy pathways, either oxidative or glycolytic, also characterize slow
vs. fast muscle ber types. Specically, oxidative bers use oxygen to create adenosine triphosphate (ATP) via a series of chemical reactions that take place in mitochondria. Oxidative bers depend on blood ow for the provision of oxygen to
produce ATP (Widmaier et al. 2004). Thus, these bers are typically situated near
blood vessels and contain myoglobin. When mitochondrial capacity is depleted or
oxygen is not available, nonaerobic glycolysis is the pathway used for creation of
ATP. Although glycolytic bers produce ATP more rapidly than oxidative bers,
fewer ATP molecules are created. Thus, oxidative bers sustain periods of moderate
148
Fig. 9.3 Micrograph of rat skeletal muscles showing presence of mitochondria (m mitochondria).
Accompanying graphs show mitochondrial volume density (% of muscle ber volume occupied by
mitochondria) in soleus, posterior cricoarytenoid, and thyroarytenoid, supporting the idea that
mitochondrial volume density is lower in limb than laryngeal muscles. Used with permission from:
Andrade FH (2011), unpublished data
muscular work over time without fatigue, whereas glycolytic bers engage in rapid
and intense activity that leads to fatigue. Type 1 bers are slow-oxidative bers and
thus, are slowly contracting and fatigue resistant. Their relative efciency results in
less ATP use per unit of work than fast contracting bers (Powers and Howley
2004). Although Type 2A bers or fast oxidative bers contract quickly, their resistance to fatigue is moderate (Widmaier et al. 2004) because they have high mitochondrial volumes and adequate blood supply/myoglobin to allow maintenance of
energy stores. In contrast, Type 2X or fast glycolytic bers exert the fastest contraction speeds and forces, but fatigue quickly due to smaller energy stores and more
ATP use per unit work than Type 1 bers (Widmaier et al. 2004).
Energy requirements of muscles may be determined by examining mitochondrial
volume or density, which is measured as the percent of muscle ber volume occupied by mitochondria (Andrade 2010). More mitochondria allow muscles to engage
in continuous work at low or moderate intensities without fatigue. Reports have
indicated that the density of mitochondria in laryngeal muscles is high especially
when compared with limb muscle (McMullen and Andrade 2006; Roseneld et al.
1982). For example, mitochondrial density in rat soleus muscle, a slowly contracting, fatigue-resistant muscle, has been reported as 6.1 0.9% (Mathieu-Costello
et al. 1992) whereas the mitochondrial density in rat PCA and CT muscles averages
15 1.1% and 10.9 0.7%, respectively (Hinrichsen and Dulhunty 1982). Recent
data have shown that the average mitochondrial density in 6-month-old rat TA muscle is the highest of the laryngeal muscles at approximately 18% (Francisco Andrade
2011, personal communication). Figure 9.3 contains a comparison of mitochondrial
densities among rat soleus and laryngeal muscles (Hinrichsen and Dulhunty 1982;
Mathieu-Costello et al. 1992; Francisco Andrade 2011, unpublished work).
The high density of mitochondria in the PCA and TA is likely related to the
muscles energy needs. Both muscles must provide slow, sustained contraction to
149
allow for breathing and sustained phonation. Thus, the high density of mitochondria
in these muscles likely allows continual engagement in respiratory and phonatory
movements without fatigue. Interestingly, reports examining aged rat and human
TA have reported that this muscle is signicantly more fatigable than in younger TA
muscles from the same species (McMullen and Andrade 2006; Kersing and
Jennekens 2004). One of the causes of this change in endurance may be an accumulation of ragged red bers in the TA (McMullen and Andrade 2006; Kersing and
Jennekens 2004). Ragged red bers are associated with defective mitochondria
found with aging (McMullen and Andrade 2006; Kersing and Jennekens 2004).
These bers appear to occur at a higher degree in aged TA than in aged limb muscles
(Kersing and Jennekens 2004). Likewise, an increase in the amount of glycolytic
muscle bers in the TA of older rats has been reported (McMullen and Andrade
2006). Both of these ndings represent changes that will decrease the endurance of
the TA. Specically, fewer healthy mitochondria are available to subserve muscle
endurance and an increase in fatigable glycolytic bers with age will likely result in
a proportional decrease in nonfatigable oxidative bers.
Myosin heavy chain composition (MyHC) with the laryngeal musculature has
distinct differences from MyHC isoform composition in the well-studied muscles of
the extremities. In contrast to MyHC isoforms found within limb muscles, hybrid
bers with more than one MyHC isoform, and isoforms other than MyHC types 1,
2A, and 2X have been reported in all laryngeal intrinsic muscles but the cricothyroid (Shiotani et al. 1999a, b; DAntona et al. 2002; Sciote et al. 2002; Wu et al.
2000; Han et al. 1999). Likewise, muscle ber types identied within the extremities may occur in different proportions within the larynx (DAntona et al. 2002;
Shiotani et al. 1999a, b). In one report, the laryngeal adductors (TA, LCA, and IA)
had a higher percentage of the fast glycolytic contracting bers (type 2X) and a
lower percentage of type 1 bers than the abductor PCA and tensor CT in human
(Shiotani et al. 1999a, b). However, all of these muscles (TA, LCA, IA, PCA, and
CT) had a relatively high percentage of fast oxidative 2A muscle bers. In the work
of Shiotani et al. (1999a, b), the TA muscle exhibited the greatest percentage of type
2X bers, followed by the LCA, then IA, PCA, and nally, the CT. The percentage
of type 1 oxidative intrinsic laryngeal muscle bers is reportedly greatest in PCA
followed by CT, then IA, LCA, and nally, TA (Shiotani et al. 1999a, b). In light of
these ndings, the TA muscle appears to be rapidly contracting. The PCA and CT,
on the other hand, possess relatively slow contraction speeds.
For some mammals, contraction time measures in TA are very short, being about
14 ms in dog and primate and 22 ms in cat (Hast 1969). There are some differences
across species. Specically, PCA and TA MyHC isoforms in humans, when considered together, have a generally slower prole than the isoforms found in rat or canine
TA and PCA (Wu et al. 2000). However, the rat exhibits the fastest isoform prole
for these muscles; perhaps providing support for the idea that larger species have
slower MyHC proles (Wu et al. 2000). Similarly, human and canine PCA and TA
musculature have a larger percentage of type I MyHC isoform, whereas type 1 bers
are nearly absent in rat (Wu et al. 2000).
Another interesting characteristic of MyHCs in the laryngeal musculature is that,
unlike the limb muscles, a large percentage of hybrid bers have been discovered
150
(DAntona et al. 2002; Sciote et al. 2002; Wu et al. 2000). Human vocalis muscle
bers that are comprised of more than one isoform appear to have properties intermediate to those expressed by each individual ber type alone (DAntona et al.
2002). In DAntona et al. (2002), 33% of bers studied within the human vocalis
were hybrids including the following types: I-2A, 2A-2X, 1-2A-2X, and 2A-2L.
Additionally, human TA and PCA muscles with mixed MyHC expression had a
large range of contraction speeds, some which were almost twice as fast as limb
muscles (Sciote et al. 2002). Wu et al. (2000) also reported hybrid expression in
20% of the bers in dog PCA and 40% of bers in human and dog LCA. Hoh (2005)
hypothesized that laryngeal muscle ber hybrids may have originated because of
the multiple, diverse neural inputs to these muscles to perform complex and differing tasks. For example, perhaps the quality of muscle contraction for phonation vs.
coughing is different. If this is the case, then adductor muscle bers might contain
hybrids to allow for different degrees or congurations of contraction speed, tension, or fatigability. Theoretically, co-expression of MyHC isoforms within one
muscle ber would allow the muscle to participate in diverse tasks including phonation and airway protection/coughing.
In the process of studying the MyHC isoforms in laryngeal muscles, several
investigators discovered additional MyHCs that are not found within the limbs.
Specically, DAntona et al. (2002) found a possible new isoform in human
vocalis muscle labeled MyHC L. This isoform is believed to be similar to extraocular (EO) MyHC in rats. EO MyHC is very fast contracting and found in the extraocular muscles in most animal species. Much controversy exists as to whether EO
MyHC occurs within human laryngeal muscles due to the assertion that TA muscle
contraction may occur at speeds similar to the extraocular muscles (Hoh 2005). On
the other hand, MyHC type 2L (which represents EOM MyHC in larynx) has also
been reported in rat TA (Wu et al. 2000; Shiotani and Flint 1998a; DelGaudio et al.
1995; Merati et al. 1996). Likewise, MyHC isoform bands from human extraocular
muscles have been found to co-migrate with some bands from laryngeal muscle
during electrophoresis (Sciote et al. 2002). This occurrence may suggest its expression in human larynges. According to DAntona et al. (2002), the mystery myosin
that was thought to possibly represent EOM MyHC was found only in a hybridized
form with type 2A. The type 2A-L ber was estimated to appear in only 3% of
muscle bers observed by these researchers. Hoh (2005) reasoned that because of
the ultra fast speeds attributed to EOM MyHC, when this MyHC was hybridized
with 2A MyHC, this mixture would likely result in faster shortening speeds than
type 2A alone. However, as indicated earlier, DAntona et al. (2002) found that
hybridized type 2A-L bers exhibited slower contraction speeds than Type 2A
bers alone. Hoh (2005) concluded that this new ber was more likely a slow tonic
MyHC than EO MyHC.
Slow tonic bers have been found in the vocalis muscle (Han et al. 1999). Unlike
other ber types, slow tonic bers are not typically found in mammals (Han et al.
1999), although a large group of these fatigue-resistant bers have been discovered
in human vocalis muscle (Han et al. 1999). Slow tonic bers do not exhibit a twitch
contraction like type 1 and 2 bers, and instead, respond to very slow, repetitive
151
neural impulses with gradually rising tension and slow tension decline after these
impulses cease (Han et al. 1999). The unique characteristics of slow tonic bers
were hypothesized to be an adaptive mechanism that allows for human vocalization
specic to speech (Han et al. 1999). Slow tonic bers would allow for precise adduction of the vocal folds without fatigue; however, the quick adjustments that are made
during vocalization (such as beginning to phonate immediately after a breath or
singing staccato notes) may not be served well by them. Perhaps hybrid bers or
fast contracting MyHC are responsible for rapid phonatory tasks and airway protection, while slow tonic bers decrease the possibility that continuous phonation will
result in fatigue. Therefore, the high concentration of hybridized bers, fast contracting bers, and STFs as well as ber types that are still under investigation
contribute to the functional properties of the adult larynx.
MyHC composition is reportedly unique in infant laryngeal musculature relative
to that found within limb skeletal muscle (Perie et al. 2000). Specically, the persistence of fetal (IIF) MyHC was present in 7-month-old human PCA and TA muscles.
Fetal isoforms have not been reported in adult laryngeal muscles. In most cases,
adult MyHC isoforms replace fetal MyHC during fetal development. For instance,
in limb muscles, slow and fast MyHC isoforms typically replace fetal isoforms
between prenatal months 6 and 9, and are gone very soon after birth occurs.
However, fetal MyHC persist in some muscles through adulthood such as masseter
and extraocular muscles (Wieczorek et al. 1985; Soussi-Yanicostas et al. 1990).
The presence of fetal isoforms well after birth in laryngeal muscles may indicate
a delayed maturation of the human laryngeal neuromuscular system in comparison to limbs, and could be related to the progressive development of these muscles
during the rst few years of life (Perie et al. 2000). The idea of an immature neuromuscular system persisting into infancy is further supported by the nding that up
until 7 months, TA, PCA, IA, and CT muscles exhibit motor end plates innervated
by more than one axon mixed with those only innervated by a single axon (Perie
et al. 1999). In adults, only uni-neuronal innervations patterns have been found in
these muscles.
Additionally, an unknown isoform was discovered in infant larynx. This isoform
was found to have a similar mobility and, hence, molecular weight as 2-month-old
rat MyHC IIL during electrophoresis. Like in rats, the concentration of this isoform
in human infant was higher in the TA vs. the PCA muscles. The presence of this
isoform in infants may be associated with their differing functional needs. Perhaps
conversion of this isoform to its adult form occurs as phonation evolves for use in
speech (Perie et al. 2000).
9.1.4
NerveMuscle Connections
A detailed discussion of concepts related to the motor unit can be found in any basic
physiology textbook (Widmaier et al. 2004). An excellent review of muscles of
interest in this chapter was written by Palmer (1989). In general, a motor unit is a
152
Fig. 9.4 Exemplar of a

confocal digital micrograph
of an NMJ from an old rat TA
muscle obtained after 3-color
uorescent
immunohistochemical
staining. Receptors appear in
red, axons in blue, and
Schwann cells and nerve
terminals in green. Scale
bar = mm
single motoneuron, the connection between the motoneuron, and all of the muscle
bers innervated by that motoneuron. Motor units throughout the body vary in size.
That is, the innervation ratio, or number of muscle ber innervated by a particular
motoneuron differs. Of interest with regard to the larynx is that innervation ratios
are relatively small within the intrinsic muscles compared with those found in other
skeletal muscles systems. For instance, as noted by Palmer (1989), innervation
ratios can be 2 or 3 within the larynx compared with 2000 within the gastrocnemius
(Feinstein et al. 1955; Faaborg-Andersen 1957). Thus, the capacity for ne-grained
control of laryngeal movements and postures is implied by the density of innervation of muscle bers. This is yet another example where the anatomic and physiologic characteristics of the laryngeal sensorimotor system differ from characteristics
found within limb skeletal muscle systems.
Connections between nerve and muscle take place at the NMJ, which contains parts
of three different types of cells, the nerve terminal, Schwann cells, and the motor end
plate postsynaptically on the muscle, as shown in Fig. 9.4 (Sanes and Lichtman 1999).
With regard to the muscles of the larynx, NMJ structure within the instrinsic
muscles has been reported in only a handful of studies (Rosen et al. 1983; Gambino
et al. 1990; Yoshihara et al. 1998; Connor et al. 2002; McMullen and Andrade
2009). These papers typically report comparisons of NMJs in normal TA and/or
PCA muscles with aging (Gambino et al. 1990; Connor et al. 2002; McMullen and
Andrade 2009) or with a pathological state, such as amyotrophic lateral sclerosis
(Yoshihara et al. 1998). Very few offer comparison of limb and cranial motor systems. However, in one study, motor end plate distribution in the TA muscle from
cats and humans was examined histologically using achetylcholinesterace enzyme
activity as a marker (Rosen et al. 1983). Results suggested that endplate distribution
153
Fig. 9.5 Wideeld uorescent image (4 objective) of a 50-mm-thick transverse section from a rat
larynx showing the distribution of motor endplates in the thyroarytenoid (TA) muscles. Motor
endplates are labeled with Alexa Fluor 488 conjugated alpha-bungarotoxin (Molecular Probes/
Invitrogen, Eugene, OR) which has a high afnity to acetylcholine receptors in skeletal muscle.
Note the difference in the distribution between the horizontal endplate band in the lateral TA compared to the diffuse distribution along the length of the medial TA. Courtesy of Aaron Johnson
in cat and human specimens was similar. That is, while most skeletal muscle appears
to have a distinct endplate band at the midbelly of the muscle, the TA muscle
appeared to have widely distributed endplates throughout the length and width of
the muscle in both cats and humans (Rosen et al. 1983). We have also observed this
widespread distribution of endplates in rat medial TA in our laboratory (Connor
et al. 2002), but not in lateral TA (Fig. 9.5) where motor endplates were conned to
an endplate band and clustered together as is observed in limb muscle.
Endplate band clustering of NMJs has also been shown for CT muscle (Rosen
et al. 1983). Thus, the medial TA muscle appears to be richly supplied with NMJs in
a complex geometry that is unique to this muscle when compared with other laryngeal and limb muscles, perhaps to serve the sensorimotor control needs of this critical muscle of the airway and voice. The abundance of NMJs is reduced with aging in
the TA and PCA muscles, thus supporting that aging putatively affects the NMJs in
a manner similar to that seen with denervation (Connor et al. 2002; McMullen and
Andrade 2009). However, there are alternative explanations for these ndings, such
as muscle ber atrophy and/or reductions in muscle ber size or length.
154
9.1.5
Summary
The intrinsic laryngeal muscles represent the nal common path for the nely tuned
actions that allow for breathing, airway protection, and phonation. Muscle ber type
morphology and mitochondrial density likely subserve the unique functions of these
muscles. While the innervation patterns of these muscles are considered well known,
conicting reports exist regarding the IA and TA. Anatomic and physiologic studies
of the intrinsic laryngeal muscles have been performed in humans and cadaveric
models, as well as in animal models. There appear to be some species differences,
but there are more similarities than differences across species. For instance, in the rat
larynx there has been note of a muscle not found in humans, the alar cricoarytenoid
muscle (Inagi et al. 1998). Because the larynx and pharynx are difcult to access in
humans, the use of animal models in research concerning muscles of larynx and
pharynx is necessary. Thus, some species differences must be tolerated but considered
when making interpretations relative to human muscle anatomy and physiology.
Clearly, the larynx has unique muscular components including a large density of
mitochondria as well as a large percentage of hybrid, slow tonic, and fast twitch
bers. These muscle ber types contribute to the specialized functions of the larynx.
Differing ber types found in human larynx compared to other species may be
linked to differences in body size and functional differences (i.e., speech in humans).
Controversy still remains as to whether adult or infant human vocal fold musculature contains EO MyHC, but this nding would support the rapid contraction speeds
of muscles like the TA. As knowledge about laryngeal muscle bers increase, further
conclusions may be drawn about their inuence on laryngeal movement in normal
and voice-disordered populations. Thus far, it is clear that the variable composition
of different laryngeal muscles suits each to differing task requirements. It is not
clear whether particular laryngeal adductor muscles predominate in specic phonatory or airway protection tasks, and how different muscle characteristics may exert
inuence on voice disorders.
9.2
9.2.1
Extrinsic Muscles of the Larynx

Role in Voice
The extrinsic laryngeal muscles contribute to voice production and modulation by

allowing for modications in laryngeal posture. While the intrinsic muscles of the
larynx have connections solely within the larynx, the extrinsic muscles have an
external origin or insertion. For example, the sternothyroid and the thyrohyoid muscles, while not located wholly within the larynx, function to control the vertical
position of the larynx and are active up to 200 ms prior to phonation onset (Shipp
1975). One example of vertical position change of the larynx was provided by
Shipp, specically, the superior laryngeal movement observed during glissando
155
with increasing pitch. Vertical position of the larynx appears to be altered with pitch
change, but the level of change is highly variable across individuals (422.5 mm)
(Shipp 1975).
The infrahyoid muscles are often referred to as the strap muscles. The strap
muscles typically include the sternohyoid (SH), omohyoid (OH), thyrohyoid (TH),
and sternothyroid (ST); with the SH and OH comprising the most supercial layer
of these muscles and the TH and ST comprising the deepest layer. All four strap
muscles are located deep to the platysma and sternocleidomastoid muscle.
Strap muscles have an important role in voice production, particularly with
regard to pitch modulation during phonation. By impacting the position of the
thyroid cartilage, they increase and decrease the distance between the thyroid and
cricoid, resulting in increases in vocal fold tension or relaxation (Kenyon 1992).
In general, the literature has focused on the role of the TH, SH, and ST, but has typically omitted the omohyoid. Figure 9.6 contains a photograph of a canine larynx
showing the ST and TH muscles.
Some studies examining the ST in human via EMG or canine or primate via
stimulation have found it to be active during pitch elevation (Faaborg-Andersen and
Sonninen 1960; Shipp 1975; Niimi et al. 1991; Ueda et al. 1972; Sapir et al. 1981)
and/or pitch lowering (Shipp 1975; Ueda et al. 1972). Other studies (again human
EMG studies or animal stimulation studies), however, have indicated that the ST is
not active or inconsistently active with pitch decrease (Shin, Hirano, Maeyama,
Nozoe, and Ohkubo 1981; Collier 1975; Atkinson 1978; Niimi et al. 1991; Sapir
et al. 1981) and/or pitch increase (Collier 1975; Sapir et al. 1981). TH activity has
been noted during increased pitch across a majority of human EMG studies (FaaborgAndersen and Sonninen 1960; Shipp 1975; Baer et al. 1976); although a few human
EMG studies indicated that the TH was not active during increases in pitch (Erickson
et al. 1977), or active during pitch lowering in addition to pitch raising (Baer et al.
1976). However, the majority of human EMG studies indicate that the TH is not
active during pitch lowering (Faaborg-Andersen and Sonninen 1960; Shipp 1975;
Collier 1975). In canine stimulation and human EMG studies, the SH has generally
been associated with pitch increases (Baer et al. 1976; Ueda et al. 1972) and decreases
(Baer et al. 1976; Atkinson 1978; Ueda et al. 1972), although one human EMG study
did not nd any activity in this muscle during pitch increase (Atkinson 1978). Thus,
the way in which these muscles truly affect pitch is still unclear due to the contradictory ndings reported in the literature (Hong et al. 1997; Vilkman et al. 1996).
As can be gleaned from the above paragraph, studies examining SH, TH, and ST
function have typically involved electrical stimulation in animals or humans (Sonninen
1956; Ueda et al. 1972; Sapir et al. 1981) or EMG (during singing and speech) in
humans (Erickson et al. 1977; Faaborg-Andersen and Sonninen 1960; Shipp 1975;
Niimi et al. 1991; Collier 1975; Atkinson 1978; Baer et al. 1976) varying from 1 to 25
participants (Vilkman et al. 1996). Cadaver experiments have also been undertaken to
provide insight into strap muscle function (Sonninen 1956; Vilkman et al. 1996).
These studies have typically drawn conclusions about function by manipulating muscle position (Vilkman et al. 1996). The hypotheses, models, and literature related to
SH, TH, and ST function have been extensively reviewed (Vilkman et al. 1996).
156
Fig. 9.6 Left lateral view of a canine larynx showing external laryngeal strap muscles including
the sternothyroid and thyrohyoid. Photograph courtesy of Dr. Seth Dailey
9.2.2
Role in Swallowing
The extrinsic laryngeal muscles play a vital role in swallowing. Specically, they
are active in producing laryngeal elevation to protect the airway (Burnett et al.
2005). Reduced or delayed laryngeal elevation is associated with aspiration (Kahrilas
1997; Lundy et al. 1999). Thus, damage of these muscles due to brain injury or
stroke, or their surgical removal often results in dysphagia. The relative contributions of some of the extrinsic muscles to laryngeal elevation have been explored
through the application of intramuscular electrical stimulation to the geniohyoid
and thyrohyoid (Burnett et al. 2003). Stimulation of these muscles resulted in 30%
of the laryngeal elevation and about 50% of the velocity that occurred during a
157
normal swallow (Burnett et al. 2003). When stimulation was applied bilaterally to
the thyrohyoid alone approximately 50% of normal laryngeal elevation and 80% of
normal speed of elevation was found (Burnett et al. 2003). Regarding temporal
factors, thyrohyoid activation was closely linked with laryngeal rise and fall with its
activation occurring an average of only 52 ms prior to laryngeal elevation (Burnett
et al. 2005).
Electrical activity of the strap muscles during swallowing as measured with surface EMG demonstrated different average electrical activity depending on swallowing parameters (Vaiman et al. 2004). For instance, electrical activity during continuous
drinking of 100 mL of water was the smallest in magnitude, followed by activity
during a single saliva swallow (Vaiman et al. 2004). However, electrical activity during single water swallows and xed 20 mL water swallows was stronger and similar
to one another in magnitude (Vaiman et al. 2004). Interestingly, electrical activity of
the infrahyoid area has been found to decrease with age (Vaiman et al. 2004).
9.2.3
Summary
Extrinsic muscles of the larynx contribute to laryngeal position during swallowing

and pitch change by altering the distance among laryngeal cartilages. Extrinsic
muscles are vital to promoting airway protection through laryngeal elevation and
exhibit different levels of electrical activity depending on age and the type of swallow. Reports about the correspondence between pitch lowering/raising and extrinsic
muscular activity are conicting. Likewise, methodologies for examining strap
muscle functional properties vary widely from manipulating muscle position in
cadavers to use of electrical stimulation in human or animals or use of EMG in
humans only. Thus, while the role of the extrinsic musculature is broadly known,
the specic function of each individual extrinsic muscle is not completely clear.
9.3
Muscles of the Pharynx
There are many muscles of the pharynx throughout the extent of the nasopharynx,
oropharynx, and the hypopharynx that have a primary role in swallowing function.
For instance, muscles within the nasopharynx (tensor palatine, levator palatini) function to elevate the soft palate and close the nasopharynx to the bolus, while altering
pharyngeal pressures to receive and propel the bolus. Movement of the pharyngeal
wall toward the soft palate as well as elevation and anterior displacement of the larynx
during the swallow is accomplished by muscles such as the mylohyoid, palatopharyngeus, salpingopharyngeus, and stylopharyngeus (Table 9.1). Increased velopharyngeal pressure relative to baseline results from these actions and has been recorded
during a swallow using high resolution manometry (Hoffman et al. 2010). In combination with reduced hypopharyngeal pressure during the swallow, a pressure gradient
is established that works in favor of bolus ow toward the esophagus.
158
9.3.1
Structure, Function, and Muscle Fiber Types
In general, the majority of the pharyngeal muscles (Table 9.1) receive motor
innervation from the pharyngeal plexus of the vagus nerve (CNX). There are a few
exceptions, including the tensor veli palatine (innervated by the medial pterygoid
nerve, a branch of the mandibular nerve branching from the trigeminal CNV),
stylopharyngeus (the only muscle receiving motor innervation by the glossopharyngeal nerve CNIX), and palatopharyngeus (innervated by the pharyngeal plexus of
the vagus CNX and the spinal accessory nerve CNXI). Although these are commonly noted innervation patterns at the most basic level, reports vary as to the
specic branches of the cranial nerves supplying certain pharyngeal muscles (Hixon
et al. 2008). We will highlight one such controversy related to the cricopharyngeus
later in this section.
Mylohyoid muscle ber characteristics in human samples were reported in one
recent study as having a hybrid composition of unusual myosin properties, such as
embryonic, neonatal, a-cardiac, and slow-tonic, in combination with typical skeletal muscle myosins including type I, Type IIA, and Type IIX (Ren and Mu 2005).
Notably, these hybrid bers comprised 84% of the total number of bers analyzed
in adult human samples. Thus, the muscle ber type composition in the mylohyoid
muscle is unique and distinct from skeletal muscles found in the extremities and is
more similar to those found in other cranial muscles. Ren and Mu (2005) interpreted
their ndings as suggestive of specialization of this muscle for chewing, swallowing, and breathing, and the need for postural stability and endurance during these
critical functions.
9.3.2
The Upper Esophageal Segment
The terms cricopharyngeus (CP) and upper esophageal sphincter (UES) are often
used interchangeably, but the CP muscle is really one muscular component of the
UES; thus, these terms are not synonymous. The CP along with the inferior pharyngeal constrictors and inferior cervical esophageal muscle make up the UES.
Although there has been some controversy over the CPs role in UES function
(Goyal et al. 1993), the CP is typically thought to facilitate the contraction and
relaxation patterns that lead to the pressure changes exhibited by the UES as a
whole. In fact, the CP is the only component of the UES which contracts and relaxes
during tasks associated with UES opening, including swallowing, emesis, and
belching (Belafsky 2010; Kahrilas 1997). The terminology UES can be used interchangeably with the pharyngoesophageal segment (PES) (Belafsky 2010). Both
refer to the same area of the esophagus, although the UES is dened as the 25-cm
high-pressure zone located between the pharynx and esophagus that is measured
by manometry (Belafsky 2010). On the other hand, the PES refers to the anatomic
components that make up the high-pressure zone (Belafsky 2010).
159
Fig. 9.7 Drawing of

cricopharyngeus muscle
showing the muscles
horizontal and oblique
compartments known as the
pars obliqua and pars
fundiformis, respectively. CC
cricoid cartilage; CPo
oblique compartment of
cricopharyngeus muscle; Cph
horizontal compartment of
cricopharyngeus muscle; CT
cricothyroid muscle; IPC
inferior pharyngeal
constrictor muscle; T trachea;
TC thyroid cartilage; UE
upper esophagus. Used with
permission from the rst
author: Mu and Sanders
(2002)
Muscle ber properties of the CP muscle have been identied as predominantly

slow contracting Type I bers based on MyHC assays (Davis et al. 2007). When the
CP muscle and the pharyngeal constrictors were compared in human samples, the
CP was found to have muscle bers with a smaller cross sectional area, while no
distinct differences in ber type composition were observed (Sundman et al. 2004).
In this study, slow muscle ber types predominated in the CP and the constrictors,
but across samples in the CP there were ndings of hybrid bers, on average, (Type
I and Type IIA) 9% of the time and 28% of the time in the pharyngeal constrictors
(Sundman et al. 2004).
As shown in Fig. 9.7, the CP has two compartments known as the pars oblique
(or simply, oblique) and pars fundiformis (Plant 1998). The pars fundiformis compartment, also known as the horizontal compartment (Mu and Sanders 2002) is
what is typically referred to when the CP is discussed (Plant 1998). The fundiformis
is a sling shaped (Belafsky et al. 2010; Belafsky 2010), striated skeletal muscle that
attaches to the posterior aspect of the cricoid cartilage. It is composed of small bers
(typically 2535 mm) that are predominantly Type I to allow for sustained contraction of the UES (Mu and Sanders 2002).
Innervation of the CP is controversial (Halum et al. 2006; Mu and Sanders 1998;
Sasaki et al. 1999). The branches of the vagus reportedly innervating the CP have
160
been identied as the pharyngeal plexus (Hwang et al. 1948), SLN (Kirchner 1958),
RLN (Hammond et al. 1997), and the cervical sympathetic chain (Hirano 1969) or
combinations of these nerves such as the pharyngeal plexus and RLN (Lund 1965;
Mu and Sanders 1998; Sasaki et al. 1999). In one study, EMG recordings of the CP
were examined to determine how similar they were to EMG recordings of different
muscles with known innervation (Halum et al. 2006). The authors obtained EMG
recordings for the CP muscle and examined either the ipsilateral inferior constrictor,
TA, or CT muscles simultaneously. The authors logic was that if the same nerve
innervated the CP and one or all of these other muscles, then EMG signals in patients
with nerve injury would have common characteristics. EMG test results fell into
one of the following categories: normal, inactive axonal injury, or neurogenic active
axonal injury. The authors found that in 27 out of 28 studies, the ipsilateral inferior
pharyngeal constrictor and CP muscle had the same muscle ndings whereas only
40 of 50 studies and 31 of 50 studies were the same between the CP and TA, and CP
and CT, respectively. Based on these ndings, the pharyngeal plexus appeared to
predominantly contribute to CP innervation because greater commonality was found
between CP EMG patterns and those of the inferior pharyngeal constrictor, which is
innervated by the pharyngeal plexus (Halum et al. 2006).
Although passive tone is typically always present in the CP, muscular tension
increases as the muscle is stretched (Lang and Shaker 1997). As previously mentioned, when swallowing occurs, the CP relaxes to allow bolus passage (Lang and
Shaker 1997; Plant 1998; Kahrilas 1997). While pressure from the bolus contributes
slightly to UES opening, the anteriorposterior movement of the hyoid bone creates
a strong negative pressure that facilitates UES opening and relaxation (Belafsky
2010; Plant 1998). The larger the bolus, the more the UES and CP will relax to
widen the UES opening and increase bolus ow rates (Plant 1998).
High-resolution manometry (HRM) provides information on pressure changes
during swallowing as well as excellent spatial and temporal resolution. Thus, it has
been used to examine how bolus size and postural changes may inuence UES
opening and pressures during deglutition. Durations of UES opening have been
found to vary with different volumes of a liquid bolus based on HRM measures
(Hoffman et al. 2010). Specically, larger liquid bolus volumes have resulted in
increased UES opening durations (Hoffman et al. 2010). Additionally, examination
of normal swallows via HRM indicated that maximal UES pressure was signicantly
lower in swallows performed in a neutral position vs. those performed with a head
turn. UES pressure was also signicantly higher post swallow with head rotation vs.
neutral positioning. The time that the UES remained open was also greater via head
turn (Fig. 9.8).
The CPs main functions include preventing reux from entering the airway
(Belafsky et al. 2010) and preventing passage of air into the esophagus and
abdomen during swallowing (Belafsky et al. 2010; Kahrilas 1997; Plant 1998).
A healthy CP also allows for quick and efcient swallowing to occur. Thus, when
CP relaxation is delayed or inadequate, the ow rate of swallowed materials may
slow and result in residual food materials collecting in the pharynx. The failure of the
CP to relax and allow for the UES to widen has been associated with progressive
161
Fig. 9.8 High-resolution manometry data showing pressure changes across time and spatial position
with 5 mL bolus swallow using head turn. Upper esophageal sphincter is plots upper border and
plots lower border is nasopharynx. Used with permission from McCulloch et al. (2010)
weakening of the pharynx (Belafsky et al. 2010). Maneuvers such as the effortful
swallow have been found to elicit longer UES relaxation durations and improve
swallow function impacted by CP dysfunction (Hiss and Huckabee 2005). Recently,
Belafsky (2010) determined that manual control of the UES was possible by placing a traction suture around the cricoid cartilages anterior edge and specically
placing an implant near the cricoid cartilage. This implant would then open up the
UES when an external magnet was placed on the neck. This Swallow Expansion
Device (SED) reportedly improved UES opening in patients with oropharyngeal
dysphagia. Testing of the suture in sheep and cadavers before implantation into
humans did not result in any cricoid abrasion but did improve opening of the UES
by over 1 cm and prevent aspiration in an ovine model. Thus, there is the possibility of using novel devices in the treatment of dysphagia related to CP muscle dysfunction as new technology emerges.
While pharyngeal muscles primarily subserve deglutition, there is some evidence
that they may be active under some respiratory conditions. These muscles are not
typically recruited during rest breathing, but there have been reports of pharyngeal
muscle activity with airway obstruction and high respiratory drive (van Lunteren
and Strohl 1986). Likewise, the superior constrictor muscle may adjust airow
resistance during expiration (Collett et al. 1986).
162
9.3.3
Summary
Pharyngeal muscles have primary roles in deglutition and as a secondary protective

mechanism. Muscles of the pharynx also act to prevent reuxate from the stomach
or esophagus from entering the airway and also restrict air from entering the digestive tract. The mylohyoids complex hybrid muscle bers likely correspond to its
varying functional roles in breathing, swallowing, and chewing. CP muscle bers
allow for fatigue resistance and sustained muscular contraction. Studies using HRM
and examining novel devices like the SED are likely to improve understanding of
and treatments for dysphagia resulting from CP dysfunction.
9.4
Conclusion
The laryngeal and pharyngeal muscles subserve the highly specialized functions of
breathing, airway protection, phonation, and deglutition. Intrinsic laryngeal muscles high mitochondrial densities, low innervation ratios, motor endplate distributions, and the presence and proportion of their hybrid, slow tonic, and fast contracting
bers are notable features that make them distinct from limb skeletal muscle. These
characteristics provide evidence for their high energy requirements, specialized
nature, and diverse functional properties. Given the common presence of hybrid
bers in the CP, pharyngeal constrictors, and mylohyoid, the pharyngeal muscles
also appear to have multiple functional properties. Likewise, reports indicate
unknown MyHC isoforms have been discovered in pharyngeal and laryngeal muscles such as the mylohyoid and vocalis muscles. There are still many gaps in knowledge about laryngeal and pharyngeal musculature that need to be addressed in future
research. For example, controversies that require further study include: the presence
of the EO MyHC in intrinsic laryngeal muscles, the innervation of CP, IA, and TA,
the specic function of each individual extrinsic laryngeal muscles, and why and
how intrinsic laryngeal muscle bers in infant vary from adults. Although there is
certainly a need for more investigation into both the basic properties of these muscles and ways to improve measurement and treatment of disorders related to their
impaired functioning, there is no question the laryngeal and pharyngeal musculature must be considered distinct and unique from limb skeletal muscle.
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166
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Chapter 10
Motor Control and Biomechanics of Laryngeal

Christy L. Ludlow
10.1
Introduction to the Integrative Systems Controlling

the Laryngeal and Pharyngeal Musculature
The purpose of this chapter is to review motor control and biomechanics of the
laryngeal and pharyngeal muscles with an emphasis on their control for voice,
speech, respiration, and swallowing in humans. The amount of knowledge in this
area is relatively sparse compared with limb control. The laryngeal and pharyngeal
muscles are controlled by several integrative systems in the central nervous systems
which differ in their origin, development and motor control, and biomechanical
demands. Vocalization for the expression of emotion and pain in mammals, such as
the birth cry in humans and the isolation cry in young mammals, depends upon a
complex integration of vocal fold closure, expiratory airow from the lungs to set
the vocal folds into vibration with the build-up of subglottal pressure, and oral
opening to emit the resulting cry. The neural substrates important for this innate
vocalization system have been studied in mammals such as the cat and the squirrel
monkey and involve the periaqueductal gray, the pons, and the reticular integrative
system in the medulla (Jurgens 2009). Voice for speech requires integration of
vocal fold adduction (closing) with expiratory airow and oral shaping, in addition
to precise control of intrinsic laryngeal muscles to alter vocal fold tension controlling frequency of vibration (the fundamental frequency). In addition, rapid and
small changes in laryngeal muscles are needed for vocal fold opening and closing
C.L. Ludlow, Ph.D. (*)

Department of Communication Sciences and Disorders, Rm. HHS 1141, MSC 4304,
James Madison University, 801 Carrier Drive, Harrisonburg, VA 22807, USA
e-mail: ludlowcx@jmu.edu
167
168
C.L. Ludlow
for voiced and voiceless consonants. Both the laryngeal and pharyngeal muscles
are used in voice and speech for communication in humans; Not only are the laryngeal muscles used to control the fundamental frequency and voicing, the shape and
position of the tongue and pharynx are used to alter resonance to amplify certain
harmonics of the fundamental frequency for producing vowel sounds (Borden and
Harris 1984).
Speech gestures are learned in humans from infancy and differ in neural control
mechanisms from innate vocalizations present in other mammals. These largely
depend upon functional relationships between cortical regions involved in speech
perception and production. The production of speech sounds is guided by speech
perception (Hickok et al. 2011); the infant must learn to manipulate air ow on
exhalation to produce similar sounds to those in their environment. With language
acquisition, they are able to produce novel combinations of speech sounds that are
recognizable by listeners of the same language. This becomes a relatively automatic
motor control behavior by late adolescence (Smith and Zelaznik 2004). Table 10.1
summarizes the intrinsic laryngeal muscles and their actions.
Swallowing involves patterns of neural control in the medulla that produce a
rapid sequence of pharyngeal muscle contractions producing sequential pressures
for bolus passage via the hypopharynx through the upper esophageal sphincter
(Kahrilas et al. 1992). With development in childhood, swallowing can come under
volitional cortical control in humans. By adulthood the cortical activation during
both volitional and spontaneous swallowing is somewhat similar (Martin et al.
2001). With the descent of the larynx in the upper airway in humans, prevention of
bolus entry into the airway depends upon laryngeal elevation and epiglottic inversion during swallowing. The need to integrate swallowing with breathing in adult
humans is critical with normal swallowing occurring primarily during expiration
(Hardemark Cedborg et al. 2009).
Therefore, the neural control of the laryngeal and pharyngeal muscle groups for
innate vocalization, voice and speech, and swallowing, may involve different integrative neural control systems, some which are present at birth while others emerge
with development to involve cortical mechanisms and learning. By adulthood, the
laryngeal and pharyngeal muscles are controlled by relatively automatic patterns,
involving both reexive and volitional control in the central nervous system. These
functions are not under explicit motor control in humans. The patterning of the
laryngeal muscles for these functions varies across individuals and from time to
time (Poletto et al. 2004). This has made them difcult to study in humans, while
the cortically based neural substrates involved in these functions in animals are
difcult to study because of anesthesia or decerebrate preparations being required.
Few have studied the neural mechanisms involved in laryngeal and pharyngeal
muscle patterning for vocalization and swallowing in naturally behaving awake
animals (Grohrock et al. 1997).
Given these limitations, this chapter will address current understanding of the
motor control and biomechanics of the laryngeal and pharyngeal muscles for vocalization, speech, and swallowing in mammals and humans in particular.
From muscular process to the

posterior surface of the
cricoid, various angles of
insertion of different
compartments
Muscular process of the arytenoid

to the upper lateral surface of
the cricoids rim
Lateral bers between the
arytenoids and diagonal bers
form the tip of the arytenoids
to the lateral aspect of the
opposite arytenoid
Anterior surface of the arytenoid

cartilage to the inner surface
of the thyroid
Lengthening muscle
Cricothyroid
Upper surface of the cricoid to the
internal surface of the thyroid
cartilage (rectus) and lateral
surface of the cricoid to the
thyroid cartilage (oblique)
Abductor muscle
Posterior
cricoarytenoid
Interarytenoid
Lateral
cricoarytenoid
Adductor muscles
Thyroarytenoid
Pulls the thyroid cartilage

forwards and downwards over the cricoid
cartilage stretching the
vocal folds
Opens the vocal folds by

pulling the muscular
process backwards
rocking the arytenoids
cartilage and elevating
and opening the vocal
process
Pulls the muscular process

forward towards the
cricoids rim
Fixes the two arytenoids
during adduction
Shortens the vocal fold and

pulls the vocal process
downward
Active during sniff to stretch the vocal

folds as they open, co-contraction
with the thyroarytenoid to tense the
vocal fold to increase fundamental
frequency during vibration
Opens the vocal folds for inhalation and

sniff and for voice offset for
voiceless consonants during speech.
May contract during increase in
fundamental frequency to stabilize
the arytenoids during high levels of
thyro arytenoid and cricothyroid
co-contraction
For sphincteric closure during

swallowing, partial adduction in
active respiration, vocal fold closure,
and co-contraction with cricothyroid
to tense to increase fundamental
frequency of vibration during voice
Vocal fold adduction, bursts seen on
vocal fold closure, and opening
during speech
Not well studied because of inaccessibility in human for
electromyography
External branch of the

superior laryngeal
nerve
Abductor branch of the

recurrent laryngeal
nerve
Adductor branch of the

recurrent laryngeal
nerve
recurrent laryngeal
nerve, may have
some bilateral
innervation

recurrent laryngeal
nerve, unilateral
only
Table 10.1 Intrinsic laryngeal muscles, their insertion points, contraction effects, function for voice, respiration and swallowing, and innervations
Muscle
Insertions
Effects of contraction
Task function
Innervation
10
Motor Control and Biomechanics of Laryngeal and Pharyngeal Muscles
169
170
10.2
C.L. Ludlow
Innervation of the Laryngeal Muscles
Only the cricothyroid is innervated by the external branch of the superior laryngeal
nerve (eSLN) while all of the other intrinsic laryngeal muscles are innervated by
branches emerging from the recurrent laryngeal nerve (RLN). The pathway of the
RLN descends from the vagus around the aortic arch on the left side and then
ascends in the tracheoesophageal groove to the posterior larynx where branches
emerge as it enters the larynx posteriorly. However, the pathway of the RLN both
between individuals and between the left and right sides is variable. On the right
side, the RLN loop downwards and then back upwards in the tracheoesophageal
groove but about 0.5% of persons have a non-RLN on the right, based on data from
thyroidectomies (Toniato et al. 2004). However, a non-RLN may be misidentied
and confused with other nerves such as the communicating branch of the recurrent
(Maranillo et al. 2008), leading to disagreements about the prevalence of non-RLN
on the right in persons (Raffaelli et al. 2000). In addition, branching and a more
variable path occurs more often on the right (Chiang et al. 2012) leading to a more
variable outcome affecting vocal fold movement following thyroid and parathyroid
surgery (Casella et al. 2009). Variability in the number and character of extralaryngeal branches on either the left or right sides may occur in 64.5% of cases (Cernea
et al. 2009) leading to more laryngeal complications post-surgery (Coady et al.
2000).
The RLN branches to the different intrinsic laryngeal muscles as it enters the
larynx on each side are also variable. The predominant pattern involves a branch
coming off the RLN near the posterior cricoarytenoid (PCA) muscle, the only muscle providing abduction (opening) of the vocal folds. However, the branch going to
the PCA may have as many as three branches dividing from the RLN or branching
again after the abductor branch emits from the RLN when examined in cadavers
from normal cases (Damrose et al. 2003). Variations in branches coming off the
RLN before entry into the larynx have been reported in 8.65% of cases undergoing
thyroidectomy and may account for transient vocal fold paresis (Shao et al. 2010).
After branching to the PCA the course of the adductor branches can also be variable.
The anterior branch to the interarytenoid was also variable in its branching pattern
when examined in cadavers (Damrose et al. 2003). A more recent study of RLN
branches going to the adductor intrinsic muscles in 75 postmortem larynges showed
extensive variability in the human RLN branching pattern with the adductor branch
coming off the PCA branch in 88% of cases (Maranillo et al. 2005). As many as
8 branches and more commonly 56 branches were identied that could innervate
parts of the adductor muscles including the interarytenoid, lateral cricoarytenoid
(LCA), and the thyroarytenoid (TA) muscles. Only the interarytenoid received both
ipsilateral and contralateral RLN innervation as well as from the internal branch of
the superior laryngeal nerve (iSLN). Branches from the iSLN went to both the
mucosa, into the interarytenoid intramuscularly or to join with branches from the
RLN in a supercial arytenoid plexus in 84% of larynges containing both ipsilateral
and contralateral bers.
10 Motor Control and Biomechanics of Laryngeal and Pharyngeal Muscles
171
The LCA muscle primarily received branches from the ipsilateral RLN; only in
a few cases bers from the eSLN were identied as innervating this muscle
(Maranillo et al. 2005), and the numbers of branches from the RLN to the LCA
varied from 1 to 8. The thyroarytenoid muscle also varied in the numbers of branches
from the RLN (16, with a mean of 1.6) and arose either from the branch to the
PCA, IA, or LCA. Only 4.6% of larynges received innervation from another nerve
than the RLN, the source being the eSLN (Maranillo et al. 2005).
Interlaryngeal variation in RLN branches to the intrinsic laryngeal muscles
complicates the interpretation of the bases for reductions in vocal fold motion in
abduction and adduction. It also impacts the outcome of attempts to selectively
stimulate individual laryngeal muscles or to reinnervate particular intrinsic laryngeal muscles for breathing (PCA), voice (TA, LCA) or for closure airway protection during swallowing (IA, TA).
In spasmodic dysphonia, abnormal bursting of motor neuron ring patterns leads
to voice disruptions during speech (Ludlow et al. 2008). Currently, anastomosis of
the RLN branch(es) to the TA to the ansa cervicalis is used to permanently denervate
the TA muscle from axons in the RLN which produce spasms in these patients (Berke
et al. 1999). This procedure identies the adductor branch of the RLN going to the
TA muscle and prevents reinnervation of the TA muscle by the RLN. On the other
hand, following laryngeal denervation, consideration of the RLN branching pattern
may be considered for selective reinnervation of the PCA and IA to restore volitional
abduction and adduction of the vocal folds, respectively (Kwak et al. 2010).
10.3
Central Nervous System Control of the Laryngeal

Motor Neurons
The laryngeal muscles are innervated by motor neurons in the ipsilateral nucleus
ambiguus in the medulla (Davis and Nail 1984) with the CT motoneurons located
more rostrally while the PCA, TA, and LCA motoneurons are located more caudally. Injury to the motor neurons in the nucleus ambiguus affects the ipsilateral
laryngeal muscles except the interarytenoid which may have some bilateral innervation. Vagal or recurrent nerve injury results in at least short term unilateral vocal fold
paralysis. However, central nervous system injury rarely results in unilateral vocal
fold movement impairment except when there is damage to the laryngeal motor
neurons or disruption of the pre-synaptic input to the motor neurons in the brain
stem as in lateral medullary stroke or Wallenberg syndrome (Kim et al. 2000;
Aydogdu et al. 2001). Cortical lesions do not result in unilateral vocal fold paralysis
suggesting that there is bilateral supramedullary input to the laryngeal motor neurons in the medulla. However, unilateral vocal fold movement reduction (bowing)
can occur in Parkinson disease (Hanson et al. 1984) on the same side as limb involvement suggesting more laterality in control above decussation in the substantia nigra
and medulla, regions involved early in Parkinson disease (Braak et al. 2003).
172
C.L. Ludlow
Transcranial magnetic stimulation has been used in human to map the cortical
region controlling the laryngeal muscles (Khedr and Aref 2002; Rodel et al. 2004).
Both groups reported bilateral muscle response latencies of approximately 10.8 ms
in the CT and TA muscles, respectively, when the primary motor cortex was stimulated unilaterally while the left and right TA muscles had latencies of 11.7 ms and
10.7 ms, respectively. These latencies are difcult to explain given the difference in
length of the RLN which innervates the TA muscle and eSLN which innervates the
CT. Further no difference in latency was noted between responses in the right and
left TA muscles despite the signicant length differences due to the longer course of
the left RLN which descends below the aortic arch on the left. In fact, previous
research in both dogs and human has shown a 3 ms latency difference in latency of
TA response between the right and left sides (Atkins 1973) and similar latency differences between the left and right sides were found when transcranial magnetic
stimulation was applied over the mastoid where the vagus emits from the skull (Sims
et al. 1996). A 2.3 ms latency was found between the right and left TA muscles, a
4.86 latency between the TA and CT on the left and 1.6 ms difference on the right.
Given the cortical to muscle latencies of 10.7 which are less than a millisecond later
than the peripheral responses, it is likely that these reports (Khedr and Aref 2002;
Rodel et al. 2004) include direct nerve responses as the magnetic eld at the cortex
induced peripheral nerve responses as has been found in other cranial nerve using
TMS (Benecke et al. 1988). A more careful TMS study using more focal coils is
needed to examine the cortico-bulbar pathway to the laryngeal muscles in humans.
10.4
Pharyngeal Muscles
The pharyngeal muscles can be divided into those that open (dilate) the oropharynx
airway (Jordan and White 2008) and those that close the airway or constrict the
pharynx to propel a bolus through the upper esophageal constrictor during swallowing (Perlman et al. 1989, 1999). During inspiration, the upper airway muscles dilate
in a sequential chain beginning at the nares to reduce resistance to air ow inwards
(Strohl et al. 1980). The dilator pharyngeal musculature have been studied by respiratory physiologists concerned with obstructive sleep apnea when the dilator musculature is reduced in activity resulting in a collapse of the upper airway (Horner
and Guz 1991). These include the genioglossus (GG), the palatal, and the hyoid
muscles (Table 10.2). The genioglossus has received the greatest attention as its
contraction will move the posterior tongue forward opening the posterior oropharynx to allow air ow through the posterior pharynx and into the glottis. The GG is
innervated by the hypoglossal motor neurons which are activated by respiratory
modulators including hypercapnia (Nicholas et al. 2010) and negative pressure in
the airway (Brennick et al. 2001). Because of the signicant role of the genioglossus
in upper airway dilation, use of hypoglossal nerve stimulation for prevention of
obstruction in patients with obstructive sleep apnea is continuing to receive attention (Smith et al. 1996; Eisele et al. 1997; Mann et al. 2002; Oliven et al. 2003).
Thyrohyoid
Geniohyoid
Mylohyoid
Hyoid to the middle of

the lateral surface of
the thyroid cartilage
Lateral inner surface of

the mandible to the
aponeurosis of the
mylohyoid and the
anterior hyoid bone
From the anterior hyoid
to the inner surface
of the mandible
Dilator muscles for inspiration

Levator veli
From the petrous part
palatini
of the temporal
bone to the soft
palate
Tensor palatini
From the medial
pterygoid plate to
the aponeurosis of
the palate
Genioglossus
Genu of mandible to
tongue surface
Anterior belly of
Internal surface of the
the digastric
mandible to the
lateral surface of the
hyoid bone
Either lowers the hyoid or

elevates the thyroid cartilage
if the hyoid is held upwards
Pulls the hyoid anteriorly
Elevates the hyoid by stiffening

and shortening to elevate the
oor of the mouth
Increased stiffness and pulls the

soft palate upwards towards
the posterior wall of the
pharynx
Moves the tongue forward,
tongue protrusion
Pulls the jaw open or elevates
the hyoid if the jaw is closed
Elevates the velum to the

posterior wall of the
pharynx
Important for dilation of the hypopharynx and elevation of the hyoid and
vestibule closure to prevent
aspiration during swallowing
Active during swallowing to pull the
thyroid and larynx up beneath the
epiglottis
Active during swallowing to pull the

hyoid bone upwards towards the
mandible
Inspiratory phase of respiration, jaw

opening during most speech sounds
Inspiratory phase of respiration, also

active to close the nasopharynx
during swallowing and most speech
sounds
Aids in inspiration to elevate the soft
palate and during swallowing
prevents entry of the bolus into the
nasopharynx
Inspiratory phase of respiration
First cervical spinal nerve

branching off the
hypoglossal
(continued)
Medial branch of the

hypoglossal
Mylohyoid nerve, a
branch of the inferior
alveolar nerve, and the
mandibular division of
the trigeminal
Mylohyoid nerve, a branch
of the inferior alveolar
nerve, off the
mandibular nerve, off
the trigeminal nerve
First cervical spinal nerve
branching off the
hypoglossal
Medial pterygoid nerve of

the mandibular branch
of the trigeminal
Pharyngeal branch of the

vagus
Table 10.2 Dilator and constrictor pharyngeal muscles: their insertion points, contraction effects, function for respiration and swallowing, and innervations
Muscle
Insertions
Task function
Innervation
10
173
Insertions
Hamulus of the
pterygoid bone,
pterygomandibular
raphe, mylohyoid
line of mandible
and lateral on the
tongue muscles
Superior and inferior
horns of the hyoid
bone, stylohyoid
ligament
Thyroid cartilage and
lateral side of
cricoid cartilage
Circular muscle
meeting at the
median raphe
posteriorly
Upper pharyngeal
constrictor
Cricopharyngeus
Lower pharyngeal
constrictor
Middle pharyngeal
constrictor
Side of the tongue to

the styloid process
Styloglossus
Constrictor muscles for swallowing

Hyoglossus
Hyoid to the root of the
tongue
Muscle
Table 10.2 (continued)
Closes to prevent regurgitation of

esophageal contents
Squeezes the pharynx closed
Pulls the root of the tongue

downwards towards the
epiglottis to push the posterior
base of tongue downwards in
the posterior oropharynx
Pulls the sides and back of the
tongue upwards and backwards constricting the
posterior oral pharynx
Active for swallowing to push the bolus

downwards in the pharynx towards
the upper esophageal sphincter
Relaxes and opens at the end of
pharyngeal phase of swallowing to
allow the bolus to enter the
esophagus and then closes to
prevent regurgitation of esophageal
contents


Active during swallowing to bring

posterior tongue downwards to add
pressure to epiglottis to aid in
inversion and closing of the
vestibule
Helps to push the bolus backwards and
down the pharynx for swallowing
Task function
Pharyngeal plexus of the

vagus, external branch
of the superior
laryngeal nerve and a
branch of the recurrent
laryngeal nerve

vagus

vagus

vagus, and external
branch of the superior
laryngeal nerve
Hypoglossal nerve
Hypoglossal nerve
Innervation
174
C.L. Ludlow
175
Other muscles that dilate the upper pharynx include the levator veli palatini
and the hyoid muscles (mylohyoid, thyrohyoid, hyoglossus, and geniohyoid)
(Table 10.2). The levator veli palatini elevates the velum, closing off the velopharyngeal port to prevent entry of the bolus into the nasal cavity during swallowing
and air ow during all speech sounds except the nasal sounds (/m/,/n/,/ng/). Elevating
the velum also serves as an upper airway dilator as it opens the hypopharynx, allowing an increased opening for air ow into the hypopharynx.
During swallowing, changes in upper airway shape and pressures assure rapid
and complete passage of the bolus (food or liquid) through the oral cavity, hypopharynx, and upper esophageal sphincter into the esophagus. Oral transit starts with
closure of the lips and jaw to prevent spillage, collection of the bolus into one mass,
and a stripping motion of the tongue blade against the roof of the mouth to move the
bolus backwards into the posterior pharynx. Prior to passage of the bolus through
the pharynx, the hyoid moves forwards and upwards to dilate the hypopharynx to
allow entry of the bolus while closing the upper airway by tucking the larynx forwards and upwards under the epiglottis. The epiglottis becomes inverted over the
entry to the laryngeal vestibule by posterior action of the tongue over the hyolaryngeal complex as it elevates under the tongue, squeezing the epiglottis downwards (Fig. 10.1a). Elevation of the hyo-laryngeal complex involves contraction of
the suprahyoid muscles pulling the hyoid forward and upward (geniohyoid,
mylohyoid, hyoglossus). Simultaneous contraction of the thyrohyoid is required to
elevate the thyroid cartilage to the hyoid as the hyoid is raising to close the laryngeal
vestibule reducing the risk of bolus entry into the airway (Fig. 10.1a). Passage of the
bolus through the pharynx begins with pressure of the posterior tongue towards the
posterior pharyngeal wall while dilating the anterior pharynx though anterior elevation of the hyo-laryngeal complex. Subsequent sequential squeezing actions of the
pharyngeal constrictors from superior to middle and inferior push the bolus downwards. Opening of the upper pharyngeal sphincter is achieved through two actions,
anteriorsuperior movement of the larynx stretching the cricopharyngeus (Fig. 10.1b)
and reexive relaxation of the cricopharyngeus.
10.5
Pharyngeal Innervation
The human pharyngeal constrictor muscles have two distinct layers, an outer fast
layer innervated by the vagus and a slow acting inner layer innervated by the
glossopharyngeal nerve (Mu and Sanders 2007). Mu and Sanders hypothesized that
the slow acting inner layer maintains stiffness in the pharyngeal wall for dilation for
respiration while the fast outer wall is essential for rapid and forceful contraction to
increase pressure on the bolus and push it downwards in the hypopharynx towards
the upper esophageal sphincter during swallowing. The inferior pharyngeal constrictor also has a two layered structure but has rostral and caudal compartments
with the caudal portion having immunohistological characteristics similar to the
cricopharyngeus muscle. For that reason, it has been proposed that the inferior
176
C.L. Ludlow
HG
MH
Bolus
aspiration
GH
Effects of hyo-laryngeal elevation
on Airway protection
HG
MH
GH
UES
UES
Effects of hyo-laryngeal elevation

on opening the UES
Fig. 10.1 (a) Schematic illustration of the muscle vectors to raise the hyo-laryngeal complex to
close the laryngeal vestibule and protect the airway from bolus entry. (b) A schematic illustration
of how hyo-laryngeal elevation can stretch the cricopharyngeus to assist with the movement of the
bolus through the upper esophageal sphincter. The muscles are mylohyoid (MH), geniohyoid
(GH), hyoglossus (HG), and thyrohyoid (TH). The upper esophageal sphincter is labeled UES
pharyngeal constrictor functions as part of the upper esophageal sphincter along

with the cricopharyngeus (Mu and Sanders 2001).
The upper esophageal sphincter is a complex structure. First, Mu and Sanders
have recently described the cricothyropharyngeus muscle found only in human specimens (Mu and Sanders 2008). This muscle originates from the anterior arch of the
cricoid cartilage, courses between the inferior pharyngeal constrictor and cricopharyngeus muscles to insert into the median raphe at the posterior midline of the pharynx with separate innervation of two compartments; a laryngeal portion innervated
by the external superior laryngeal nerve, and a pharyngeal portion innervated by the
pharyngeal plexus. The cricopharyngeus forms the major part of the upper esophageal sphincter and is of great importance to swallowingthis muscle is normally
tonically active keeping the sphincter closed to prevent spillage of the contents of the
upper esophagus into the hypopharynx and the upper airway. Relaxation is essential
to allow the bolus to be cleared out of the hypopharynx and into the esophagus.
Without relaxation and bolus clearance there is the collection of residual of the bolus
which will collect in the pyriform sinuses, and spillage back into the glottis and
through the vocal folds places the person at risk of aspiration of food or liquid into
177
the lungs. Innervation of the cricopharyngeus is controversial and may include the
pharyngeal plexus, the glossopharyngeal nerve, the cervical sympathetic ganglion or
the RLN or a combination of these (Brok et al. 1999). Clinical studies in humans
have investigated the relationship between RLN and the cricopharyngeus muscle with
some suggesting that the RLN may contribute innervation (Brok et al. 1999) while
others have found no relationship (Halum et al. 2006). As Mu and Sanders (1998)
suggested, several muscles are involved in this upper esophageal sphincter with different innervation patterns; the inferior pharyngeal constrictor is innervated by the
pharyngeal plexus, while the cricopharyngeus may receive innervation from both the
pharyngeal plexus and the RLN. The more recently identied cricothyropharyngeus
is innervated by the eSLN and the pharyngeal plexus (Mu and Sanders 2008).
10.6
Sensory-Motor Interactions Controlling

the Laryngeal and Pharyngeal Muscles
For airway protection and swallowing, sensory inputs to mechanoreceptors in the

laryngeal mucosa elicit brainstem reexes that produce vocal fold closure (Sasaki
and Suzuki 1976; Andreatta et al. 2002) referred to as the glottic closure reex or
laryngeal adductor response (LAR) (Ludlow et al. 1992), while pharyngeal stimulation with water elicits a pharyngoglottal closure reex and reexive swallow (Shaker
et al. 1998, 2003). The importance of sensory triggers for the elicitation and motor
production of swallowing was demonstrated in healthy young volunteers when
anesthesia in the region of the iSLN not only interfered with the initiation of swallowing but produced both penetration and aspiration during swallowing in normal
persons (Jafari et al. 2003). Aviv and his colleagues measured laryngeal sensation in
patient with strokes who were with and without dysphagia and suggested that many
patients with aspiration had disruption of the LAR (Aviv et al. 1996). However, this
has been controversial with some investigators supporting this association (Flaksman
et al. 2006) while others have questioned this association (Widdicombe and
Addington 2006). Stimulation of the laryngeal mucosa for testing whether or not
upper airway reexes are intact for laryngeal closure is used clinically (Aviv et al.
1998) but needs further study to determine the role of this reex in airway protection during swallowing. One study demonstrated that this reex was actually suppressed during swallowing (Barkmeier et al. 2000), although it remained intact
during voice and speech (Henriquez et al. 2007).
The powerful effects of sensory stimulation to the glossopharyngeal and superior
laryngeal nerve for eliciting reex swallowing has recently received attention as a
method for inducing swallowing in patients with swallowing disorders secondary to
neurological diseases or disorders. Using air pulse stimulation to the faucial pillars,
Martin and colleagues have shown that this can increase the frequency of swallowing both in healthy persons as well as in the aged (Theurer et al. 2005, 2009).
Both mechanical and electrical stimulation to the pharyngeal branch of the
glossopharyngeal nerve and to the iSLN, and electrical stimulation to the pharynx
178
C.L. Ludlow
wall are powerful stimuli for inducing ctive swallowing in the rat (Kitagawa et al.
2002, 2009). This has recently been used clinically for inducing the return of swallowing in stroke patients by use of electrical stimulation to the pharyngeal wall
(Jayasekeran et al. 2010). The powerful effects of sensory triggers to the brainstem
centers controlling the laryngeal and pharyngeal muscles for swallowing are an
attractive mechanism for enhancing reexogenic swallowing in patients who have
lost volitional control.
10.7
Central Neural Control of the Laryngeal

Some neural substrates controlling this automatic motor patterning for voice and
speech are located in the cortex. Brain lesions or disease affecting the basal ganglia,
cerebellum, and thalamus often produce a slowing or a loss of the normal rhythm of
speech, producing disorders referred to as dysarthrias but the pattern of muscle
activation for the production of speech sounds is retained. Only when damage
involves cortical regions or interactions of other brain regions with the cortex is the
motor pattern for speech articulation disturbed, resulting in the loss, distortion, or
errors in speech articulation programming accuracy resulting in a disorder referred
to as apraxia of speech (Kent 2000).
Vocalization which is not based on speech or singing is present at birth (the birth cry)
and depends upon mammalian vocalization systems which are contained in the brain
stem, pons, and periaqueductal gray and have a similar bases in humans as in other
mammals (Jurgens 2000). In contrast, voice production for speech is cortically based
and unique to human species (Jurgens 2002). As a result, studies of the neural control
of voice and speech in humans are limited to the study of the effects of brain lesions
or more recently to functional brain imaging and transcranial magnetic stimulation.
The neural substrates for swallowing involve subcortical brain mechanisms that
are similar in humans and other mammals and involve patterning of the laryngeal
and pharyngeal muscles. Cortical control for the volitional elicitation of swallowing
on command is also present in the human and has more recently been studied using
functional brain imaging showing cortical control is present similarly for volitional
and automatic swallowing (Martin et al. 2001, 2007) while brainstem control centers are also active (Komisaruk et al. 2002).
10.8
Effects of Neurological Diseases on Laryngeal

and Pharyngeal Muscle Control
Motor control for speech and swallowing are affected by a multitude of neurological diseases. Peripheral neuropathies that are length dependent and impacted by the
RLN, the longest nerve innervating craniofacial muscles, are often affected by
179
genetic mutations resulting in neural transport abnormalities (Benson et al. 2010;

Landoure et al. 2010). Brain stem strokes in the lateral medullary region, referred to
as Wallenberg syndrome, disrupt pre-synaptic input to the laryngeal motor neurons
in the nucleus ambiguus, resulting in a unilateral vocal fold paralysis for voice and
swallowing. In addition, lateral medullary lesions often result in a serious disturbance in swallowing patterning as the integrity of the brainstem central pattern
generator for swallowing is affected on one side (Kim et al. 2000; Aydogdu et al.
2001). Disorders and diseases of the basal ganglia can interfere with the timing of
muscle patterning and level of muscle activation. Most prominent are those that
accompany Parkinsons disease particularly as the disease progresses (Dickson and
Grunewald 2004) to involve regions well beyond the substantia nigra (Braak et al.
2003) impacting the precision of recruitment of laryngeal muscles for rapid voice
onset and offset during speech (Gallena et al. 2001).
Given the important contribution of cortical mechanisms in the left hemisphere
for speech and voice production, mechanisms of enhancing left hemisphere cortical
control while suppressing interfering brain mechanisms in the right hemisphere
have recently received a great deal of attention. Using transcranial magnetic stimulation at slow rates which are inhibitory to motor function over the right hemisphere
has been found to induce recovery in a few patients with motor speech disorders
(Martin et al. 2009a, b; Hamilton et al. 2010).
For the elicitation of swallowing, sensory stimulation seems to enhance the elicitation of reexogenic swallowing, perhaps at the brain stem level. However, recent
studies using functional magnetic resonance imaging now suggest that the application of sensory stimulation in the oropharynx can enhance cortical activation not
only in the somatosensory regions but also in regions of the cortex that are active for
the volitional control of swallowing in normal humans (Lowell et al. 2008; Soros
et al. 2008), indicating that sensory stimulation may be useful in up-regulating cortical motor control mechanisms involved in the control of both the laryngeal and
pharyngeal muscles for automatic and volitional swallowing.
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Chapter 11
Laryngeal Muscle Response to Neuromuscular

Diseases and Specific Pathologies
J.C. Stemple, L. Fry, and R.D. Andreatta
Musculature of the craniofacial region represents a diverse group of skeletal muscles

responsible for processes underlying respiration, deglutition, speech production,
vision, hearing, and the display of emotions. Together, these muscles demonstrate a
remarkable degree of anatomical specialization that permits their successful engagement in behavioral functions. Because the functional demands placed upon craniofacial muscles differ substantially from those imposed upon other skeletal muscles, the
craniofacial muscles show marked anatomical, physiological, and biological deviations from typical limb skeletal muscles. The uniqueness of the craniofacial muscle
phenotype has led to their being described by some as paradoxical members of the
skeletal muscle group (Noden and Francis-West 2006).
It is increasingly recognized that the anatomical and physiological differences
that exist between craniofacial and limb skeletal muscles are vast. Architectural differences related to muscle insertion patterns, fascicle orientation, muscle ber size,
and sarcomeric structure have been noted (Porter and Baker 1996; Andrade et al.
2003, 2004, 2005; Porter et al. 2003; Sadeh et al. 1981). Additionally, differences in
contractile protein expression, mitochondrial content, neuromotor innervation, and
contraction-related proprioceptive mechanisms have recently been documented.
These latter specializations produce functional differences in contractile times, force
generation, fatigability, and motor unit recruitment patterns (Porter and Baker 1996;
Zemlin 1988; Bendiksen et al. 1981; Brandon et al. 2003a, b; Perie et al. 1997,
2000; Rossi and Cortesina 1965; Sciote et al. 2002; Shiotani and Flint 1998; Shiotani
et al. 1999; Konig and von Leden 1961; Close and Luff 1974; Luff 1981; Lynch
et al. 1994). The exact nature of the distinctive phenotype of craniofacial muscle has
yet to be elucidated; however, it has been suggested that phenotypic diversity is
J.C. Stemple (*) L. Fry R.D. Andreatta

Division of Communication Sciences and Disorders, University of Kentucky,
900 South Limestone Street, Lexington, KY 40536, USA
e-mail: joseph.stemple@uky.edu
185
186
J.C. Stemple et al.
established during morphogenesis and is later regulated and inuenced by musclegroup specic patterns of gene expression (Noden and Francis-West 2006; Spencer
and Porter 2006; Cheng et al. 2004; Fischer et al. 2005).
The consequences of the biological and functional diversity between craniofacial
and limb skeletal muscle are signicant. Specialized phenotypes of craniofacial
muscles likely underlie and permit these muscles to (1) engage in extremely rapid
yet prolonged contraction, (2) contribute to highly rened patterns of movement,
(3) recover consequently from mechanical and neurological insult, (4) resist the
inuence of aging and lastly, (5) escape the pathological cascade of select neuromuscular diseases (Porter and Baker 1996; Zemlin 1988; Spencer and Porter 2006;
Cheng et al. 2004; Marques et al. 2007; McLoon et al. 2004, 2007; Muller et al.
2001; Norton et al. 2001; Thomas et al. 2008; Pavlath et al. 1998). One subset of the
craniofacial muscles emerging as highly specialized in the mammal is the intrinsic
laryngeal muscles (ILMs). The ILMs are intricately involved in the life-sustaining
functions of respiration, airway protection, and swallowing, with critical secondary
functions in vocalization and communication behaviors (i.e., human speech).
11.1
Differences in Limb vs. Craniofacial Muscles

Point to the Existence of Unique Phenotypes
It has been well established that limb skeletal muscle has the capacity to regenerate
in the face of injury via the action of satellite cells. After myober injury for example, satellite cells progress from a quiescent state to an active state. Once active,
these cells move to the site of injury, fuse with one another, and differentiate into
new myobers (Mauro 1961). However, recent work in the extraocular muscles
(EOM) and laryngeal muscles of rabbits suggests that myober remodeling is an
ongoing event in these select muscle groups, occurring in the absence of any apparent ber injury (McLoon et al. 2004; Goding et al. 2005; Shinners et al. 2006).
Seminal work in this area by McLoon et al. (2004) found evidence of continual
myonuclear removal and addition in uninjured single bers of rabbit EOM.
Remodeling was noted to proceed at a rate of one myonuclear addition per 1,000
myobers in cross section every 12 h. Subsequent work by Goding et al. (2005)
identied similar patterns of uninjured ber remodeling in rabbit thyroarytenoid
(TA) and posterior cricoarytenoid (PCA) muscles, estimating that myonuclear addition in the laryngeal muscles occurred at a rate of 2 myonuclei per 1,000 myobers
in cross section per 24 h. Together, these ndings suggested that muscle precursor
cells, generally quiescent in limb skeletal muscle, are continuously active in subsets
of craniofacial muscles, and that this enhanced remodeling capacity may be related
to the great potential of these muscles to recover after insult (Goding et al. 2005;
McLoon et al. 2004).
Along this same vein, the laryngeal muscles have long been recognized for their
ability to survive and reinnervate following neurological insult (Gardner and
Benninger 2006; Nomoto et al. 1993; Shindo et al. 1992). Following denervation of
11
Laryngeal Muscle Response to Neuromuscular Diseases and Specic Pathologies
187
a vocal fold, reinnervation ensues in a portion of cases, even after extended periods
of time (Shindo et al. 1992). This marked ability to reinnervate has not been fully
explained; however, it has been suggested that regenerating axons from the damaged nerve or supplemental innervation from the superior laryngeal nerve (SLN)
may play a role (Nomoto et al. 1993; Shindo et al. 1992). Such patterns of reinnervation and muscle maintenance post-insult are not observed in limb skeletal muscle,
where reinnervation is less common and denervation atrophy can be marked (Engel
and Banker 1994; Watras 2004; Kobayashi et al. 1997).
11.2
Differences in Limb and Craniofacial Muscle

Response to Neuromuscular Disease and Injury
Most neuromuscular diseases exert their pathological cascade universally across

skeletal muscles. However, some craniofacial muscles respond uniquely to neuromuscular disease challenges that target typical skeletal muscle. For example,
differential response of the extraocular and laryngeal muscles in Duchenne muscular dystrophy (DMD), amyotrophic lateral sclerosis (ALS), myasthenia gravis, and
mitochondrial myopathy have been recently documented (Porter and Baker 1996;
Spencer and Porter 2006; Fischer et al. 2005; Marques et al. 2007; Thomas et al.
2008; Kaminski et al. 1992; Andrade et al. 2000). Generally, the neuromuscular and
cell biological underpinnings for the EOM and ILMs unique responsiveness to
these select disorders have not been fully explained, and the mechanism of the
groups differential response in these diseases has not yet been determined. Current
hypotheses suggest that constitutive features of the laryngeal muscles (e.g., exquisite remodeling capabilities, ber types, rened calcium sequestration mechanisms,
and/or lower levels of mechanical force generation during contraction) may play a role
(Andrade et al. 2000; Karpati et al. 1988; Kjellgren et al. 2003; Lexell et al. 1986).
The following section highlights the cell biology response of ILM to select neuromuscular diseases and specic pathologies for which any empirical data exist.
11.3
Laryngeal Muscle Response to Muscular Dystrophy
DMD is a recessive X-linked form of muscular dystrophy characterized by rapid

progression of muscle degeneration, eventually leading to loss of ambulation and
death. The disease is a result of a spontaneous mutation of the Xp21 gene, which
results in the absence of the cytoskeletal protein dystrophin (Lansman and Franco
1991; Lapidos et al. 2004). In the absence of this pivotal support protein, the muscle
cell membrane is subject to the mechanical forces of muscle contraction (Lapidos
et al. 2004). Sarcolemmal tearing often results, permitting the entry of extracellular
calcium into the muscle ber. High levels of intracellular calcium trigger the activity
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of protein destroying enzymes and the subsequent destruction of the muscle ber.
Over time, the disease results in widespread necrosis and brosis throughout the
muscle (Lapidos et al. 2004; Menache and Darris 2001). The main symptom of
DMD is muscle weakness and marked wasting of musculature of the hips, pelvic
area, thighs, shoulders, and calf. Muscle weakness also occurs in the arms, neck,
and other areas, but not as early as in the lower half of the body. Symptoms usually
appear before age 6 and may appear as early as infancy. Curiously, the laryngeal
muscles do not appear to be affected in the same manner as appendicular and axial
muscle groups.
Marques et al. (2007) examined the effects of dystrophin deciency on the medial
& lateral thyroarytenoid (TA), lateral cricoarytenoid (LCA), PCA, and the cricothyroid (CT) muscles in 4 month (adult) and 18-month-old (aged) dystrophin decient
mdx and C57Bl/10 (control) mice. No evidence of myober degeneration or regeneration was observed in the medial TA, lateral TA, LCA, and PCA muscles.
Interestingly, mild markers of disease (e.g., central nucleation) were evidenced in
the CT muscle of the mdx mice. While percentages of central nuclei in the mdx CT
(adult mean (M) = 9.3, standard deviation (SD) 4.0; aged M = 18.0, SD = 1.5) did not
approach those of the typically affected tibialis anterior (adult M = 50.0, SD 1.0;
aged M = 96.0, SD = 2.0), they were signicantly higher (p < 0.05) than those
observed in other mdx ILMs (range 1.02.5) and in control CT muscles (adult
M = 4.8, SD 1.1; aged M = 5.3, SD 1.1). The authors proposed that mild disease
effects in the CT in the face of otherwise widespread laryngeal muscle sparing may
have been secondary to the CTs biochemical and/or structural differences from
other ILM.
Findings by Fry et al. (2010) also suggested that the CT and superior cricoarytenoid (SCA), the murine analog to the human interarytenoids (IA), are spared
from the pathological consequences of dystrophin deciency in the mdx mouse.
These results parallel to those of earlier studies using the mdx mouse that showed
sparing of the TA, PCA, and LCA muscles (Marques et al. 2007; Thomas et al.
2008) (Fig. 11.1).
While subtle morphologic changes were found in the mdx CT (i.e., percentages of
central nuclei that were twice that of control muscles), these changes did not reach
statistical signicance (p = 0.058), and there was no corresponding evidence of sarcolemmal disruption or other classic dystrophin deciency markers, suggesting that
CT was spared. These ndings regarding the CT are in contrast to those of the 2007
study by Marques et al. (2007). In that study, small increases in central nucleation
were accompanied by mild markers of myober degeneration (i.e., inammation,
sarcolemmal disruption). The combination of these factors led the authors to conclude a mild disease effect for the CT, a disease response falling between that of the
fully spared ILM and that of classically affected limb skeletal muscle. A similar pattern of slightly increased central nucleation in the absence of marked myober
degeneration has been previously described in other craniofacial muscles known to
be marginally affected by dystrophin deciency (Muller et al. 2001; Andrade et al.
2000). Fry et al. (2010) also demonstrated that utrophin was not up-regulated or
relocalized in the laryngeal muscles, indicating that utrophin regulation alone cannot
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Fig. 11.1 Hematoxylin and eosin staining of hindlimb muscles (upper frames) and laryngeal
muscles (lower frames). Control gastrocnemius shows normal gastrocnemius morphology with
rectangular muscle bers and peripheral nuclei; mdx gastrocnemius evidences brosis, pleomorphic bers, and central nuclei. Control and mdx laryngeal bers demonstrate peripheral nuclei and
consistent ber size and shape. TA thyroarytenoid; PCA posterior cricoarytenoid (Thomas et al.
2008. Reproduced by permission of the American Speech-Language-Hearing Association,
Rockville, MD.)
explain muscle sparing. These ndings point to the continued need to search for a
mechanism of laryngeal muscle sparing in dystrophin deciency.
At present, investigators are considering a number of such mechanisms, including
the over-expression of other associated proteins (e.g., integrins), the mechanical
advantage offered by a smaller muscle ber size, the presence of a superior mechanism of calcium ion handling, and the advanced regenerative capacity inherent in the
muscles (Fischer et al. 2005; Andrade et al. 2000; Karpati et al. 1988; Khurana et al.
1995; McLoon et al. 2004; Porter et al. 2004). The results of the Fry et al. (2010) study
demonstrate that the IA, like the TA, PCA, and LCA possess unique cellular features
that appear to imbue a resistance to the effects of dystrophin deciency. When such
ndings are considered in light of previous work by Tellis et al. (2004) showing the IA
to be phenotypically similar to limb muscle, it is possible that the IA may represent a
phenotypic variant or blended muscle type, sharing properties of specialized craniofacial muscles and properties of typical limb muscle.
With regard to the CT, these results suggest that like other ILMs, this muscle may
be highly specialized with features that offer protection from disease processes. Yet,
the results of other studies showing the CTs phenotype (e.g., metabolic prole,
general morphology, response to disease) as falling between that of specialized
laryngeal muscle and that of prototypical limb muscle, point away from this conclusion. Considering the full body of research on the CT, Fry et al. (2010) supported
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the depiction of the CT as a blended or phenotypically variant form of skeletal

muscle and suggest that additional work is necessary to further characterize this
critical laryngeal muscle. Given the collective results to date, it is suggested that
phenotypical variation of ILMs may exist on a continuum, with some muscles (such
as the TA and PCA) expressing a highly distinct nature that is clearly different from
typical limb muscle and other related muscles (such as the IA and CT) demonstrating a more transitional form.
11.4
Laryngeal Muscle Response to Amyotrophic

Lateral Sclerosis
ALS is a neurodegenerative disorder of the motor cortex and ventral horn cells of
the spinal cord and brainstem motor nuclei. It is the most common motor neuron
disease affecting muscles that control voluntary movement. In approximately
510% of cases, ALS is genetically familial and caused by mutations of CuZn
superoxide dismutase type 1. The mechanism underlying the characteristic selective
degeneration and death of motor neurons in ALS is unknown in the remaining 90%.
Typical onset of ALS is between the fth and seventh decade of life, with diagnosis
typically based on neurological examination conrming the presence of progressive
symptoms: upper and lower motor neuron degeneration, progressive muscle weakness,
atrophy, fasciculations, spasticity, and speech and swallowing disturbances. Tests
often added to the clinical diagnosis of ALS include electromyography (EMG) and
neuroimaging through MRI (Hardiman et al. 2011; Ropper and Samuels 2009).
The presentation of ALS is of two distinct types, limb and bulbar. Seventy-ve
percent of individuals present with a combination of upper and lower motor neuron
degeneration localized to the extremities with noted atrophy, weakness, and fasciculations. In the remaining 25% of individuals with ALS, the presentation is that of
bulbar symptoms of the oropharyngeal muscles including difculty with speech
(articulation, dysphonia, hypernasality, breathiness) and swallowing (oral control of
saliva and aspiration). These speech and swallowing symptoms are recognized as
possible early signs of bulbar onset of ALS (Langmore and Lehman 1994). The
early laryngeal manifestation of ALS appears to be a function of the preferential
involvement of the cranial nerve nuclei responsible for laryngeal function (DePaul
and Brooks 1993).
Tomik et al. (2007) proled the gross laryngologic abnormalities in patients with
both limb and bulbar onset ALS. In their study, 35 ALS patients were recruited for
laryngeal examination, with participants divided into limb (n = 11) and bulbar
(n = 24) groups. The bulbar group was further subdivided into predominantly lower
motor neuron presentation (n = 10), and those with predominantly upper motor neuron presentation (n = 14). The larynx and vocal folds were assessed for vocal fold
vibration dynamics, mobility, and phonatory closure by a combination of mirror
examination, exible endoscopy, and videostroboscopy. All visual examinations
were augmented by audio-perceptual judgments of voice quality.
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In the ALS limb group, vocal fold mobility demonstrated a slight deviation from
normal in nine out of 11 patients. Sluggish movement of both vocal folds and lack
of complete closure during phonation were detected in three participants. There was
a unilateral decrease in tension and mobility of the vocal fold in four cases and vocal
fold bowing in two others. However, audio-perceptual assessment of the voice
qualities of the limb onset patients revealed no disturbances to vocal pitch.
Bulbar onset participants with predominantly lower motor neuron involvement
presented with smooth vocal fold edges and decreased vocal fold mobility and
adduction during the respiratory phase. During phonation, some patients showed
lack of complete vocal fold closure, with an hourglass shaped glottis closure pattern.
In these cases, voice quality was described as husky and low. For bulbar onset
participants classied as predominantly upper motor neuron, their presentation
demonstrated slight disturbances with mobility, hypoadduction of the vocal folds,
and hyperadduction of the ventricular folds. The vocal folds were described as
thicker, and voice production was characterized by increased tension in the cervical
musculature causing a harsh, strain-strangled voice quality, similar to that heard in
spasmodic dysphonia (Tomik et al. 2007; Lundy et al. 2004). In addition, this group
demonstrated a hypernasal quality.
These distinct laryngeal and voice quality ndings may be used to supplement
other clinical diagnostic tools especially with individuals suspected of presenting
with bulbar onset ALS. Indeed, it has been suggested that early bulbar signs such as
reduced voice frequency range and phonatory instability may be present in patients
with ALS before the occurrence of perceptually aberrant vocal characteristics
(Silbergleit et al. 1997; Watts and Vanryckeghem 2001). Another frequent laryngeal
symptom of ALS that occurs when the respiratory muscles become weak is dyspnea.
Dyspnea may also result from a narrowing of the glottis due to paresis of the PCA
muscles, the vocal fold abductors. This paresis may lead to laryngeal symptoms
including hoarseness, hypophonia, and short phonation time to nocturnal nonproductive cough and attacks of inspiratory stridor and shortness of breath (van der
Graaff et al. 2009).
Beyond the laryngeal function of voice quality is the vegetative function of swallowing. The laryngeal musculature is responsible for the protection of the airway
during this life-sustaining event. Laryngeal muscle paresis leading to reduced glottal
closure may lead to swallowing problems. Indeed, mortality in the ALS population is
often associated with aspiration pneumonia. Although typically considered only as a
motor neuron disease, Amin et al. (2006) studied the contribution of sensory dysfunction as a contributor to this disease process. The sensation of the larynx was
studied in 22 patients with ALS with abnormal sensation found in 54.5% of the tested
population. The authors concluded that in addition to muscle weakness, decreased
sensation may also contribute to the swallowing difculties of individuals with ALS.
Very little is known of the exact laryngeal muscle biological response to ALS,
although a handful of quantitative studies examining motor end plates and other
histological and physiological studies have been conducted in selected ILM (Gambino
et al. 1985; Kanda et al. 1983; Yoshihara et al. 1984, 1991; Nomoto et al. 1991).
Yoshihara et al. (1998) examined the TA and PCA muscles in four patients with ALS
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Fig. 11.2 Ultrastructure of the NMJ in ALS. (a) NMJ of the TA muscle retaining almost normal
nerve terminals, synaptic clefts and synaptic contact (bar 1.0 mm, 6,400). (b) Small nerve terminal
(arrow) on the attened primary synaptic clefts (arrowheads) and well-preserved secondary synaptic
clefts (PCA muscle). Inset: higher magnication of the nerve terminal (bar 1.0 mm, 7,600).
(c) Schwann cell (arrowheads) covering the degenerating nerve terminal (PCA muscle) (bar 1.0 mm,
10,000). (d) Distorted primary and secondary synaptic clefts and aggregation of myobrils (PCA
muscle) (bar 1.0 mm, 10,000) (Ultrastructural Pathology by Taylor & Francis Inc. Reproduced with
permission of Taylor & Francis Inc. in the format Journal via Copyright Clearance Center.)
following total laryngectomy due to severe dysphagia and dysphonia. Control specimens were obtained from non-affected muscles of three individuals who had total
laryngectomy secondary to laryngeal cancer. The TA and PCA muscles were examined histochemically and with electron microscopy. Results demonstrated that the
affected specimens from participants with ALS exhibited typical neurogenic changes
such as small angulated bers and grouped atrophy. Acetylcholinesterase (AchE)
activities of the neuromuscular junctions (NMJs) of many bers in the ALS group
were decreased as compared to controls. In addition, some motor end plate areas on
each ber detected by AchE histochemistry were larger than those of the controls.
The ultrastructure of the ALS muscle ber specimens showed an increased number
of lipofuscin granules and/or nuclei, numerous mitochondria, and the disappearance
of myolaments. The NMJ also demonstrated varying degrees of structural change
ranging from almost normal to the absence of nerve terminals and Schwann cells
covering the junctional sites. In addition, primary synaptic clefts were attened while
the secondary synaptic clefts appeared relatively well-preserved. The authors also
described several small nerve terminals that were occasionally seen on the severely
distorted postsynaptic folds, suggesting regenerative efforts. In severely degenerated
muscle bers, the NMJ was generally absent (Fig. 11.2).
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11.5
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Laryngeal Muscle Response to Myasthenia Gravis
Myasthenia gravis (MG) is an autoimmune neuromuscular disease that causes

uctuating muscle weakness and fatigue. The muscle weakness is caused by failure of
neuromuscular transmission, resulting from the binding of autoantibodies to proteins
involved in signaling at the NMJ. Antibodies bind to postsynaptic acetylcholine (ACh)
receptors, resulting in a reduction in the number of available ligand binding sites.
Normal repetitive nerve stimulation also leads to a successive decrease in the amount
of acetylcholine released presynaptically. The combination of fewer available binding
sites and reduced acetylcholine release at the motor end plate gives rise to the induced
muscle fatigue observed in patients with MG (Patel and Forsen 2001).
Although any skeletal muscles can be affected by MG, the ocular, facial, oral, pharyngeal, laryngeal, and respiratory muscles seem to be the most susceptible. The laryngeal musculature was implicated in MG as early as 1914, when Edward Davis reported
to the Royal Society of Medicine a case of a 25-year-old woman who presented with
aphonia, dysphagia (Kluin et al. 1996), and nasal regurgitation (Davis 1914). Mao et al.
(2001) reported a series of 40 patients who presented with hoarseness as their primary
complaint. Voice diagnostic testing including laryngeal videostroboscopy, EMG with
repetitive stimulation and Tensilon testing; radiographic evaluations were also conducted. Stroboscopic observations revealed a uctuating unilateral or bilateral impairment of vocal fold mobility. EMG detected evidence of NMJ abnormalities in all
subjects. Only one patient had evidence of AChR antibodies, but the authors reported
that many other abnormalities suggestive of autoimmune dysfunction were present.
Pyridostigmine therapy was initiated in 34 patients but was not tolerated in 4. Of the
remaining 30 patients, 23 reported improvement of symptoms. The authors concluded
that myasthenia gravis can present with symptoms conned primarily to the larynx and
should be included in the differential diagnosis of dysphonia.
Of primary concern in human populations is weakness of laryngeal and pharyngeal
musculature leading to ineffective swallowing with poor airway protection. This
situation may be further compounded by a poor cough as respiratory musculature is
also frequently involved in patients with MG. The combination of poor respiratory
effort and an ineffective swallow with the absence of protective mechanisms can
lead to aspiration and, potentially, pulmonary infection. Indeed, Higo et al. (2005)
studied the swallowing function of 11 patients diagnosed with MG via
videouoroscopy. Aspiration was seen in 34.8%, with half of these cases involving
silent aspiration. Three of the four cases that showed silent aspiration went on to
experience aspiration pneumonia during the follow-up term.
Unfortunately, while descriptive reports on peripheral clinical features abound,
the pathophysiological effects of MG on laryngeal muscle cell biology are currently
unknown. While it is tempting to extrapolate ndings from studies conducted with
other skeletal muscle systems, our own experience with the differential effects of
Duchennes muscular dystrophy on ILM cell biology provides a cautionary note to
blanket application of muscle features across differing functional systems. Critical
basic and functional work is needed to further advance our understanding of MG
pathophysiology in the human.
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Laryngeal Muscle Response to Peripheral Paralysis
Laryngeal muscle denervation is caused by peripheral involvement of the recurrent

laryngeal nerve (RLN) and less commonly of the SLN. Proximal involvement of the
vagus (cranial nerve X) affects both the recurrent and SLNs while more distal injury
may affect just one nerve. The location of the lesion along the nerve pathway will
determine the type of paralysis and the resulting voice quality. Etiologies of vocal
fold paralysis include surgical trauma (i.e., thyroid, anterior cervical fusion, carotid
surgeries), cardiovascular, neurologic, chest diseases, and accidental trauma (Rubin
et al. 2003; Wilatt and Stell 1991; Kelchner et al. 1999; Benninger et al. 1998) with
idiopathic unilateral vocal fold paralysis accounting for 16.323% of all cases.
11.7
Recurrent Laryngeal Nerve Paralysis: Unilateral
The RLN innervates all the ILM except the cricothyroid. Patients with unilateral
RLN paralysis present with varied vocal symptoms, ranging from mild to severe
dysphonia. Typically noted perceptual symptoms of paralysis are breathiness, low
vocal intensity, low pitch, and diplophonia, resulting from irregular and incomplete
glottal closure during vocalization. Inadequate valving of the laryngeal system will
also compromise airway protection during deglutition. Because the RLN mediates
both adductor and abductor functions, the positioning of the paralyzed fold, varying
from fully abducted, to paramedian, to a midline state will inuence the nature and
severity of the associated voice and swallowing disruption. The most common outcome of unilateral RLN paralysis is a paralyzed fold in the paramedian position,
approximately 12 mm from midline. This aberrant positioning of the paralyzed
fold will inuence factors such as glottal gap size, phonation dynamics, and airway
protection. Voice quality is usually characterized by breathiness and diplophonia,
and the inability to develop adequate lung pressures that result in dramatically
decreased vocal intensity. Patients with paralysis describe physical fatigue resulting
from the greater effort that is required to produce a sufciently clear and loud voice.
Current treatment strategies include a large range of behavioral, surgical, and combination approaches (Stemple et al. 2009).
11.8
Recurrent Laryngeal Nerve Paralysis: Bilateral
Bilateral vocal fold paralysis is by far more serious than unilateral forms of paralysis.
The underlying etiology is typically a higher vagal injury or progressive neuropathy. When vocal folds are paralyzed in the adducted position (at midline), they
cannot abduct to create an airway opening sufcient to sustain respiration. This
critical condition is called bilateral abductor paralysis and requires a surgical
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procedure to re-establish adequate airway patency, often through a tracheostomy.

Surgical manipulation of one arytenoid cartilage also will create a sufcient airway by either removing the arytenoid entirely or suturing it laterally (Gardner and
Benninger 2006; Lawson et al. 1996; Feehery et al. 2003). If an arytenoid lateralization is performed, voice quality will be permanently weakened and aphonic. If
bilateral paralysis of the folds results in a paramedian or laterally abducted position, ventilation is no longer a concern but airway protection becomes a much
larger threat because of the inability of the vocal folds to adequately close to prevent aspiration. With bilateral adductor paralysis in the paramedian conguration,
neither voice production nor airway protection can be achieved, with patients
often requiring gastrostomy tube feedings because of poor airway protection.
Augmentative communication aids such as speech ampliers and electrolarynx
devices have been used before to augment the whispered voice. In some cases,
vocal fold contracture and brosis may arise several months after injury. These
conditions result in a drawing of the folds closer to midline, allowing for harsh
and breathy phonation quality to emerge and improvements to airway management during swallowing (Stemple et al. 2009).
11.9
Superior Laryngeal Nerve Paralysis: Unilateral

or Bilateral
The external branch of the SLN innervates the CT while internal branches provide
for sensation to the inner lumen of the larynx. Unlike RLN trauma, SLN injury is
not readily observable and difcult to ascertain, especially in unilateral cases
(Dursum et al. 1996; Robinson et al. 2005). In a recent study, Roy et al. (2009)
demonstrated a tilting of the epiglottal petiole toward the side of paralysis during
the production of a high-pitched/eee/sound. In addition, unilateral SLN paralysis
may also result in an oblique positioning or an overlap of the folds because of the
unequal rocking of the cricothyroid joint. The overlap creates a gap between the
folds that limits the midline closure pattern during vocal fold vibration and decreases
the ability to build subglottic air pressure, thus limiting vocal intensity. Often these
voice disturbances are not noticeable during connected speech production, but the
laxness of the affected fold creates an imbalance that reduces the pitch. Most patients
with unilateral SLN paralysis complain of vocal fatigue and the inability to sing
(Dursum et al. 1996; Robinson et al. 2005). Bilateral paralysis of the cricothyroid
muscles is rare and must be conrmed through the use of LEMG studies (HemanAckah and Barr 2006; Sataloff et al. 2004). If paralysis should occur, the vocal folds
will lack their normal tone and will not lengthen sufciently during attempts to
increase pitch. Voice quality is limited in frequency, intensity range, and stability.
Although there is no medical treatment for SLN paralysis, behavioral voice therapy
may help maximize vocal potential.
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Neurapraxia, acute temporary laryngeal paralysis, results from a loss of signal

conduction as a result of demyelination without disruption of the axons.
Remyelination by Schwann cells results in full recovery. Axonotmesis (e.g., nerve
crush) is a more severe injury that disrupts the axons but leaves the investiture of the
nerve intact. Recovery begins when regenerating axons enter the native endoneurial
tubes leading back to the original target muscles (Zealear and Billante 2004).
Reinnervation is often inappropriate as regenerating axons may randomly enter
endoneurial conduits of the wrong muscle leading to synkinetic reinnervation.
Synkinesis results in chronic dystonia or xation because of simultaneous contractions of antagonistic muscles. In cases where the muscle connection is appropriate,
paralysis may be the result of partial muscle denervation and abnormalities in the
type, size, and number of reinnervating motor units (Zealear and Billante 2004).
11.10
Morphological Cell Changes of the ILMs:

Denervation and Reinnervation Effects
Several recent studies have characterized the morphology of laryngeal muscles

following denervation (Miyamaru et al. 2008; Vega-Cordova et al. 2010; Romo and
Curtin 1999; Woodson et al. 2008; Xu et al. 2009), yet our current appreciation of
laryngeal muscle ber typing and morphological changes as a function of denervation remains incomplete. What literature does exist is suggestive of important
differences in ber type composition and plasticity of ILM following denervation
and repair in animal models. A report from Rhee et al. (2004), demonstrated that
ILM myosin heavy chain (MyHC) expression differs across tested ILMs and that
ber type modication does occur after transection and subsequent repair of the
RLN in the rat model. Specically, Rhee et al. noted that MyHC is differentially
expressed in the CT and the TA muscles, with CT expressing limb MyHC isoforms
and the TA expressing MyHC variants typically found in the EOM. CT muscles
were noted to possess all recognized MyHC isoforms found in limb skeletal muscles. The TA, in contrast, was found to have three primary isoforms (2B/EOM,
2X/2B, and 2X) with each isoform localized to distinct compartments within the
TA. The TA was described as having an external division consisting mostly of 2B/
EOM bers, and a vocalis division composed of 2X, 2B/EOM, and some 2X/2B
bers. Experimental transection of the RLN and subsequent surgical repair resulted
in random cross-reinnervation patterns across different compartments within the TA
muscle. De-innervated TA bers from the external compartment progressively
declined in their expression of EOM and 2B MyHC, and increased in their expression of 2x MyHC. These ndings are consistent with other reports describing similar proportional changes in the ratios of type 2B, type 2B/EOM, and 2X isoforms
following denervation of the TA, LCA, PCA, and CT in animal models (Shiotani
and Flint 1998; Wu et al. 2004). Together, these data indicate that rodent ILMs may
reect distinct allotypes, and that constituent contractile proteins can be modied
by changes in neural inputs.
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In addition to changes of MyHC isoforms as a function of denervation in ILMs,

other immunohistochemically identied factors have been discovered that impart
upon selected ILMs the capacity to resist nerve input loss and support repair. For
example, a recent report by Vega-Cordova et al. (2010) described changes to three
neurotrophic factors in the TA and PCA muscle following experimental denervation
of the RLN. Using immunohistochemistry to track the expression of brain-derived
neurotrophic factor (BDNF), nerve growth factor (NGF), and neurotrophin 4 (NT-4)
the investigators noted that neurotrophin expression in the TA and PCA responded
differentially to denervation over time. For the TA, NGF levels were initially
decreased, but rebounded after 6 weeks post-injury (Vega-Cordova et al. 2010).
Both BDNF and NT-4 expression were unchanged 3 days following denervation
and 6 weeks post-injury in the TA. In contrast, the PCA demonstrated lower BDNF
level post-injury that never returned to pre-injury values. The PCA did not show any
differences in NGF or NT-4 expression levels at any point during the experiment.
A handful of reports suggest that TA muscle biology may differ signicantly
from other forms of skeletal muscle in its inherent capacity to support reinnervation.
In typical skeletal muscle, denervation leads to atrophy and brosis, diminishing the
potential of the tissue to support reinnervation efforts (Kobayashi et al. 1997). In
contrast, reports suggest that most laryngeal muscles, with the exception of the
PCA, are functionally and morphologically resistant to long-term loss of nerve
inputs (Johns et al. 2001; Morledge et al. 1973), suggesting a greater potential for
recovery. In fact, a recent report by Miyamaru and colleagues has demonstrated that
the TAs capacity to survive prolonged denervation may be due in part to the preservation of optimal ratios of ACh receptors to nerve terminals. Preservation of ACh
receptors is an important prerequisite for robust reinnervation in skeletal muscle
tissue, since regenerating axonal sprouts target ACh receptors to re-establish effective neuromotor communication (Miyamaru et al. 2008). Subsequent reinnervation
of the TA by the RLN also has been demonstrated to effectively reverse denervationrelated MyHC expression changes (up-regulation of type 2X and down-regulation
of type 2B isoforms) at the level of the whole muscle (Wu et al. 2004). Considering
that denervation of the TA leads to the transition of one fast isoform (type 2B) to
another (type 2X), as noted above, it is not surprising that minimal functional
changes are noted in shortening velocities and contraction force (Johns et al. 2001;
Wu et al. 2004). Together, these data support the conclusion that the TA is amenable
to re-innervation procedures and that the outcome of such procedures would likely
be quite efcacious. Current work by Zealear and colleagues is testing these suppositions through the development and use of implantable stimulators and electrotherapy in canine models (Nomura et al. 2010; Zealear and Billante 2004; Zealear
et al. 2009).
Work by Shinners et al. (2006) has related the survivability of laryngeal muscles
after neurological insult to the distinctive remodeling capacity discussed above. The
authors identied heightened levels of ber remodeling immediately following
RLN nerve section that was maintained for 24 weeks post-injury. The authors concluded that the remarkable regenerative capacities of the muscles may have facilitated their ability to survive and regenerate following neurological insult. Regardless
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of the precise mechanism at play, spontaneous reinnervation of the laryngeal

musculature does not often restore normal vocal fold abduction and adduction. It
does, however, appear to offer sufcient nerve input to prevent or impede severe
muscle atrophy in a number of cases (Gardner and Benninger 2006; Nomoto et al.
1993; Shindo et al. 1992; Titze 1994; Kano et al. 1991).
Reports describing human ILM biology after paralysis are exceptionally rare, yet
occasionally can be found in the literature. One such report by Brandon et al. (2003a)
analyzed normal functioning and immobilized PCA muscle sub-samples in a set of
patients who had undergone total laryngectomies. In this study, the PCA was determined to consist of two bellies (horizontal and vertical) distinguished by the MyHC
isoform present. Horizontal bellies were primarily type 1 (slow) bers with only
20% of the remaining sample consisting of type 2a and 2x (fast) variants. In contrast,
the vertical bellies had a more uniform distribution of type 1 and type 2 bers. Upon
inspection, morphological indications related to immobilization vs. normally functioning vocal folds were difcult to determine. For example, neonatal MyHC, a
marker for regeneration, was present in both normal and immobilized PCA samples.
Additionally, ber type grouping was found to occur in both PCA sub-samples, and
no changes to ber diameter and morphology were noted in either group. The lack
of differences in the PCA of the normal functioning vs. immobilized group suggested that immobilization may have resulted from a cause other than neuropathy.
11.11
Concluding Remarks
It is apparent from our brief review in this chapter that our appreciation of laryngeal
muscle biology in general, and its specic response to neuromuscular disease or
injury, is poor when compared to limb muscle cell biology. The increasing recognition
of the unique nature and structural prole of ILM compared to typical skeletal muscles makes interpolation of data from limb muscle biology tenuous at best. Together,
these factors strongly argue for substantially greater study of laryngeal muscle biology. By far, of the data that does exist, reports in animal models represent the bulk
of the literature on ILM cell biological changes as a function of neuromotor disease
and injury. Unlike human limb skeletal muscle investigations, cell biological studies of the larynx in man are rare and exceptionally challenging given the inherent
inability to biopsy and extract sample tissue for histochemical and morphological
analyses without causing unacceptable damage to the same structure being examined.
While animal studies have critically added to our understanding of laryngeal muscle
biology, they are limited in their capacity to inform investigators with interest in
human behavior, specically human vocal behavior. The extent to which we understand the nature of human laryngeal muscle biology and the role that muscle ber
changes have in the pathophysiology of voice and swallowing disorders is quite
small. To date, the vast majority of human laryngeal muscle studies have used
electrophysiological measures to document central neural perturbations, yet only a
limited number of studies could be identied describing cell biology changes in
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199
human ILMs. Given the known cell biology changes that are manifest as a function
of denervation, we hypothesize that other forms of neurological insult and disease
produce different forms of histological changes in ILMs. The nature of these changes
remains to be discovered.
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Part VI
Tongue Musculature
Chapter 12
Tongue Structure and Function

Alan Sokoloff and Thomas Burkholder
Abbreviations
MyHC-emb
MyHCeom
MyHC-neo
MyHC-st
12.1
MyHCembryonic
MyHCextraocular
MyHCneonatal
MyHCslowtonic
Introduction: The Tongue in Neuromuscular Context
The mammalian tongue is essential for normal respiration, swallowing, oral

transport, emesis, coughing and, in humans, speech production. To achieve these
behaviors, tongue musculature produces myriad changes in tongue shape and in
concert with other head and neck structures a wide range of tongue movement
speeds. Head and neck muscles are often described as having unconventional
kinematic and mechanical demands. They may be required to apply prolonged,
continuous force, as the activation of genioglossus to maintain airway patency, and
they may be required to change force very rapidly, as the extraocular muscles during
saccades. In this chapter, we describe the neuromuscular specialization that facilitates tongue behavior, and contrast this with typical limb function, in which the
muscles undergo cyclical motion during relatively infrequent behaviors.
A. Sokoloff (*)
Department of Physiology, Emory University,
615 Michael Street, Atlanta, GA 30322, USA
e-mail: Sokoloff@physio.emory.edu
T. Burkholder
School of Applied Physiology, Georgia Institute of Technology,
Atlanta, GA, USA
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A. Sokoloff and T. Burkholder
The most obvious contrast between conventional skeletal muscle systems and
the tongue is the lack of rigid structural elements. Tongue movement is a consequence of deformation of the constant-volume soft-tissue tongue body, movement
of the tongue body relative to the head and neck by tongue muscles with extrinsic
attachment, and movement of attached head and neck structures (e.g., mandible or
hyoid bone). Changes in tongue shape are enabled by arrangement of tongue muscle
fibers in multiple axes and innervation by hypoglossal nucleus motoneurons
(approximately 6,000 hypoglossal nucleus motoneurons in the rat; 15,000 in the
human; Arvidsson and Aldskogius 1982; OKusky and Norman 1995). Tongue
movements are accompanied by spatially diverse tongue body deformations indicating spatially complex patterns of muscle fiber and motor unit activation (motor
unit, MU: a motoneuron and the muscle fibers it innervates).
12.2
12.2.1
Tongue Muscular Anatomy

Muscle Anatomy and Innervation: Classical Description
In the appendicular musculature, muscles are defined anatomically as discrete populations of muscle fibers which are substantially separate from other fiber populations. Activation of contractile material anywhere within many appendicular muscles
has a similar mechanical action due to the constraints imposed by discrete muscle
attachments and by skeletal and ligamentous structures. Although considered as
separate entities, muscles frequently share common tendons, such as the gastrocnemius and the soleus, and are linked by intermuscular connective tissue that limits
their mechanical independence (Maas et al. 2001). Some muscles with large distributed attachments may have very divergent regional functions, however, and there
can even be some variability in mechanical action within fusiform muscles (Chanaud
et al. 1991; Carrasco and English 1999).
Nonetheless, locomotion and other tasks of the appendicular musculature are well
described by rigid segments connected at discrete joints, and simplifying contractile
material into discrete units has greatly facilitated the analysis of locomotion and understanding of the control structures involved. Treating appendicular muscles as functionally discrete structures is an illustrative simplification that facilitates analysis.
The musculature of the tongue is classically divided into extrinsic muscles,
which have their origins on bony structures outside the tongue body, and intrinsic
muscles, whose fibers exist entirely within the tongue body.1 The extrinsic muscles,
genioglossus (GG), hyoglossus (HG), palatoglossus (PG), and styloglossus (SG)
1
Dissection, histological, and MRI investigations have produced detailed descriptions of tongue
muscle organization in relatively few mammal species (primarily cat, dog, human, and rat). Primary
descriptions in the human are those of Abd-El-Malek (1939) and Gaige et al. (2007) for the adult
and Barnwell (1977 and related) for the fetal tongue. For organization of tongue musculature in
non-mammals see Herrel et al. (2001) and Nishikawa et al. (1999).
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Fig. 12.1 Muscle anatomy and fiber architecture of the human tongue. (a) Fiber tracts of extrinsic
and human intrinsic tongue muscles near midline revealed by DTI tractography (Gaige et al. 2007;
used with permission). (b) Stylized diagram of the human tongue (Takemoto 2001; used with
permission). Note the fan-like radiation of the genioglossus and primarily vertical orientation of
the hyoglossus. PG palatoglossus; SG styloglossus (c) Arrangement of the superior longitudinal
muscle (SL)
bear superficial similarity to appendicular muscles. Outside the tongue body they
are discrete populations of muscle fibers encased in an epimysium and separable
from surrounding tissue by gentle dissection. They have discrete origins, and one
can ascribe a displacement of the whole tongue to shortening of each: GG originates
from the anterior mandible and pulls the tongue forward and down; HG originates
from the hyoid bone and pulls the tongue back and down; PG originates in the soft
palate and pulls the posterior tongue up and back; SG originates from the styloid
process and retracts the tongue. The external portions of these muscles appear to act
on the tongue in the same way that limb muscles act on bones. Fibers of each of
these muscles continue within the body of the tongue, where the epimysium loses
its definition and fibers intermix with fibers of intrinsic tongue muscles.
The intrinsic muscles, inferior longitudinalis (IL), superior longitudinalis (SL),
transversus (T), and verticalis (V), however, bear little similarity to the discrete
appendicular and axial muscles. These muscles are not physically separate, but
occupy overlapping volumes of space. The central body of the tongue comprises alternating laminae of vertically and horizontally oriented fibers, the former being the
verticalis muscle and the latter being the transversus (Figs. 12.112.3). Along the
dorsal and ventral surface of the tongue, fibers that comprise the IL and SL are woven
among intrinsic fibers of T and V and extrinsic tongue muscle fibers. These intrinsic
muscles fail the first criterion of muscles, which is to be a discrete structure. Functionally,
these fibers modify local tongue body shape, which may include effects similar to protrusion, retrusion and dorsal bending, but they lack the discrete mechanical function
that has made the muscle model so powerful in the appendicular system.
12.2.2
Theoretical Considerations: Tongue as Deformable Solid
The muscle fibers of the tongue are not easily divided into discrete populations, and
motion of the tongue is not well described by rigid segments with discrete articulations.
The simplifications that offer so much clarity in the appendicular musculature do not
210
Fig. 12.2 Stylized illustration of parasagittal section of the murine tongue with photomicrographs
in the mouse of boxed regions. Note alteration of Transversus (T) and Verticalis (V) fascicles (c),
superficial T fibers (arrow in a, asterisk in e) interlacing of V and longitudinal fibers (b, e), anterior-to-posterior distribution of motor endplate (MEP) zones in intrinsic longitudinal muscles (b,
c, e) and single MEP band in the oblique GG (f). MEPs stained for acetylcholinesterase in bf.
Calibration bar = 200 mm
Fig. 12.3 Coronal sections of rat and mouse tongue. (a) Anterior rat tongue stained for glycogen.
Note intermixing of fibers of different orientation, superficial continuation of transverse fibers
adjacent to epithelium (arrow), lateral location of vertical fibers and medial extent of longitudinal
fibers. (b) Diagrammatic representation of rat anterior tongue body showing features discussed in
text. (c) Acetylcholinesterase stain for motor endplates (MEP) in the anterior-middle mouse
tongue. Note MEP bands in vertical and transverse fascicles but sporadic MEPs in longitudinal
fascicles indicative of in-series fiber organization. Arrow points to lateral vertical fibers. Calibration
bars = 200 mm
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clarify control of the tongue, which is much better described as a deformable solid,
using the formalism of continuum mechanics or a muscular hydrostat model (Kier
and Smith 1989). Diffusion spectrum imaging (DSI) and tagged magnetization MRI
techniques reveal regional specialization of both fiber orientation and deformation
that might be used to develop a 3D mesh appropriate for reconciling tongue structure and function (Gilbert et al. 2007).
Structural division of the tongue should reflect its functional properties,
specifically the nature of its deformations. Conventional definitions of tongue muscles do not offer sufficient anatomical resolution to account for regionally diverse
deformations of the tongue body. Extrinsic and intrinsic tongue muscles have complex and distributed muscle fiber architecture and motor units localized within the
tongue body. These features suggest that tongue deformation may be determined by
the differential activation of motor units by orientation and region (and not by muscle or compartment membership per se). Information on tongue motor unit anatomy,
the mechanical consequences of motor unit activation and the activation of motor
units with respect to location and orientation is, however, limited, and it is not currently possible to correlate motor unit activation with tongue deformation.
12.2.3
Architecture of Tongue Muscles
One approach to simplifying the description of a complex deformable solid is to

divide it into smaller regions over which local material strains vary little. This suggests that two functionally important criteria for describing tongue structure are the
organization of motor units, which specifies the spatial resolution of the nervous
system and the geometry of deformation. There is only limited information on motor
unit localization, but single motor units appear to innervate fibers of only one orientation, to be restricted to one side of the midline, to be localized with respect to the A/P
axis but to span multiple fascicles and multiple laminae. The nervous system appears
to distinguish fibers strongly by orientation and weakly by position.
Although below we describe tongue architecture in terms of fiber orientation,
one should bear in mind these caveats. (1) Tongue muscle fibers of different orientations are present in all regions of the tongue body. (2) Many fibers are oriented
obliquely to conventional anatomical axes and a muscle fiber may curve to assume
different orientations along different parts of its length. (3) Fibers of a classically
defined muscle may have highly divergent orientations in different regions. (4) Within
the tongue body fibers of extrinsic muscles interdigitate with intrinsic muscles so as
to be indistinguishable histologically. (5) Posterior intrinsic muscle fibers of IL, SL,
and T can have attachments to the hyoid bone and associated fascia suggesting
direct consequence of contraction for movement of the tongue body relative to the
hyoid bone. (6) Most muscle fascicles have a single motor endplate (MEP) band and
most fibers a single MEP, but dual MEPs are present in a subset of tongue muscle
fascicles and on some muscle fibers.
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12.2.3.1
Muscle Fibers with Primarily Vertical Orientation
Muscle Fiber Architecture

Fibers with primarily vertical orientation are present in all regions of the tongue
body and contributed mainly by GG and V with additional contributions from HG,
PG, SL, and T.2 GG fibers are absent in the anterior tongue of the rodent and cat but
are present in anterior human tongue (Abd-El-Malek 1938, 1939; Hellstrand 1980;
Gaige et al. 2007). In most species the anterior-most GG fibers ascend vertically to
the dorsum near the midline with fibers with progressively posterior insertion radiating obiquely in a fan shape such that the deepest fibers travel horizontally to the
tongue root (Figs. 12.1 and 12.2). In some species, oblique (anterior-dorsal fibers)
and horizontal (ventral fibers) divisions of the GG are recognized. In the posterior
tongue, GG fibers occupy the majority of the medial volume, displacing V fibers to
the lateral periphery. Although nominally vertical, V fibers often have a dorsomedial to ventrolateral orientation which would tend to form an A/P trough upon contraction. In rodents, V fibers may originate and insert in the lateral epithelium
forming a lateral arc of fibers (Fig. 12.3). V fibers are organized into laminae orthogonal to the A/P axis of the tongue body. V fascicles alternate with T fascicles and
course through dorsal and lateral-ventral longitudinal fibers to insert in epithelium
or connective tissue (CT) investing fascicles of other muscles (Fig. 12.2). At the
tongue tip, fascicles of V are less coherent and alternation with T irregular.
Fibers with vertical orientation are additionally contributed by HG fibers that
course dorsally or antero-dorsally to the dorsum, and by PG fibers that descend in
the lateral body and mingle with fibers of SG (Fig. 12.1). The posterior-most fibers
of SL originate near the hyoid bone and also course vertically, deep to the posterior
dorsum. In some species, T fibers originating from the dorsal and ventral limits of
the medial septum course vertically to the dorsal and ventral epithelium, respectively (Fig. 12.3). Vertical fiber components are thus contributed by extrinsic and
intrinsic muscles and muscles classically considered retrusors and protrusors.
Innervation
GG and V fibers extend for much of muscle origin to insertion length. V and vertical/
oblique GG fascicles appear to have a single MEP in the middle third, indicative of
in-parallel fiber organization (Fig. 12.2). However, more horizontal GG fascicles
may contain two or more MEP zones (Mu and Sanders 2010). The extent to which
multiple MEPs along GG fascicle length reflect offset of muscle fibers, branching
of a single terminal nerve to innervate multiple MEPs on a single fiber or innervation
2
Most tongue muscles have complex architecture the details of which may differ substantially
between species (e.g., minimal lateral longitudinal muscle fibers in the anterior cat tongue,
Hellstrand 1980). Cross-species differences in tongue muscle organization have not been studied
in detail and can offer insights into neuromuscular bases of tongue movement.
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Tetanus
Twitch
b 26
26
22
22
18
18
14
14
10
10
NUMBER OF MOTOR UNITS
12
75 mg
Anterior EMG 1v
Middle EMG 1v
Posterior EMG 1v
2
A
200 ms
P AM MP AMP
P AM MP AMP
LOCATION OF INFERIOR LONGITUDINALIS

LOCATION OF GENIOGLOSSUS, TRANSVERSUS
AND SUPERIOR LONGITUDINALIS MOTOR UNITS
AND VERTICALIS MOTOR UNITS
Fig. 12.4 Anteriorposterior localization of tongue motor units (MU) in the rat. (a) Intra-axonal
stimulation of single MU with EMG signature in the middle tongue. (b) Localization of MUs to
anterior, middle, posterior, or multiple tongue regions. From Sokoloff (2000, American
Physiological Society; used with permission) and unpublished data
of a single fiber by multiple nerves is not known. Vertical fascicles of HG are

centrally innervated by a single MEP band (Mu and Sanders 2010).
Retrograde axonal tracer studies reveal somatotopic organization of GG, T, and
V motoneurons such that anterior regions of these muscles are innervated by caudal
hypoglossal nucleus motoneurons whereas posterior regions are innervated by rostral hypoglossal nucleus motoneurons (Sokoloff and Deacon 1992; Aldes 1995).
These findings are compatible with compartmental innervation of oblique vs. horizontal regions of the GG. Stimulation of single axons projecting to GG, T, and V in
the medial hypoglossal nerve (CNXII) produces activation of fibers primarily localized to anterior, middle, or posterior regions of the tongue body (Fig. 12.4), also
indicating MU localization with respect to the A/P tongue axis. A/P localization of
GG motor units is supported by discrete anterior vs. posterior activation of GG
regions during speech (Miyawaki et al. 1975; Baer et al. 1988). Thus motor unit
localization with respect to the A/P tongue axis appears to be a feature of extrinsic
and intrinsic muscles of vertical orientation.
12.2.3.2
Muscle Fibers with Primarily Transverse Orientation
Architecture
Fibers with transverse orientation are present in all regions of the tongue body and
are contributed primarily by SG and T. Fibers identified with the classical T originate on the median septum and are grouped in laminae that alternate with more
vertically oriented fibers of V and GG (Figs. 12.2 and 12.3). These fibers insert on
epithelium or CT investing superficial muscles. Although nominally transverse, in
some species the radial array of T fibers is so strong that the most dorsal and ventral
T fibers attain a near-vertical orientation. In other species, transverse fibers are not
radially arrayed but extend primarily medio-laterally (Hellstrand 1980). In the anterior tongue of the rat and mouse, T fibers pierce longitudinal fascicles to form an
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outer superficial fiber layer just deep to the epithelium (Figs. 12.2 and 12.3).
Transversus fibers may also have a longitudinal component, with anterior T fibers
arcing anteriorly and posterior T fibers arcing posteriorly to intermix with fibers of
SG. Activation of T fibers would primarily be expected to condense the tongue medially with consequent midline raising. Fibers of transverse orientation in the tongue
are also contributed by the SG (DuBrul 1976; Gaige et al. 2007; Saito and Itoh 2007)
and by inferior-lateral GG fibers which may course laterally to the lateral epithelium
(Mu and Sanders 1999; Gaige et al. 2007).
Innervation
T fascicles in the mouse and rat have a single MEP band (Fig. 12.3c). T fascicles in
humans have two bands (Mu and Sanders 2010) but whether this reflects dual innervation of fibers is not known. Stimulation of single axons in the medial branch of the
rat CNXII evokes regional EMG signatures with respect to the A/P axis, suggesting
limited A/P distribution of at least some T motor units (Fig. 12.4). Whether T motor
units are restricted in the transverse dimension is not known, nor is it known whether
the different components of SG receive discrete innervation.
12.2.3.3
Muscle Fibers with Primarily Longitudinal Orientation
Architecture
Fibers with longitudinal orientation are present in all regions of the tongue body and
are contributed by GG, HG, IL, SG, SL, and T. Longitudinal fibers contributed by
intrinsic and extrinsic muscles intermix extensively and make histological distinction difficult. However, from current descriptions two longitudinal fascicle morphologies appear to be present which coincide with intrinsic and extrinsic identity.
In one, short, in-series fibers are organized into multiple fascicles that overlap along
the A/P axis. These are associated with superior, lateral, and inferolateral intrinsic
muscle fibers (Figs. 12.2 and 12.3). In the other, longer, in-parallel fascicles and
fibers are contributed by SG, HG and, at least in some species horizontal GG. Fibers
of both morphologies coexist in most tongue regions, although in-parallel fibers are
dominant in the posterior tongue.
Longitudinal fibers of the classical IL form a distinct mass in its posterior extent,
defined by intramuscular septa and bordered by the GG medially and HG laterally
(Abd-El-Malek 1939; Gaige et al. 2007; Fig. 12.1). IL fibers blend anteriorly with
longitudinal fibers of other extrinsic and intrinsic muscles. In some species, longitudinal fibers of the SL are most prominent along the dorsal midline and are partially
delimited laterally by dorsal T fibers. However, longitudinal fibers are also present in
lateral and ventrolateral tongue body regions, and in some species these fibers may be
numerous especially anteriorly (Fig. 12.3). Because the consequences of longitudinal
fiber activation on tongue body deformation will differ with respect to radial location,
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we assign these radially arrayed intrinsic longitudinal fibers (i.e., not classical IL) to
a superficial intrinsic longitudinal muscle system that includes superior (the classic SL),
lateral (LL), and inferolateral (ILL) components (Fig. 12.3).
Activated as a group, longitudinal fibers will tend to reduce the A/P dimension of
the tongue, but regional activation will cause local bending in the sagittal or transverse planes.
Innervation
MEPs of intrinsic longitudinal muscles are scattered along the A/P tongue length in
a pattern typical of muscles of in-series fiber design (Slaughter et al. 2005; Fig. 12.2).
MEPs of HG and SG in contrast appear to be concentrated in single bands near the
tongue root in a pattern typical of muscles of in-parallel design (Mu and Sanders
2010). Innervation of the horizontal GG differs with species and in the dog and
human some fascicles have two or more MEP bands (Mu and Sanders 1999, 2010).
In the human SL, dual MEPs may be present on single fibers in close proximity and
appear to be innervated by a single axon (Slaughter et al. 2005). Single unit stimulation of lateral CNXII axons that project to intrinsic longitudinal fibers evokes regional
EMG, indicating limited A/P distribution of motor units (Fig. 12.4; Sokoloff 2000).
12.3
12.3.1
Neuromuscular Basis of Tongue Movement

Theoretical Considerations
The relatively clear separation of limb contractile material into discrete muscles is
reflected in neural organization. Each motor unit is restricted to a single muscle, and
sometimes to an identifiable compartment, set off by a thick connective tissue
boundary, within that muscle. Motor units within each muscle or compartment are
recruited in a rigid, size-based order that closely couples the motor unit physiological and biochemical properties (Binder and Mendell 1990; Gordon et al. 2004).
Kinematic diversity can be described by the relative activation of these discrete
muscles and compartments, which may simplify neural control by separating the
intensity of activation from the selection of specific motor units.
Muscle-based and compartment-based descriptions of control presuppose that
the motor unit pools used by the nervous system are the muscle or compartment
pools. However, there is evidence that motor unit groups used by the CNS are not
solely defined by muscle or compartment identity. On the one hand, orderly recruitment of motor units occurs among motor units from different muscles (Henneman
et al. 1965; Sokoloff et al. 1999), indicating that the nervous system can use motor
unit pools that span muscles. Reports of motor primitives in the frog spinal cord and
synergies in several senses in mammals also seem to indicate control structures
that span muscle and compartment boundaries. On the other hand, motor units can
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be organized into multiple pools independent of muscle region or compartment

identity (Herrmann and Flanders 1998).
In the human GG, grouping of tongue motor units appears to be related to motor
unit location in some tasks but independent of motor unit location in others. During
speech tasks, GG motor units are selectively activated in anterior vs. posterior
regions (Baer et al. 1988) which may represent selective motor unit activation by
virtue of compartment membership (for example in anatomically defined oblique
vs. horizontal GG regions) or by virtue of the specific effect of motor unit activation
on tongue deformation. During wakeful respiration however, multiple groups of GG
motor units can be defined by activity patterns recorded from the same electrode
and thus the same muscle region (Saboisky et al. 2006). Whether differing respiratory GG motor unit pools are grouped by virtue of metabolic, contractile, or other
motor unit properties are not known.
Above we reviewed the muscle architecture that constrains the geometry of
tongue deformation. The capacity of the nervous system to use this geometry is
dependent on the organization of motor units and the ways in which the nervous
system can combine and regulate their activation. Although evidence is limited, we
next review contractile features of tongue motor units that reflect molecular composition of constituent muscle fibers and anatomical features that determine the specific
effect of motor unit activation on tongue deformation.
12.3.2
Tongue Motor Unit Organization and Activation
12.3.2.1
MEP Morphology and Muscle Fiber Innervation
Synapses of head and neck muscles show some differences from conventional
appendicular muscles. Two MEP morphologies have been described in human
tongue muscles, plate-like en plaque MEPs typical of appendicular systems and
grape-cluster-like en grappe MEPs present in many head and neck muscle systems (Oda 1986; Perie et al. 1997, 1999; Slaughter et al. 2005; Mu and Sanders
2010). A third MEP pattern described in extraocular muscles, which consists of
small terminal boutons distributed along the muscle fiber length (Oda 1986) is not
present in the tongue. Functional and molecular correlates of en grappe MEP morphology in human tongue muscles are not known. In human tongue, laryngeal, and
suprahyoid muscles, the absence of appreciable slow/tonic myosin heavy chain
(MyHC) precludes a relationship between MyHCslow tonic and en grappe MEP
morphology (Sokoloff et al. 2007).
As discussed above, some tongue muscle fibers have two MEPs. In extraocular
muscles, multiple MEPs per muscle fiber may reflect innervation of a single fiber by
multiple nerves (Chiarandini and Stefani 1979; Oda 1986). SL fibers with dual
MEPs appear to be singly innervated (Slaughter et al. 2005), an organization similar
to human laryngeal muscle fibers (Perie et al. 1997). It is not known whether other
tongue muscle fibers with dual MEPs are multiply or singly innervated.
12
12.3.2.2
217
Motor Unit Physiology
Physiological investigations, primarily in the rat, demonstrate that tongue motor

units are predominantly nonfatiguing and are similar to appendicular motor units
with respect to speed of contraction (Gilliam and Goldberg 1995; Sokoloff 2000;
for similar findings in cat see Hellstrand 1981). These findings correlate with muscle biochemistry; most rat tongue muscle fibers have a moderate-to-high oxidative
capacity and are composed of conventional fast MyHC isoforms. However, rat
tongue motor units produce 1001,000-fold less force than rat appendicular motor
units (Gilliam and Goldberg 1995; Sokoloff 2000). Motor unit force is determined
primarily by the number and cross-sectional area of constituent muscle fibers
(Totosy de Zepetnek et al. 1992). Although studies are limited, the cross-sectional
area of rat tongue muscle fibers appears to be one to four times less than the crosssectional area of equivalently typed fibers in rat neck and appendicular muscles
(e.g., Oliven et al. 2001; Matsumoto et al. 2007). This suggests that, compared to
most appendicular motor units, tongue motor units comprise many fewer fibers.
12.3.2.3
Motor Unit Anatomy and Localization
Direct anatomical evidence of tongue motor unit location, fiber architecture, and
fiber number (i.e., innervation ratio, IR) is lacking. Independent activation of anterior vs. posterior regions of the GG during speech indicates localization of at least
some tongue motor units with respect to the A/P tongue axis in humans (Baer et al.
1988). Localization of motor units with respect to the A/P tongue axis has also been
demonstrated physiologically in the rat. Following intra-axonal activation of individual motor units, 65/105 SL-IL motor units and 41/42 GG, T and V motor units
were localized by EMG to either anterior, middle, or posterior tongue body regions
(Fig. 12.4).
Studies have not described motor unit IR, the dorso-ventral and medio-lateral
extent of motor unit territories and whether motor unit territories respect muscle
architecture divisions. Estimated motor unit innervation ratios of less than 25 in the
rat SG and GG suggest that motor unit territories may be circumscribed in the coronal plane as well (Sutlive et al. 2000).
We saw above that muscle fibers of all orientations are found in most regions of
the tongue and that traditional division of contractile material into discrete, anatomically defined volumes does not simplify description of tongue motion and does
not facilitate understanding. The ability to voluntarily change the local curvature of
the tongue indicates that the nervous system controls sub-volumes of contractile
material and our goal is to describe tongue structure in a way that clarifies both the
deformations and their control. Although data on anatomical localization and distribution of motor unit territories are limited, data reviewed above indicate that motor
units span more than one T/V laminae but are spatially restricted. Some inferences
can also be made from observed behavior. Imaging data indicate that the tongue
deformation gradient is relatively low frequency, and a high-resolution finite
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element model (Mijailovich et al. 2010) also suggests that the tongue body might be
adequately described using a coarse spatial mesh, e.g., anterior/middle/posterior,
dorsal/ventral/root, and left/center/right, giving a total of 27 spatial regions. Further
determination of regional strain fields and further evaluation of motor unit distribution have great potential for deciphering tongue control.
12.4
Gross Tongue Function During Respiration,

Mastication, and Speech
During open-mouth respiration, the tongue is pulled toward the floor of the mouth
to free the airway. This is accomplished primarily by activation of GG motor units,
but in some animals intrinsic muscles are also involved (Lu and Kubin 2009). Phasic
activation of other muscles is also observed (e.g., Inoue et al. 2004) and the tongue
may undergo rhythmic protrusion and retrusion or elevation and depression (e.g.,
panting, lapping, feeding; Biewener et al. 1985; Thexton and Crompton 1989).
During mastication, the tongue follows systematic movements during transport,
processing, bolus formation, and deglutition (Hiiemae and Palmer 2003; Felton
et al. 2008). These movements may be asymmetric with respect to the left and right
side, but generally have low spatial frequency, i.e., between 0.5 and 1 wavelength
along the length of the tongue and 0.5 wavelength or less in the coronal plane. For
example, Abd-El-Malek (1955) describes four tongue shapes during processing,
two of which amount to formation of an anterior hollow composed of a 0.5 wavelength cup in the transverse direction and a 1 wavelength A/P cup-and-hill. Other
tongue shapes are even less complex.
Even during speech production most vowel shapes can be accommodated by a
limited number of basic tongue postures, and specific spatial control does not seem
critical (Stone and Lundberg 1996). The spatial frequency of many tongue deformations is thus quite low, compatible with data that suggest the neural structures that
organize tongue movement are larger and more diffuse than the lamina of T and V
fibers, but smaller and more localized than the whole tongue. Localization of motor
unit territories may enable maximal diversity of tongue deformation for movements
that involve disparate and complex patterns of expansion and compression in different tongue regions, for example, during oral transport when different tongue regions
may behave independently (e.g., Hiiemae et al. 1995).
Current understanding of tongue motor unit territories is compatible with the
reported regional tongue deformations. To form a hollow or trough in the tongue, a
central depression bounded by raised lateral edges, the simplest deformation is uniform transverse shortening of the dorsal surface without shortening of the ventral
surface. The largest transverse motor units to cause this motion could span the entire
dorsal surface, but should not cross the transverse mid-plane. Smaller motor unit
territories would allow a sharper corner between the floor of the hollow and the
walls. Vertical fiber contribution to the motion could be uniform throughout the
tongue body. So formation of half-wavelength C shapes requires only one motor
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219
unit, and formation of whole-wavelength S shapes requires two. As discussed,

motor unit territories have been localized only coarselyto anterior, middle, or
posterior regions and to left/right sides, but this localization is all that is required to
achieve the many tongue shapes used during routine behavior. It is also possible that
motor unit territories are much smaller and could allow either sharper (Z-like) or
more serpentine shapes.
12.5
12.5.1
Tongue Muscle Fiber Biochemistry

Background
Studies in appendicular and cranial muscles demonstrate a relationship between

MyHC isoform and muscle fiber contractile properties. For example, among muscle
fibers that uniformly express one of the four conventional MyHC, shortening velocity progresses from slowest to fastest in the order: MyHCI, MyHCIIA, MyHCIIX,
MyHCIIB. Although shortening velocity is one of the most dramatic differences
among fibers, MyHC isoform is highly correlated with a range of specializations
that include calcium kinetics, glycolytic capacity, and mitochondrial content.
Experimental models indicate that fiber type is plastic and can be altered to meet
functional demands, most notably duty cycle, suggesting that muscle protein expression is regulated to provide specific contractile or metabolic properties. Muscle fiber
contractile diversity can additionally be achieved by hybridization of multiple
MyHC in single fibers, thereby creating fibers with intermediate properties in proportion to the prevalence of constituent MyHC.
In mammals, including human appendicular muscles, single extrafusal fiber contractile diversity is typically achieved by homogeneous expression of MyHCI,
MyHCIIA, MyHCIIB, or MyHCIIX and only limited hybridization of MyHC isoforms (primarily MyHCII) (as opposed to single intrafusal fibers found in muscle
spindles). Head and neck muscles diverge from this appendicular norm in two
respects. In addition to the four MyHC isoforms expressed in limb and body skeletal
muscle, some adult head and neck muscles express developmental isoforms
MyHCembryonic and MyHCneonatal and additional isoforms MyHCalpha-cardiac,
MyHCextraocular, MyHCmasticatory, and MyHCslow tonic, which are absent from
normal appendicular muscles. Further, some head and neck muscles contain many
hybrid fibers, including fibers with MyHCI-MyHCII hybridization and MyHC
hybridization where single fibers contain mixtures from all three categories of
MyHC isoforms. MyHC hybridization is most extensive in masticatory and extraocular muscles where single fibers may contain five MyHC (Yu et al. 2002; McLoon
et al. 2011).
Many head and neck muscles, but not tongue muscles, undergo a different
developmental path than axial and appendicular musculature. Limb, body, and
tongue muscles originate from the embryonic somites and are dependent on
Pax3/7 for differentiation (Buckingham et al. 2003). Head and neck muscles
largely originate from the branchial arches of the embryonic somitomeres and
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Fig. 12.5 Myosin heavy chain (MyHC) mRNA profiles for anterior tongue body muscles in
human, rhesus macaque, and rat determined by quantitative PCR (Rahnert et al. 2010; S. Karger
AG, Basel; used with permission). (a) Conventional and prominently expressed isoforms.
(b) Developmental and unconventional isoforms, eo: extraocular muscle specific; beta: beta cardiac; alpha: alpha cardiac; emb: embryonic; neo: neonatal; st: slow tonic
cranial mesoderm and undergo differentiation via a Tbx1 or Pitx2 pathway (Kelly et al.
2004; see Chap. 2). Expression of unconventional MyHC isoforms (MyHCalphacardiac, MyHCextraocular, MyHCmasticatory and MyHCslow tonic) is largely
restricted to these branchial arch muscles and the extraocular muscles, and the Tbx1
and Pitx2 pathway may be less effective in silencing their expression.
12.5.2
MyHC Composition of Tongue Muscles
Quantitative PCR, separation SDS-polyacrylamide gel electrophoresis (SDS-PAGE),

western blot, and immunohistochemistry (IHC) demonstrate that adult tongue muscles of the mouse, rat, macaque, and human consist almost entirely of MyHCI,
MyHCIIA, MyHCIIX, and MyHCIIB. By PCR, only limited mRNA (0.10.8% total
mRNA) of MyHCembryonic and MyHCneo is detected in anterior tongue body
muscles of the rat, macaque, and human with the exception of MyHCalpha-cardiac
in the human (5%) and MyHCeom in the macaque (3.7%) (Rahnert et al. 2010)
(Fig. 12.5). The developmental and additional MyHC proteins are not visualized in
tongue muscles of the adult mouse, rat, and human by SDS-PAGE (dAlbis et al.
1990; Agbulut et al. 2003; Granberg et al. 2010; Daugherty et al. 2012).
MyHC phenotype prevalence by IHC has been studied most extensively in
humans. In human extrinsic muscles, phenotype prevalence is generally ordered
MyHCIIA > MyHCI > MyHCI-IIX with limited MyHCI-IIA and minimal MyHCIIX
(Sokoloff et al. 2010). Predominance of MyHCIIA and MyHCI with minimal
MyHCIIX has also been reported in human intrinsic tongue muscles (Granberg
et al. 2010). These studies however, suggest differences between extrinsic and
intrinsic muscles with respect to the presence of phenotype MyHCI-IIX (in human
extrinsic but not intrinsic muscles) and phenotype MyHCIIA-IIX (in human intrinsic muscles but not GG (Daugherty et al. 2012). MyHC expression is related to the
pattern of nerve activation (Ausoni et al. 1990; Pette 2001; Schiaffino et al. 2007),
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and MyHC phenotype disparity might reflect differential patterns of MU recruitment

between intrinsic and GG tongue muscles. Further studies with equivalent IHC
methods are required to confirm MyHC phenotype differences between intrinsic
and extrinsic muscles.
Few studies have investigated MyHC phenotype or fiber type with respect to
extrinsic muscle architecture. By ATPase, a greater prevalence of Type II vs. Type I
fibers was reported in dog anterior-oblique compared to horizontal GG regions (Mu
and Sanders 1999). In the human, the oblique GG contains relatively more MyHCIIA
and less MyHCI than the horizontal GG (Daugherty et al. 2012). In contrast, greater
prevalence of faster isoforms was reported in the posterior vs. anterior GG of the rat
(Volz et al. 2007). Greater prevalence of faster myosin isoforms in anterior vs.
posterior intrinsic tongue muscles of the human and macaque is demonstrated by
ATPase and separation SDS-PAGE, with specific type/MyHC prevalence varying
by region and muscle (dePaul and Abbs 1996; Stal et al. 2003; Granberg et al. 2010).
A general anteroposterior disparity in fast (anterior) vs. slow (posterior) fiber
composition might reflect relatively greater participation of anterior tongue regions
for feeding and oral transport tasks and of posterior tongue regions for respiration
and maintenance of airway patency.
By IHC only occasional fibers are positive for the developmental MyHC isoforms,
MyHCalpha-cardiac, and MyHCslow tonic in macaque and human tongue muscles
(03% of total fibers in any individual; Sokoloff et al. 2010; Granberg et al. 2010).
Thus, mammalian tongue muscles studied to date differ from some head and neck
muscles, which have appreciable expression of developmental and additional MyHC
isoforms.
The bases for the limited expression of the developmental and additional nonlimb skeletal muscle MyHC in the human tongue are not known. IHC studies of the
human HG and SG suggest that MyHCneonatal is primarily localized to fiber endings, possibly reflecting fiber remodeling at the myotendinous junction (Sokoloff
et al. 2010). Appendicular muscles may also express MyHCneonatal at fiber terminations (Rosser et al. 1995), and expression of MyHCneonatal at fiber terminations
may account for low levels of MyHCneonatal reported in many head and neck muscles by PCR and IHC (see also Tellis et al. 2004). The absence of significant levels
of developmental MyHC suggests however that persistent muscle fiber remodeling
is not a feature of human tongue muscles, even in very old age.
12.5.3
Capillarization and Oxidative Metabolism

of Tongue Muscles
In appendicular muscles, there is a general relationship between fiber type/MyHC

phenotype, capillarization (capillary number/mm2 fiber), and oxidative metabolism
such that type I fibers tend to have a higher capillarization and higher oxidative
capacity than type II fibers. However, capillarization, mitochondrial density, and
oxidative capacity of muscle fibers are highly plastic and change with age and use.
222
Compared to appendicular muscles, many cranial muscles have relatively high

capillarization and mitochondrial content (Stal and Lindman 2000; Kjellgren et al.
2004). Human intrinsic tongue muscle fibers also have relatively high capillarization with values similar to extraocular and jaw-closing muscles but two times greater
than appendicular muscles (Granberg et al. 2010). Human intrinsic tongue muscles
also have a moderate to high mitochondrial enzyme activity as do most tongue
muscle fibers in the cat and rat (Hellstrand 1980; Sato et al. 1990).
Interestingly, high capillarization and high mitochondrial enzyme activity in
human tongue muscles are present in fibers of slow and fast MyHC, suggesting that
tongue muscle fibers generally are refractive to fatigue. These characteristics accord
with measures of high resistance to fatigue following CNXII branch and hypoglossal nucleus motoneuron stimulation in the rat (Gilliam and Goldberg 1995). The
high oxidative capacity of human tongue muscle fibers may support two features of
the tongue motor system that differ from the appendicular system, the constitutive
activity of some tongue motor units (Tsuiki et al. 2000; Saboisky et al. 2006; Bailey
et al. 2007a) and the relatively high firing rates of motor units activated during
respiration or voluntary tasks (Bailey et al. 2007b).
12.6
Aging of Tongue Muscle
Age-related loss of muscle mass and muscle function (i.e., sarcopenia, Cruz-Jentoft
et al. 2010) occurs in many motor systems. Features of sarcopenia vary extensively
by muscle but often include decrease in muscle fiber number and size (especially of
fast fibers). Aging is also associated with changes in MyHC prevalence, increased
hybridization of different MyHC in single fibers, and increased expression of developmental MyHC (Andersen 2003; Snow et al. 2005). Most motor systems lose
motoneurons with age, and the resultant denervation/reinnervation remodeling of
muscle fibers may account for some of the above-mentioned anatomical and molecular changes (Delbono 2003; Snow et al. 2005).
Tongue muscles appear spared from many age-related changes typical of motor systems. Although studies of aging of mammal tongue musculature are few, there is little
evidence of fiber atrophy, expression of developmental MyHC, change in fiber type
prevalence/MyHC composition (Connor et al. 2009; Sokoloff et al. 2010; Rother et al.
2002; but see Nakayama 1991), and evidence for only minimal change in neuromuscular junction morphology (Hodges et al. 2004). Interestingly, hypoglossal nucleus
motoneuron number is preserved with age (Sturrock 1991; Gai et al. 1992), which protects tongue muscles from cell-loss-induced denervation/reinnervation remodeling.
The bases for the apparent protection of tongue muscles from typical age-related
neuromuscular pathology are not known. As noted, some GG motor units are constitutively active indicating a high duty cycle of some tongue motor units. Tongue
motor units typically have high rates of activation. During swallowing high tongue
pressures are generated in normal swallows, although this can be increased in effortful
swallows (Hind et al. 2001). In appendicular muscles, resistance exercise can delay
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age-related muscle decline, although it does not mitigate motoneuron loss or prevent
sarcopenia. Hypoglossal motoneurons also receive inputs from numerous central and
peripheral sources, and it is possible that this rich synaptic milieu supports hypoglossal nucleus motoneurons during dysfunction in any one projection system.
12.7
Conclusions
The architectural and neural specialization of the tongue reflects its unique lack of
skeletal constraints. Deformations of the tongue during oromotor behaviors are varied and are not well described by activation of classically defined muscles. Tongue
muscle architecture is complex and tongue motor units occupy limited territories,
enabling localized contraction of fibers with different orientation that is needed to
achieve the dimensional control required by the muscular hydrostat model. The
extent to which the nervous system actually uses the fine-grained control structure
during routine behavior is not yet clear.
The tongue appears to be composed of conventional skeletal muscle fibers with
specific structural and control adaptations that reflect an unusually high degree of
daily activity and the absence of skeletal constraints on motion. In many species
tongue muscles are comprised principally of two conventional MHC isoforms. In
the rat, tongue motor unit contraction times are similar to those of other fast appendicular motor units but produce much less force likely reflecting a low number of
muscle fibers per motor unit.
Compared to appendicular muscles, tongue motor units have high duty cycles,
whether constitutively active to maintain airway patency or phasically active during
respiration or swallowing. Highly localized and small motor units may require high
firing rates for meaningful force production. Persistent activation of many motor
units may require high mitochondrial content and capillarization and protect tongue
muscles from typical aging dysfunction.
Acknowledgements We thank Audrey Jernigan for illustrations. This work was supported by
grant DC005017 from the National Institute on Deafness and Other Communication Disorders.
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Chapter 13
Tongue Biomechanics and Motor Control

Mary Snyder Shall
13.1
Introduction
The tongue is one of the most intriguing of the skeletal muscles, considering that it
consists of several muscles and as a group, takes many shapes. It plays a vital role
in respiration, suckling, acquiring and manipulating food, swallowing, and speech.
Obviously, not all species use the tongue in the same way, so the tongue has adapted
to deform into different shapes and mechanisms of movement to meet the needs of
the animal. Even when considering only mammalian tongues, two categories of
tongue have been proposed (Doran 1975). The type II tongues in animals such as
marsupials, monotremes, and pholidota protrude at least 100% of their resting
length to gather food such as ants or flies. Many of these tongues reach their prodigious lengths by a hydrostatic mechanism typically created by contraction of the
vertical and transverse lingual muscles, compressing the longitudinal muscles,
resulting in more elongation of the tongue (McClung and Goldberg 2000; Smith and
Kier 1989). While intriguing, the type II tongues are not discussed further.
This chapter focuses on the higher order mammalian type I tongues that protrude
less than 50% and function more for intra-oral manipulation. In humans, the normal
tongue moves quickly and precisely to speak and enunciate clearly. Many patients
with central nervous system disorders must speak slowly due to the lack of coordination of the tongue. We discuss the impact of anatomical and contractile characteristics on the biomechanics and motor control of the tongue in higher mammals.
M.S. Shall (*)

Department of Physical Therapy, Virginia Commonwealth University,
Richmond, VA 23298, USA
e-mail: msshall@vcu.edu
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13.2
M.S. Shall
Biomechanics
Dr. Sokoloff described the anatomy of the muscles in the previous chapter; Figure 1
in that chapter illustrates their orientation. The body of the tongue is composed of
three pairs of intrinsic muscles and four pair of extrinsic muscles. By definition,
the vertical, transverse, and longitudinal intrinsic muscles originate on muscle fibers
and insert on other muscle fibers or the connective tissue within the body of the
tongue. The extrinsic genioglossus (GG), styloglossus (SG), hyoglossus (HG), and
palatoglossus (PG) muscles originate on bone (genial tubercle of the mandible, the
styloid process, the hyoid bone, and the lateral palate, respectively) and insert onto
the base of the body of the tongue. There has been debate on the intrinsic/extrinsic
terminology since muscles from both groups interdigitate and work together on
many actions.
The jaw and hyoid positions must be part of the pattern that strategically places
the entire tongue for the appropriate muscle movements for speech or mastication.
The masseter muscle is important to position the mandible and is examined thoroughly in Chaps. 6, 7, and 8. As the jaw opens to accept food, the mylohyoid and
geniohyoid contract to move the hyoid bone forward relative to the mandible to
elevate and close the larynx. Like the GG, the geniohyoid originates on the genial
tubercle of the mandible, but inserts on the hyoid bone rather than the tongue. The
mylohyoid forms the floor of the oral cavity from the mandible to the hyoid bone.
13.3
Motor Activation by the Hypoglossal Nerve
Hypoglossal (cranial nerve XII) motoneurons are dedicated to providing innervation to all the tongue muscles except for the palatoglossus, which is innervated by
the vagus nerve (cranial nerve X). Most of the innervation details of the tongue
muscles have been discovered by retrograde labeling techniques from injections
into various regions of the tongue (McClung and Goldberg 1999, 2000, 2002;
Sokoloff 1993; Sokoloff and Deacon 1992). The hypoglossal nucleus, located close
to the midline of the medulla is subdivided into two major compartments, which
have been most thoroughly studied in rats (Uemura-Sumi et al. 1988; Sokoloff
1993; Aldes 1995; McClung and Goldberg 1999, 2000) (Fig. 13.1).
The motoneuron projections from the ventral portion of the nucleus travel
through the medial branch of the hypoglossal nerve to supply the GG muscle, a
protrusor muscle. Aldes (1995) found that some hypoglossal motoneurons in the
ventral aspect of the hypoglossal nucleus innervate the vertical and transverse intrinsic muscles, implying shared functions of intrinsic muscle fibers with the GG muscle. The motoneurons innervating the geniohyoid muscle mostly originate in the
lateral accessory subcompartment of the hypoglossal nucleus and travel in the
medial branch of the hypoglossal nerve. A small number of the motoneurons supplying the geniohyoid arise from the medial subnucleus of the caudal hypoglossal
nucleus and pass through the upper root of the ansa cervicalis before jumping on
Fig. 13.1 Retrogradely labeled entire hypoglossal nucleus motoneurons on the left and only the
dorsal subdivision of the nerve intact on the right. Cells are seen 600 mm rostral to the internal
obex in (a), at the internal obex in (b), and 600 mm to the internal obex in (c). The dorsal subgroup
is surrounded by the thick line and includes motoneurons supplying the styloglossus (SG), hyoglossus (HG), and the inferior (Inf) and superior (Sup) longitudinal (long) intrinsic tongue muscle
fibers. The ventral subgroup is surrounded by a thin line and includes motoneurons supplying the
genioglossus (GG), and the vertical (vert) and transverse (trans) intrinsic tongue muscle fibers. The
geniohyoid (GH) motoneurons are located in the lateral accessory subgroup. CC central canal.
Scale bar = 100 mm for (a), (b), and (c)
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M.S. Shall
the medial branch of the hypoglossal nerve (Aldes 1995; Kitamura et al. 1985;
Uemura-Sumi et al. 1988). In the human, the hypoglossal cranial nerve receives a
contribution from the first cervical nerve for its innervation of the geniohyoid muscle (Curto et al. 1980). The more dorsal compartment of the hypoglossal nucleus
contributes motoneurons to the lateral branch, which supplies the HG and SG.
McClung and Goldberg (1999) also found that the superior and inferior longitudinal
muscles are involved in tongue retrusion and are innervated by the motoneurons
located in the dorsal part of the hypoglossal nucleus.
13.4
Somatic Sensation
Tongue sensation is frequently associated only with taste, supplied by cranial nerves
VII, IX, and X. However, somatic sensation of the tongue surface plays a vital role
in both proprioception of the tongue and manipulation of food so that the food bolus
is of an appropriate size for the esophagus and in a position for swallowing. Steele
and Miller (2010) emphasize in their review that sensory feedback is important to
all phases of deglutination. Anterior tongue sensation triggers the subconscious
pharyngeal swallow. Sensory receptors continue to monitor the bolus as the sequential motor activity of the tongue moves it along. The esophageal swallow intensity
is modified in response to the sensory evaluation of the bolus, and secondary peristalsis is initiated.
The lingual nerve off the mandibular division of cranial nerve V is responsible
for the somatic sensation of the anterior 2/3 of the tongue surface, while branches of
the maxillary division provide input from the palate. The lingual branch of cranial
nerve IX supplies both surface sensation and taste of the posterior 1/3 of the tongue
(Goetz 2007). The internal branch of the superior laryngeal nerve and other branches
of the vagus nerve provide the feedback in the pharyngeal region. Cortically, the
mammalian tongue homunculus is one the largest cortical areas dedicated to sensation, even at birth, leading the infant to explore everything with its tongue. Sakamoto
et al. (2008) found that most of the somatosensory processing is located in the primary somatosensory cortex (SI), Brodmann area 40 and the anterior cingulate cortex (ACC). A fraction of the tongue SI is primarily activated by the anterolateral
tongue, implying its voluntary activity in speech as well as the initiation of feeding
and drinking. It is interesting that children show symmetric patterns of lingual twopoint discrimination whereas adults develop an asymmetric pattern (McNutt 2009).
This seems to indicate a maturing of language skills as the child learns to emphasize
particular patterns of speech that are specific to the language and region.
Somatosensation of the posterior parts of the tongue is processed less by SI and
more by Brodmann Area 40 and ACC (Sakamoto et al. 2010a). It is known that the
ACC plays an important role in sensory, motor, cognitive, and emotional information (Sakamoto et al. 2010b), and pain processing (Schnitzler and Ploner 2000; Vogt
2005; Qiu et al. 2006). It follows that posterior tongue sensation is more involved in
the maintenance of the patent airway, vomiting and swallowing functions, and the
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connection with the limbic system. Choking, retching, etc., may be accompanied by
tears and a sense of panic and pain.
Masseter muscle spindle afferents synapse with cranial nerve XII premotor
neurons via the trigeminal mesencephalic nucleus (Luo et al. 2006). These synaptic
connections provide some of the proprioceptive mediated jawtongue coordination.
Less is known about the proprioceptive feedback from the human tongue during
tongue movement. Anesthesia of the lingual nerve (carrying cranial nerve V afferents) induces a delay in the corticomotor control of tongue muscle (Halkjaer et al.
2006). It is common knowledge that there are neural network motoneurons, sensory
neurons, and interneurons known as central pattern generators that can generate
basic motor patterns for repetitive movement. These networks are particularly useful for activities such as locomotion that are performed the same way, at the same
rate, many times in a day. Similarly, rhythmic movements of the tongue, driven by
the hypoglossal nuclei, receive inputs from the dorsal medullary reticular column
(DMRC) and the nucleus of the tractus solitarius (NTS). These interconnections are
helpful for repetitive functions such as respiration and chewing (see below) with
sensory feedback from cranial nerves V and IX.
13.5
13.5.1
Functions
Protrusion and Retrusion
The GG muscle originates on the genial tubercle on the inside of the anterior mandible and inserts on the ventromedial base of the tongue (McClung and Goldberg
2000) to pull the tongue toward the mandible, i.e., protrude the tongue. The SG
muscle angles inferiorly from the styloid process of the temporal bone to the ventrolateral base of the tongue to retract the tongue up and back. Synergistically, the
HG muscle originates on the hyoid bone and runs superiorly to insert on the superolateral aspect of the base of the tongue (McClung and Goldberg 2000). Downward
movement (depression) of the base of the tongue is performed by the combined
action of the GG and HG muscles. Conversely, the SG and PG lift (elevate) the base
of the tongue.
The functional organization of the intrinsic muscles has been more difficult to
pin down. It is generally accepted that intrinsic muscles shape the tongue to execute
more finely controlled movements as well as contribute to protrusion and retrusion.
Protrusion is not a major function of the human tongue, though it is usually the
function tested to evaluate the status of the hypoglossal cranial nerve. A dysfunctional nerve will result in the GG contracting only on the intact side so that the
tongue appears to point to the side of the lesion. It is interesting to study the
mechanics of protrusive activities such as licking and lapping in experimental animals such as dogs, cats, and rats (Reis et al. 2010). As expected by our own observation, a dogs tongue penetrates the water and quickly scoops the liquid into a ventral
cup and into the mouth as it closes. In contrast, the cat quickly touches the dorsal
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M.S. Shall
tip of the tongue and pulls up a column of water to be partially captured by jaw
closure, only seen by high speed videography. These are two very different adaptations of the tongue to perform the same function though lost as humans adapted to
drinking from a cup or sucking through a straw.
Contraction of the intrinsic muscles can thicken the body of the tongue or bend
the tongues tip downward or upward (Napadow et al. 1999). Humans restrict their
movements to within or around the oral cavity, e.g., bending the tip to the side
would be activated by that sides longitudinal intrinsic muscles.
13.5.2
Respiration
Rather than tongue protrusion, humans are much more concerned about the development and maintenance of the ability to suck, chew, swallow, breathe, speak, and
coordinate all of those activities to avoid problems such as biting the tongue, aspirating food, or losing nourishment.
Obviously respiration is the first function recognized at birth, and the tongue plays
an important role in maintaining an open airway. At birth, the rat GG muscle expresses
only neonatal/embryonic isoforms (Brozanski et al. 1993). The myosin heavy chain
(MyHC) isoforms rapidly mature to adult expression of 2A, 2X, and 2B but neonatal
MyHC still accounts for about 10% of the total MHC composition at postnatal day 25.
Considering that the neonatal rat is comparable to a human fetus in the third trimester
(Romijn et al. 1991), it is understandable that the human tongue motor units would
to be ready for independent respiration but still have room for modification.
The GG co-contracts with the HG during inspiration to decrease pharyngeal collapsibility in both animal and human subjects (Fregosi and Fuller 1997; Fuller et al.
1999). If stressed to clear the airway, the superior longitudinal intrinsic muscle will
assist in opening the airway by helping to pull the tongue forward.
Human tongue movement has been most extensively studied in terms of its role
in respiration. Most of the single unit recordings of the tongue have focused on the
GG because of the ease of human access under the tongue or percutaneously with
fine wire electrodes (see Bailey 2011 for review). Some of the earliest recordings
described rhythmic activation of the GG during inspiration to pull the tongue forward and open the airway when the subjects are sitting or standing upright (Sauerland
and Mitchell 1970). The activity changed to continuous activity when supine, even
in stable non-REM sleep (Bailey et al. 2007a). The EMG activity decreases during
REM sleep (Sauerland and Harper 1976). This data led to the hypothesis that
the GG was the vital key that modulated the oropharyngeal aperture that should
counterbalance the collapsing force exerted by inspiration (Remmers et al. 1978).
Clinically, this seemed to indicate that a lazy GG might cause sleep apnea. However,
data from further research has reformulated the hypothesis to involve the co-activation
of multiple pharyngeal airway muscles along with the GG to maintain the airway
and prevent sleep apnea (Fregosi and Fuller 1997; Fuller et al. 1999).
Indeed, it became important to define the type of breathing or types of recruitment to determine the possible reasons for the muscles that are active and their
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firing patterns. It is easy to understand that vestibular input (Tsuiki et al. 2000), state
of wakefulness (Bailey et al. 2007a), hypoxia (Hwang et al. 1983), or laryngeal
mechanoreceptor stimulation (Withington-Wray et al. 1988) will alter recruitment
and the respiratory pattern, considering that these are very different functions. The
vestibular system would provide information that the head is vertical or horizontal
in a gravity controlled environment before there is feedback of hypoxia. If the head
is horizontal, the tongue might collapse into the oro-pharyngeal space. As a result,
a greater number of GG motor units are recruited during sleep because of the recumbent position (Tsuiki et al. 2000). One might think that the recruitment of the GG
might be a simple train of potentials to pull the tongue forward during inspiration
when sleeping in the supine position. Instead, Bailey et al. (2007a) found at least six
different firing patterns in non-REM sleep, which persist after arousal from sleep
(Wilkinson et al. 2010) and in quiet wakefulness (Saboisky et al. 2007). Recognition
of insufficient oxygen is a primitive reflex that attempts to maintain an open airway
at all times. Hypoxia is recognized in the blood by the chemoreceptors located in
the carotid sinuses and sensed by cranial nerve IX. The sensation is directly connected to the breathing centers of the brainstem, which recruits the respiratory
muscles including the GG to open the airway and increase the rate of inspiration
(Hwang et al. 1983). If there is food or liquid aspiration into the larynx, the recruitment of motoneurons may shift from inspiratory to expiratory to expel the problem
(Withington-Wray et al. 1988).
Recruitment of motor units and rate coding vary during respiration, depending
on how much is needed to meet the need for sufficient oxygen. It is suggested that
the modulation of force in the hypoglossal motoneuron pool is biased in favor of
recruitment rather than rate coding (Bailey 2011). There seem to be some localized
areas of the posterior GG that are active during quiet breathing (Bailey et al. 2007b).
Magnetic resonance imaging (Cheng et al. 2008, 2011) and intramuscular stimulation (Oliven et al. 2007) reveal the mechanical action of deeper transversely oriented
GG fibers that particularly contribute to opening the pharyngeal airway. The intrinsic motor units may be more involved in respiration than previously considered.
The documentation of respiratory-related co-activation of protrudor and retrusor
tongue muscles reinforced the hypothesis of a respiratory central pattern generator
(CPG) (Bailey and Fregosi 2004; Peever et al. 2002). The motor units of the tongue
and chest wall fire in synchrony at frequencies between ~1.5 and 8 Hz (Rice et al.
2011). As the breathing becomes more rapid, the chest wall and diaphragm work
efficiently together while leaving the tongue to other complex tasks.
13.5.3
Suckling, Acquiring and Manipulating Food,

and Swallowing
Fortunately, at birth, most animals are ready to voluntarily protrude the tongue on
the nipple using the GG, apply the upward pressure or stroking on the nipple, using
the SG and vertical intrinsic tongue muscle fibers which causes the milk to be
expressed. The tongue intrinsic muscles and HG propel the bolus toward the back
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M.S. Shall
Fig. 13.2 Contractile responses of the postnatal day 14 tongue retractor musculature in a damreared (left) and artificially reared (right) rat pup. (a) Constant frequency stimulation with 200ms
duration trains at 20, 40, 60, and 80 Hz from bottom to top. The dam-reared rat pups fusion frequency = 80 Hz and maximum tetanic tension = 25.91 g. The artificially reared rat pups fusion
frequency = 60 Hz and maximum tetanic tension = 25.91 g. (b) Fatigue response to stimulation at
50 Hz for 500 ms, 1 train/s for 2 min. The first response is the top trace (showing greater tension)
and the last response is the bottom trace. The fatigue index (ratio of the last response to the first
trace) of the dam-reared pup = 0.81 and the artificially reared rat pups fatigue index = 0.55
of the tongue, which triggers the swallow. If the baby is intubated because of other
health issues, and has no opportunity to practice nutritive suckling and swallowing, then these are activities that require learning later, and the baby may develop
speech at a later developmental age or have a persistent speech disorder (Jennische
and Sedin 1998, 1999).
Newborn rats transition from nutritive suckling to chewing in 30 days (Maeda
et al. 1987), during which time the MyHC isoform composition shifts from developmental to adult fast MyHC (Brozanski et al. 1993). A rat model mimicking perinatal infants with disrupted suckling was developed in the Goldberg/McClung lab
to study the neuromuscular development in the absence of suckling experience.
Artificial feeding via a gastric cannula from day 4 to postnatal day 14, eliminating
nutritive suckling behavior during the initial postnatal period, caused at least a
short-term alteration of the contractile characteristics of the SG muscle. Relative to
dam-reared animals, the rats had a decrease in fusion frequency and a decrease in
fatigue resistance. A 1-month resumption of dam-rearing and transition to rat chow
was sufficient for recovery of the contractile speed and fatigue characteristics of the
SG (Fig. 13.2).
However, in the long-term, there was an increase in MyHCIIA isoform expression and a decrease in the MyHCIIB isoform expression (Kinirons et al. 2003). This
subtle change in muscle fiber MyHC isoform expression may partially explain the
subtle changes in the motor control of the tongue. The rat is not deprived of all sensory sensation during this period but fails to gain the sensory experience of nutrition
in the mouth to fully develop tongue coordination.
Swallowing is a complex sensorimotor function involving the tongue (see Ertekin
and Aydogdu 2003). The initial oral phase is accepted as mainly voluntary, though
the duration of the phase may vary depending on hunger, taste, motivation, etc.
Initially, while still in the oral phase, the food is acquired and chewed into small
13
237
enough sizes to fit through the pharynx and esophagus. All of the tongue muscles
are active in manipulating the food into the correct position for the teeth. The SG
and the PG lifts the posterior tongue to close off the pharynx while the intrinsic
muscles manipulate the bolus. If the food moves too quickly to the pharynx or a
tongue depressor depresses the tongue and stimulates the oral pharynx, the gag
reflex is stimulated. The vagus nerve senses the stimulation and makes a monosynaptic connection with the hypoglossal nerve.
The pharyngeal phase propels the bolus to the esophagus while coordinating
inhibition of respiration, closing the palatopharyngeal isthmus, and constricting the
larynx. The genioglossus and the anterior digastric may be active initially, followed
by the mylohyoid, stylohyoid, and geniohyoid, working to lift the hyoid anteriorly
(Ono et al. 2009). Finally, the posterior tongue is depressed to form the anterior wall
of the pharynx as the pharyngeal muscles take over in the effort to propel the bolus
toward the esophagus.
It is also important to consider the role of the mandible during eating and speech.
Obviously, several of the muscles attach to the mandible and so need the stability of
the bone on which to move the tongue. The temporomandibular joint facilitates the
synchronicity of anteroposterior movement of the mandible and tongue but limits
horizontal movement. The hyoid, on the other hand, moves with the tongue to produce large amplitude horizontal movements.
There has been a lot of exploration of a masticatory CPG focused on the medial
bulbar reticular formation, with most of the studies using in vitro isolated mammalian brainstem preparations (Katakura et al. 1995; Nakamura et al. 1999). It became
apparent that sucking rhythm generators coupled with cranial nerves V, VII, and XII
were initially necessary to coordinate suckling during late gestation and infancy
(see Barlow 2009 for review). At birth, the system has to develop an interaction
between the swallow and a protection of the airway. Once again, sensory experience is important during this critical period to develop a brainstem pattern for swallowing proficiency. As the infant develops, the tongue begins to discern the size of
the food bolus and how to move it to the back of the tongue for swallowing. The
more mature patterns of mastication involve the rhythmic opening and closing of
the jaws but rhythmical bursts also occur in hypoglossal motoneurons (Dellow and
Lund 1971).
13.5.4
Speech
Manipulation of the tongue during speech is highly variable depending on the language, acoustic feedback, and learned pattern of speech. Therefore the movements
of the muscles are extremely complex and only somewhat follow a pattern. Models
of the tongue and vocal tract have been enhanced by computer power. Specifically,
the models have tried to relate muscle recruitment and tongue shape (Perkell and
Zandipour 2002). More recently 3D biomechanical models of the tongue and oral
cavity have provided a view of the activity of parts of muscles rather than whole
238
M.S. Shall
muscles (Buchaillard et al. 2009). For example, the general activity of the GG is one
of lowering the tongue while pushing it forward. When the focus is on forming a
sound with the fine nuances of the muscle, one can see that the anterior GG enlarges
the tongue in a transverse direction while moving the tongue downward. The posterior GG elevates the tongue while pushing it forward. The HG also lowers the tongue
but in a posterior direction. On the other hand, the SG pulls the tongue backward but
the action may be up or down depending on the synergist.
One assumes that synergies exist in the motor control of the tongue which is not
evident at birth. Human infants listen and watch and practice, with the result that the
word mama comes first after watching the lips and the word dada is more
difficult since the tongues contact with the palate is concealed. The three-dimensional orientation of the intrinsic muscles is finely coordinated to position the tongue
relative to the palate and the teeth to form vowel and consonant sounds.
In summary, the tongue is a wonderful complex of muscle fibers that have developed to meet the needs of each species. The masseter and the hyoid muscles position
the mandibular platform for the four pairs of extrinsic muscles to move the tongue
forward and back. The three pairs of intrinsic muscles deform the body of the tongue
in three dimensions for its respiratory, nutritional, and speech functions.
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Chapter 14
Tongue Muscle Response

to Neuromuscular Diseases and Specific
Pathologies
Zi-Jun Liu
14.1
Overview
The tongue is the only muscular organ in the craniofacial region and plays fundamental
roles in almost all oral motor functions, including drinking, ingestion, chewing,
swallowing, respiration, and speech. A number of neuromuscular diseases, such as
epilepsy, multiple sclerosis, cerebral palsy, muscular dystrophy, Parkinsons and
Huntingtons diseases, and myasthenia gravis, signicantly affect tongue motor
functions. These negative impacts include reduced or complete loss of control in
moving the tongue (tongue displacement) and/or changing the shape of the tongue
(tongue deformation), tongue spasm or convulsion, muscle dystonia, and ankyloglossia. Several sensational disorders may also occur due to these neuromuscular
diseases, including burning tongue, loss of taste function (ageusia), decreased ability to taste (hypogeusia), and changes in taste (dysgeusia). In recent decades, extensive studies have demonstrated that tongue size, volume, position, and neuromuscular
activity, especially in the tongue base, are signicantly implicated in obstructive
sleep apnea (OSA), a potential life-threatening disorder of breathing, which affects
24% of the adult population (Schwab 2003; Schwab et al. 2003).
In addition to the complex network of interwoven bers and ber bundles from
four intrinsic and four extrinsic tongue muscles which facilitate complicated and
delicate tongue kinematics, the tongue also has a large network of subdividing nerve
branches and blood supply. Studies have shown that the hypoglossal nerve alone has
more than 50 primary branches innervating tongue musculature (Mu and Sanders
1999). Unlike other body motor organs, the tongue is composed almost entirely of
Z.-J. Liu (*)

Department of Orthodontics, University of Washington, Seattle, WA 98195, USA
e-mail: zjliu@uw.edu
241
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Z.-J. Liu
skeletal muscular tissue and lacks an internal bony support for motor function. While
the extrinsic tongue muscles arise externally from bony structures, the intrinsic
tongue muscles originate and terminate within the tongue proper (see Sokoloff and
Burkholder, Chap. 9). By contracting these complex muscular structures, the tongue
performs motor function and exerts force through various shape changes (Mu and
Sanders 1999). As a muscular hydrostat, the tongue kinematics and biomechanical effects (displacement, deformation, and load production) are produced by complex changes of its shape in various dimensions. For example, the tongue is capable
of simultaneously lengthening and shortening in different regions. These kinematic
features may produce a great variety of nonlinear movements and deformations
without altering its tissue volume (Kier and Smith 1985; Kier et al. 1989; Nishikawa
1999; Sokoloff 2004). It has been recently advocated that the tongue neuromuscular
organization and motor control are no longer entirely muscle-based but use grouped
motor unit- or segmented structure unit-based strategies (Slaughter et al. 2005;
Sokoloff 2004; Takemoto 2001).
14.2 Tongue Kinematics

Because of anatomical complexity and inaccessibility, tissue attributes, and functional precision and diversity, studying tongue kinematics and biomechanics by
examining its shape changes (deformation) or position changes (movement) during
manipulation and function has been an ongoing challenge (Napadow et al. 1999a, b;
Takemoto 2001; Sawczuk and Mosier 2001). In addition to various imaging techniques including videouoroscopy, cineradiography, X-ray microbeam, and MRI,
ultrasonography has been extensively used to study tongue kinematics in feeding
and speech. However, even with the availability of 3D reconstruction, this technique can only trace movements represented by surfaces of the tongue, and deformational changes remain undetectable. Due to the incompressibility and complex
ber structure, studying tongue biomechanics from changes of its overall tissue
shape or displacements may not be appropriate. Rather, internal muscular deformation should be examined and analyzed (Napadow et al. 1999a, b). Therefore, tongue
internal kinematics are a key component of tongue biomechanics.
For years, our group has developed an innovative approach of digital microsonometrics to study real-time tongue kinematics by measuring the changes in tongue
shape in multiple dimensions as well as tongue regional volume during various
functions. By implanting 6 ultrasonic crystals in the anterior 2/3 of the tongue blade
and body (Fig. 14.1a) or 8 in the posterior 1/3 tongue base (Fig. 14.1b) in a minipig
model, together with other techniques such as high-speed jaw movement tracking,
wire electromyography (EMG), in vivo loading, and respiratory monitoring, the
normal kinematics of the tongue and ensuing biomechanical consequences have
been extensively investigated.
14
Tongue Muscle Response to Neuromuscular Diseases and Specic Pathologies
243
Fig. 14.1 Congurations of the two ultrasonic crystal arrays. (a) Six crystals in anterior 2/3 of the
tongue. (b) Eight crystals in posterior 1/3 of the tongue. Empty circles and numbers indicate
implanted crystals, and two dark dots indicate circumvallate papillae the border of anterior 2/3
(body and blade) and posterior 1/3 (base) of the tongue. Inset: ultrasonic crystals with B barbs
14.2.1
Tongue Kinematics During Manipulations

of the Hypoglossal Motor System
Investigation on the relationship between regional tongue deformation and manipulation with the hypoglossal motor system is essential in understanding the role of
the tongue in maintaining upper airway patency and loading on its surrounding
bony structures. When the tongue is manually moved forward, the major changes
are a large increase in the length (~1820%) and a small decrease in the width
(~56%) and thickness (~911%). The anterior width symmetrically decreases to
2830% when the tongue is moved laterally. However, the changes in the posterior
widths are side-dependent, decreasing in the dorsal and increasing in the ventral for
the ipsilateral side and vice versa. This side dependence feature is also seen in the
changes in length and thickness, i.e., length decreases and thickness increases for
the ipsilateral side. When the tongue is bent, either dorsally or ventrally, it results in
a small decrease in the width and thickness, but considerable increase in the length
(~3653%). Therefore, at least in pig, the tongue has more exibility of length
change in ventral bending compared with dorsal bending (Liu et al. 2006).
The hypoglossal nerve is the somatomotor nerve that innervates all the intrinsic
and all but one (palatoglossus) of the extrinsic muscles of the tongue. The medial
branch supplies motor output to the tongue protrudor complex (genioglossal,
Z.-J. Liu
244
Fig. 14.2 Stimulation of hypoglossal motor system. Dots indicate the locations of hook electrodes
for stimulations. HG hypoglossal nerve trunk; LB hypoglossal nerve lateral branch; MB hypoglossal nerve medial branch; GG genioglossus; SG styloglossus; LN lingual nerve, LF lingual frenum;
CP circumvallate papillae; FP follicle papillae
geniohyoid, and intrinsic tongue muscles) whereas the lateral branch supplies motor
output to the tongue retractor complex (styloglossal and hypoglossal muscles)
(McClung and Goldberg 2000; Fuller and Fregosi 2000; Yoo and Durand 2005).
Electrical stimulations to its trunk, medial, and lateral branches (Fig. 14.2) widen
the posterior tongue body by increasing its dorsal and ventral width (~810%).
However, tongue body shortening and thickening (~49%) are evoked by the trunk
and lateral branch stimulations. In contrast, stimulation to the medial branch lengthens the sagittal dimension of the tongue body (~79%) along with moderate tongue
protrusion. On the other hand, stimulation to the major tongue protrudor, the genioglossus, results in the widening of the anterior tongue body and thinning of the
posterior tongue body, along with tongue body lengthening. All of these deformations have the effect of dilating the upper airway in the ventral and lateral pharyngeal wall, thereby maintaining upper airway patency. Because the stimulations to
the tongue protrudor (medial branch and genioglossus) and retractor (lateral branch
and styloglossus) show opposite directions in the tongue deformation, the notion
that coactivation of both complexes has an effect on maintaining upper airway patency may not be true. While the tongue manipulations result in signicantly larger
changes in width, length, and thickness than those by electrical stimulations to the
hypoglossal motor system, the changes by stimulations are surprisingly similar to
each other no matter which nerve trunk, branches, or muscles is stimulated. This
similarity may imply that at least in the hypoglossal motor system, the supramaximal activation of a nerve branch could produce motor output strength analogous to
that caused by the tetanic contraction of its innervated muscle (Liu et al. 2006).
14.2.2
Tongue Kinematics During Function
As illustrated in Fig. 14.1, it has been veried that the implantation of a number of
crystals (2 mm in diameter) into the tongue has no signicant functional impairment
14
245
Fig. 14.3 Deformational patterns in the anterior 2/3 of the tongue during chewing (a), ingestion
(b), and drinking (c). RL and LL right and left lengths (#13# and #2#4); AW anterior width
(#1#2); PDW and PVW posterior dorsal and ventral widths (#3#4 and #5#6); RT and LT right
and left thicknesses (#3#5 and #4#6). Refer to Fig. 14.1a for the locations of crystal pairs
(modied from Shcherbatyy and Liu 2007, with permission)
(Kayalioglu et al. 2007). Accordingly, tongue kinematics during various functions

such as mastication, drinking, swallowing, and respiration could be examined using
such a method. Similar to humans, the mastication sequence of the pig is composed
of ingestion, chewing, and swallowing. Tongue dimensional changes during chewing and ingestion cycles are stereotypical with considerable regularity, and the
frequency is about two times faster for ingestion than for chewing cycles (~240 ms
vs. ~450 ms). The ingestion cycles are dominated by length changes (sagittal plane),
whereas changes in width and thickness (transverse plane) are more prominent in
chewing cycles. The bilateral thickness changes are symmetrical during ingestion
but side-dependent during chewing, which clearly reects the side difference of
alternating chewing in pigs (Fig. 14.3a, b) (Liu and Herring 2000). Swallowing
occurs every 3040 chewing cycles and lasts about 550600 ms without the interruption of mastication sequence. Widening and lengthening of the tongue base are
the major changes for bolus swallowing during feeding accompanied by activity
bursts of the middle pharyngeal constrictor and thyrohyoid muscles (Fig. 14.4a).
Spontaneous salivary swallowing, on the other hand, is characterized by posterior
widening and anterior narrowing of the tongue base as well as activity bursts in the
middle pharyngeal constrictor, thyrohyoid, and styloglossal muscles (Fig. 14.4b)
(Herring et al. 2011). The initial tongue shape alters signicantly from mastication
to drinking, at which the tongue body elongates and the posterior part becomes thinner. During drinking cycles, the overall dimensional changes reduce signicantly as
compared to chewing and ingestion cycles (~1020% vs. ~1033%) and their
amplitudes are symmetrically distributed in all dimensions (Fig. 14.3c). Water
swallowing occurs every 34 drinking cycles and is characterized by narrowing in
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Z.-J. Liu
Fig. 14.4 Deformational pattern of tongue base and accompanying muscle activities during
voluntary bolus (a) and spontaneous salivary (b) swallowing. BWA and BWP base anterior (#1#2)
and posterior (#3#4) widths; BL base length (#1#3); BT base thickness (#1#5); MA masseter;
GG genioglossus; SG styloglossus; TH thyrohyoid; MC middle pharyngeal constrictor; Ppres palatal pressure; Flow, Pres. and Vol respiratory air ow, pressure, and volume. Refer to Fig. 14.1b for
the locations of crystal pairs. Red arrows indicate swallowing episode
posterior width and shortening in length of the tongue body, along with the activity
bursts in styloglossus. The time analysis clearly indicated that the reversals of
expansioncontraction of various dimensions of the tongue body are not synchronous but occur in a sequential manner as a function of performing tasks. Therefore,
we may conclude that: (1) tongue internal deformations are task-specic in both
timing and amplitude; (2) these deformations are dominant in the transverse plane
(width and thickness) for chewing, sagittal plane (length) for ingestion, and symmetric in both planes for drinking (Fig. 14.3) (Shcherbatyy and Liu 2007).
Our group has also examined the internal deformations of the tongue base
(Fig. 14.1b) in relation to respiration in the same pig model. During the inspiration
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247
Fig. 14.5 Deformational pattern of the tongue base during respiration. BWA and BWP base
anterior (#1#2) and posterior (#3#4) widths; BL base length (#1#3); BT base thickness (#1#5);
GG genioglossus; SG styloglossus; TH thyrohyoid; MC middle pharyngeal constrictor; V/T transversus/verticalis; SL superior longitudinalis; Flow, Pres. and Vol. respiratory ow, pressure, and
volume. Two dash lines dene the phase of inspiration (ins.), and red arrows indicate tongue base
deformation during the inspiration phase. Refer to n for the locations of crystal pairs
phase, the tongue base becomes thinner, narrower, and longer, and the genioglossus
muscle is the most active. During the expiration phase, rhythmic activity bursts of
tongue muscles disappear except for sporadic activation of the styloglossus (Fig. 14.5)
(Herring et al. 2011).
14.2.3
Spatio-Temporal Coupling in Volumetric

and Dimensional Changes
According to the muscular hydrostat theory of tongue motor control, the constant
volume of the tongue is achieved by its deforming or displacing in various regions
and dimensions via contractions of highly dened intrinsic and extrinsic tongue
muscles (Kier and Smith 1985). Although the entire tongue is incompressible, a
volumetric change deriving from independent motor control of regions may occur
to allow its diverse functions to be accomplished (Slaughter et al. 2005; Hiiemae
and Palmer 2003), as the tongue motor control is far beyond the whole muscle level
(Odeh et al. 1995). Therefore, the changes in distance (elongation or shortening) in
Z.-J. Liu
248
various dimensions (width, length, and thickness) in a region of the tongue may not
be parallel or compensatory to each other, thus incompatible with the hydrostat
theory. Our 3D digital ultrasound recording demonstrated that rhythmic and stereotypical regional volumetric changes do occur during mastication and drinking, and
these volumetric changes are signicantly larger in chewing (~45.6%) than in ingestion (~31.4%) and drinking (~30.4%). The regional volumetric expansion mainly
results from widening and shortening, and posterior thinning in the tongue body.
The data also suggest that the theory of region-independent motor control of the
tongue (Slaughter et al. 2005; Hiiemae and Palmer 2003), i.e., one dimension of the
tongue compensates for the other dimension or the loss of one dimension is parallel
to the gain of other dimension, may not really occur. The time-series analyses
between the dimensional and volumetric changes further revealed that the volume
expansion is primarily due to the increase of widths while thickness and length actually decrease. If the overall changes in amplitudes of various dimensions are
counted, decreases in thickness and length are the two biggest contributors to volumetric expansion. Therefore, regional volumetric changes are coupled with changing widths in the same direction and with changing thickness and length in the
opposite directions (Liu et al. 2008c).
14.2.4
Tongue Kinematics in Relation to Jaw Movement

and Muscle Activity
Tongue kinematics are restricted neither to the simple protrusionretrusion and/or

descendingascending axes, nor to vertical rotation like that seen for the jaw, but
involves complex shape and regional volumetric changes during function. These
changes are produced by sequential muscular activity and accompanied by jaw
movement (Hiiemae et al. 1995; Napadow et al. 1999a, b, 2002; Liu et al. 2008c).
A number of studies have indicated a strong linkage between tongue and jaw movements during feeding (Liu et al. 1993; Thexton et al. 1982; Palmer et al. 1997), but
the linkage between internal deformation of the tongue and jaw movement is largely
unknown. High-speed video with uorescent markers glued to the lips and the
tongue tip revealed that during mastication, the tongue tip retracts when jaw opening begins, with a time delay of 1624 ms (Fig. 14.6). This very rapid movement
most likely relates to the control of the bolus, and this observation contradicts the
widely accepted notion that tongue protrusion coincides with jaw opening during
rhythmic chewing (Thexton et al. 1982; Liu et al. 1993; Palmer et al. 1997).
Conversely, during jaw closing it is the corner of the mouth which retracts suggesting that the cheek is responsible for guiding the bolus at this stage. The realtime and synchronized study on tongue internal deformation, jaw movement, and
EMG activities revealed that expansion of tongue widths mainly occurs in the
occlusal phase of jaw movement and is less coupled with the activity of tongue
muscles, but the expansions of length and thickness are seen in the opening and
closing phases of jaw movement and are better coupled with activities of tongue
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249
Fig. 14.6 Fluorescent marks of jaw (a) and tongue tip (b), and tracings (digitized) of jaw and
tongue movement during chewing (c)
muscles. Ingestion function is characterized by early expansion of anterior width

prior to the occlusal phase and strong associations between tongue deformation and
muscle activity. During drinking, the durations of tongue widening and lengthening
are signicantly shortened whereas these are signicantly prolonged during the
opening and closing phases of jaw movement. Anterior widening is predominant in
the opening whereas posterior thickening lasts from early jaw opening through late
closing. This specic pattern of dimensional changes suggests that the tongue
stretches in width rst before jaw opening, then elongates and thickens to form a
central groove during drinking. This is an ideal shape to exert the mechanism of
suction, because no lapping and licking for liquid feeding is reported in pigs and
most of ungulates (Shcherbatyy and Liu 2007; Herring and Scapino 1973; Thexton
et al. 1998). Interestingly, intrinsic tongue muscles do not have more or stronger
correlations with tongue deformation than do extrinsic tongue muscles. The time
and correlation analyses further found that the initiation of tongue dimensional
increase does not correspond with the activation of tongue muscles simultaneously.
A better coupling between tongue deformations and tongue muscle activations
exists in the sagittal (lengthening and thickening) than the transverse (widening)
planes of the tongue. Furthermore, expansion magnitudes of tongue deformation do
Z.-J. Liu
250
Fig. 14.7 The estimated overall tongue shape in relation to three phases of jaw movement during
chewing. Column A: dorsal view; Column B: sagittal (right-side) view. (a) Opening phase;
(b) closing phase; (c) occlusal (power stroke) phase. Arrows indicate the direction of deformational changes (modied from Liu et al. 2008c, with permission)
not show closer correlation with the amount of EMG activity in intrinsic than
extrinsic tongue or jaw muscles.
In summary, the estimated tongue shapes during three stages of chewing are
sketched in Fig. 14.7. Compared to the overall shape during jaw opening phase
(Fig. 14.7a), elongation in the body and narrowing and thickening in the posterior
body are the main deformations during the jaw closing phase (Fig. 14.7b). During the
power stroke, the tongue extensively widens and shortens, along with its thinning in
the posterior body (Fig. 14.7c). Taking all of these dimensional and volumetric
changes together, it can be concluded that increases in the widths are greater than
decreases in the length and thickness, and their combination is most likely responsible
for the volumetric expansion during the power stroke. On the other hand, decreases in
the widths and length are greater than the increase in the thickness, and their combination is most likely responsible for the volumetric contraction during jaw closing.
14.3 Tongue Volumetric Reduction and Consequences

of Motor Function
14.3.1
Mass Reduction and Tongue Kinematics
Abnormalities in tongue size and morphology have been implicated in various clinical diseases such as malocclusion, OSA, dysphagia, Beckwith-Wiedemann and
Downs syndromes, and cerebral palsy. Tongue volume reduction is a valuable
approach for treating symptomatic macroglossia and some related functional disorders (Deguchi 1993; Davalbhakta and Lamberty 2000; Wolford and Cottrell 1996;
Ruff 1985; Herren et al. 1981; Li et al. 2002; Stuck et al. 2005). Given the fact that
the tongue is a volume-dependent muscular organ due to the nature of its hydrostat
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251
Fig. 14.8 Schema of the

tongue surgery. Dark area
indicate the removed tongue
mass. (a) Dorsal view; (b, c):
anterior and posterior coronal
views. CP circumvallate
papillae. Empty dots indicate
the implanted ultrasonic
crystals
(Kier et al. 1989; Kier and Smith 1985; Bailey and Fregosi 2004), this muscular
mass reduction is expected to alter the tongue motor function signicantly.
Furthermore, some types of post-injury adaptations could be less appropriate for the
functional demands and even become a dysfunction rather than a positive adaptation, which may lead to maladaptive motor function over time. By using digital
ultrasonic techniques in the same pig model receiving ~1820% tongue volume
reduction through surgery (Fig. 14.8), our group examined these immediate and
longitudinal effects on tongue kinematics (Shcherbatyy et al. 2008a, b).
As to an immediate effect after surgical tongue volume reduction, the basic feature of the tongue kinematics still remains but the regularity and amplitude of the
dimensional changes during chewing are diminished. While the major dimensional
losses of the tongue by the surgery are the anterior (66%) and posterior dorsal widths
(16%), the major decreases in tongue kinematics during chewing are found in the
length (~31%) and the anterior width (~44%). Conversely, changes in the posterior
widths and thickness are signicantly enhanced by ~1020% after the surgery, indicating an immediate compensatory effect. Anatomically, the orthogonally oriented
intrinsic muscle bers are the major components of the anterior 2/3 of the tongue,
and extrinsic bers are mainly inserted laterally (hyoglossus and styloglossus) and
compose a large central region of the tongue base (genioglossus) (Napadow et al.
1999b; Sicher 1960; Gray 2000; Peter 1995; Odeh et al. 1995). Therefore, intrinsic
tongue musculature is the major component of the tongue tissue removed by the
surgery (Fig. 14.8), although muscle bers from extrinsic tongue musculature,
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Z.-J. Liu
particularly genioglossus, might be also included. From this point of view, such a
compensatory effect by the posterior tongue may suggest that there is a mutual
interaction and adaptation between these two types of tongue musculature: intrinsic
and extrinsic. The previous notion that extrinsic muscles are to position the tongue
and the intrinsic muscles are to shape the tongue (Sutlive et al. 1999; Gray 2000)
may not be correct. In fact, tongue kinematics are driven by both intrinsic and
extrinsic tongue muscles, and these two muscle groups are not only structurally
interwoven but also functionally interacting. It is expected that this compensatory
effect for the loss of tongue mass may not occur under neuromuscular stimulation
to the hypoglossal motor nerves due to the lack of interaction and coordination
between different groups and regions of the tongue muscles. However, this expectation is not fully supported by our stimulation tests, in which the change in posterior
dorsal width (the second largest dimensional loss by the surgery) was adversely
enhanced under the stimulation to the medial branch of hypoglossal nerve. On the
contrary, the deformational change in the least surgically involved dimension, posterior ventral width, was signicantly reduced. This contradictory nding suggests
that the muscular mass reduction might not be the major factor causing the decrease
in deformational range in the surgically altered tongue.
To verify whether the above changes in tongue kinematics by muscular mass
reduction is a transient effect or a relatively permanent consequence, our group
further examined the longitudinal changes before and after the surgery. Signicant
modications in the feeding function were observed during this 6-week time period.
Typically, the animal utilizes the mandible, instead of the anterior tongue, to shovel
food into the mouth for ingestion, and moves and shakes the head intentionally for
chewing and swallowing as a way to take an advantage of gravity (inertial pattern),
which results in making the feeding session signicantly longer. The food leaking
from the mouth corners during mastication and more frequent and longer ingestion
episodes interposed in the masticatory sequence are often seen in the initial weeks
after the surgery. However, the amount of daily food consumption shows no change.
With regard to tongue kinematics, at week 1 after the surgery, masticatory deformations decreased in the anterior width and body length, but increased in the posterior
widths and thickness signicantly, as compared to the baselines (week 0). At week
2, the reduced deformational capacity in the anterior tongue (width and length) was
slightly restored with better regularity of stereotypical chewing cycles than those
seen at week 1. However, the increased deformation in the posterior tongue (widths
and thickness) diminished as compared to those seen at week 1. At week 4, the restoration of anterior tongue deformation continued, but the deformational range in
the posterior tongue further decreased and almost returned to those seen at the baseline (week 0). These time-course changes in tongue kinematics clearly indicated that
although there is a short-term loss of deformational capacity in the anterior tongue
and a compensatory enhanced deformation in the posterior tongue, these distorted
features diminished over time, featured by the restoration of reduced deformation in
the anterior tongue and the vanishing of enhanced deformation in the posterior
tongue over time. Nevertheless, the complete restoration of the deformational
capacity in the anterior tongue was not seen at the end point of week 4 (Fig. 14.9a, b).
This type of functional modication in tongue kinematics most likely stems from
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253
Fig. 14.9 Comparisons of masticatory tongue deformational ranges of each dimension over time
between reduction and sham (surgical incisions without mass reduction) animals. Asterisks above
the data points indicate signicantly larger or smaller deformational ranges at each time point
between the reduction and sham animals. All values were converted to % of altered distance/initial
distance of each dimension. P0: pre-surgery (baseline); P1, P2, and P3: 1, 2, and 4 weeks after the
surgery; AW anterior width; LENG length; PDW and PVW posterior dorsal and ventral widths;
THICK posterior thickness
muscular plasticity and adaptation, and also can be attributed to the motor learning
process after the surgery. Apparently, this type of adaptation in tongue kinematics
does not result in as good a functional performance as in an intact tongue, evidenced
by behavior alterations during feeding as described above and potentially negative
effects on craniofacial growth (Shcherbatyy et al. 2008a; Liu et al. 2008a; Liu 2009).
Thus, maladaptation in tongue kinematics may occur with muscular mass reduction
of the tongue, because the chance of full recovery through myogenic regeneration
is unlikely. Fibrosis would be the most likely outcome, which may be a permanent
consequence after tongue mass reduction (see below).
14.3.2
Morphological and Histologic Consequences

After Mass Reduction
The muscular mass reduction results in remarkable morphological changes in the

tongue. The tongue becomes much shorter and narrower in its body as compared to the
sham surgery, which leads to the entire lower dental arch becoming visible (Fig. 14.10).
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Z.-J. Liu
Fig. 14.10 Comparison of tongue morphology and its relation to mandibular dentition 4 weeks
after the surgery. Top: Tongue received sham surgery; Bottom: Tongue received reduction surgery.
Note that the remarkable decreases in length and width (double-arrowed red lines) in the reduction
as compared to the sham tongues (from Perkins et al. 2008, with permission)
The tongue cast and postmortem measurements further indicate that despite ongoing
growth (compare before and after in sham-surgery animals in Table 14.1), the reduction surgery signicantly reduces the length and width of tongue body, and results
in about 15% loss of both volume and weight of the tongue over a 4-week period
postoperatively (Perkins et al. 2008).
Although complete healing of surgical incisions is seen from the tongue surface
(Fig. 14.10), muscle ber reconstitution does not occur histologically in the surgical
site. Instead, disorganized collagen bers are interwoven without any detectable
arrangement or orientation. A few atrophied myobers with reduced perimysium
and endomysium are sporadically distributed in brous tissue (Fig. 14.11). These
features are typical signs of brosis. Therefore, the recovery of normal muscular
architecture and functionality is compromised (Perkins et al. 2008). The formation
of brosis may cause further decreased muscle contractility and reduced range of
kinematics. A cell proliferation assessment study (Ye et al. 2010) further revealed
that like other skeletal muscles, myogenic regeneration in the tongue follows a centripetal gradient that ows from outer to inner regions, showing most and least
Length
Width
Thickness
Volume (mL)
Mass
Loss (%)
Before
103.45 4.90
60.15 2.24
7.91 0.33
n/a
n/a
4 weeks after
113.05 5.21*
67.76 0.61*
9.16 0.58*
71.45 2.20
n/a
Reduction
Before
104.52 3.68
57.88 2.26
8.03 0.33
n/a
n/a
4 weeks after
82.99 4.69*
50.66 2.41*
10.49 0.27*
60.62 0.91#
15.21 0.78
Dimension measures on tongue casts (anterior 2/3), and mass measures on postmortem tongue specimens
% of loss calculated by specimen volume (weight)/removed part volume (weight) 100%
*p < 0.05 before and 4 weeks after surgery in each group; #p < 0.05 between the two groups 4 weeks after surgery
Sham
Table 14.1 Comparisons of dimension and mass between reduction and sham tongues
Dimensions (mm)
Weight (g)
n/a
71.43 1.52
n/a
59.42 1.33#
Loss (%)
n/a
n/a
n/a
15.18 0.19
14
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256
Z.-J. Liu
Fig. 14.11 Muscular structures in the sham and reduction tongues (trichrome staining). (a, b): 4
horizontal images showing muscular structure from sham (a) and reduction (b) tongues. The inset
area of image (b) shows disorganized collagen bers linked with a few intermittent muscle bers.
(c, d): 20 sagittal images showing the endomysium and perimysium from sham (c) and reduction
(d) tongues (from Ye et al. 2010, with permission)
Fig. 14.12 Pattern of muscular repair after the surgery (H&E staining). (a) A 4 coronal image
from a reduction tongue, showing the scar tissue in the middle center area of the surgical site; the
centripetal repair is shown by small arrows. (b) A 10 coronal image from the insert area of the
image (a), showing a number of intermeshed myobers surrounding the scar tissue (from Ye et al.
2010, with permission)
mature myobers in the outer and inner regions, respectively (Fig. 14.12). All of the
regenerated myobers have central nuclei, and their polygonal shape and organization in fascicles are similar to normal myobers (Charge and Rudnicki 2004;
Lefaucheur and Sebille 1995). This immunohistochemical study further discovered
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257
that despite the enhanced cellular proliferating activity in response to surgical injury
of the tongue, signicantly more proliferating connective cell nuclei were found
than myonuclei in the surgical site. Therefore, the proliferation of connective tissue
prevails, while the capacity of myogenic regeneration is limited in the repair of
tongue injury. Because both muscle bers and connective tissues are oriented more
in the longitudinal than transverse and/or dorsal-ventral directions, sagittal views of
the tongue tissue usually contain the highest counts of proliferating cells. In conclusion, the partial brosis without predominant myogenic regeneration is the major
histological consequence in the volume-reduced tongue, and the repair process does
not reconstitute the muscular structures of the tongue but rather is an adaption to a
new morphology, which in turn limits the functional recovery of an injured tongue
(Ye et al. 2010).
14.3.3
Influences on Craniofacial Growth

and Dentition Formation
Even though the controversy of whether the tongue adapts to existing oral morphology, or actively molds its surrounding tissues, is long-standing (Ingervall and
Schmoker 1990; Frohlich et al. 1991, 1993), numerous clinical studies have claimed
that tongue size/volume/position may affect a number of elements of craniofacial
growth and dental/occlusal development (Lowe et al. 1985). Prolonged low tongue
position from oral breathing in children may initiate a sequence of events resulting
in excessive molar eruption, which causes a clockwise rotation of the growing
mandible, a disproportional increase in anterior lower vertical face height, retrognathia, and open bite. A low tongue position may also impede lateral expansion and
anterior maxillary development (Harvold 1968; Harvold et al. 1973; Principato
1991). Therefore, examining the causeeffect relationship between modication of
tongue mass and alteration in craniofacial skeletal growth is imperative for understanding the underlying mechanism.
To this end, our group performed a series of studies on a growing pig model, and
compared the effects on craniofacial skeletal components and dentition formation
longitudinally between the animals with and without tongue mass surgical reduction (Liu 2009; Liu et al. 2008a). Our results indicated that tongue mass reduction
has an overall negative effect on the linear expansion of craniofacial skeletons, manifested by signicantly decreased amounts in premaxilla and anterior mandibular
lengths, mandibular ramus height, midface width, and anterior dental arch width
during the period of rapid growth (Fig. 14.13). A mass-reduced tongue also causes
a decrease of bone mineral density in premaxilla/maxilla and anterior mandible
examined by dual photon/energy X-ray absorptiometry (DEXA). It is worthwhile to
indicate that despite the growth effects occurring in all three dimensions (width,
height, and length) of both facial and mandibular bones, the two appearances are
distinctive. First, the majority of these inuences are around the anterior mouth
or anterior dental arch, particularly in the mandibular symphysis and premaxilla.
It should be noted that the mass reduction only involved the anterior 2/3 of the
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Z.-J. Liu
Fig. 14.13 Effects of tongue mass reduction on craniofacial growth. (a) Sites of slowed skeletal
growth (red lines) detected by longitudinal tracking of cephalometric radiography. (b) Decreased
variables in elements of skeletons (red double-headed arrows) and dentition (black double-headed
arrows) detected by biometric measurements on the harvested skulls. Red and black dots indicate
measurement points in skeletons and dentitions, respectively (modied from Liu et al. 2008a, with
permission)
14
259
tongue which is thought to produce greater forces than does the tongue base
(Pouderoux and Kahrilas 1995). Our in vivo loading study revealed that the tongue
produces more load in mandibular lingual surfaces than the premaxillary and maxillary palatal surfaces, and these loads decrease in the anterior mouth (symphysis and
premaxilla) after the mass reduction. Loads in the posterior mouth (mandibular corpus and posterior maxillary palatal surface) are less affected (Liu et al. 2008b).
Therefore, the observed slow growth in the skeletal components may in part contribute to the decrease of functional loads in the anterior mouth by a mass-reduced
tongue. Second, among affected components of the craniofacial skeleton, the mandible is affected more than the nasomaxillary skeleton in all dimensions: length,
width, and height. This striking difference between upper and lower jaws was also
conrmed by the examination of bone mineral density in which the only signicant
decrease was found in the mandibular symphysis bloc of the mass-reduced animals
(Liu et al. 2008a). Anatomically, the tongue is directly attached to the mandible
through its musculature. Functionally, there is an inherent linkage between the
tongue and mandible (Palmer et al. 1997). Furthermore, the mechanism of cranial/
nasomaxillary postnatal growth is mostly attributed to sutures, different from that of
the mandible which mainly depends on appositional deposition through intramembranous ossication at the borders and alveolar ridges, and on secondary cartilage
through endochondrous ossication at the condyle (Sarnat 1997; Kantomaa and
Ronning 1997). Based on these ndings, it is not surprising that the postnatal mandibular growth would be suppressed more than the other elements of the craniofacial skeletons by the tongue mass reduction.
14.4
Conclusions
Thus, compared to body skeletal muscles, the tongue musculature presents striking
differences with the following features: (1) myobers of extrinsic (with bony attachment) and intrinsic (without bony attachment) tongue muscles are aligned in both
parallel (longitudinal) and perpendicular (transverse, vertical, circumferential, or
radial) directions, and interweave with each other. This forms an intricate array and
provides the basis for multidirectional contraction and regional-dependent deformation; (2) the unique architecture of the tongue musculature grants this organ an
enormous biomechanical versatility to fulll various functional demands, and the
tongue motor control most likely uses grouped motor unit- or segmented structure
unit-based, rather than entirely muscle-based strategies. Thus, the tongue kinematics in regions may not apply to the widely held theory of a muscular hydrostat;
(3) the extrinsic and intrinsic tongue muscles are not only structurally interwoven
but also functionally interacting. The reversals of expansioncontraction of various
dimensions of the tongue are not synchronous but occur in a sequential manner as a
function of performing tasks; (4) changes in the tongue mass not only signicantly
alter the pattern of tongue kinematics, but manifest biomechanical effects on surrounding hard tissue, which in turn affects the growth of the craniofacial skeleton
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Z.-J. Liu
and the development of dentition, particularly in the mandible; (5) although the
healing of tongue musculature after injury follows the centripetal pattern seen in
other skeletal muscles, its capacity for myogenic regeneration is relatively weak.
Therefore, brosis becomes the major histological consequence after tongue injury,
which leads to compromised recovery of muscular architecture and functionality.
Acknowledgements I would like to thank the following persons for their important contributions
to the work described in this chapter: Drs. Volodymyr Shcherbatyy, Janathan Perskins, Mustafa
Kayalioglu, Gaoman Gu, Amir Sei, Wenmin Ye, and Mrs. Brandon Yamamura, Alfadhli Abu,
and Aaron Huang. Special thank goes to Dr. Sue Herring for her constructive discussions and critical comments during the entire course of the study. This work was supported by the grant R01
DE15659 from NIDCR. The participation of Dr. Wenmin Ye was supported by China Government
Scholarship Program 20082010 (File No. 2008659018), and the participations of Mrs. Brandon
Yamamura, Alfadhli Abu, and Aaron Huang were supported by the grant T32 DE007132 from
NIDCR.
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Part VII
Facial Muscles
Chapter 15
Facial Nerve Innervation and Facial Palsies

Adriaan O. Grobbelaar and Alex C.S. Woollard
15.1
Introduction
There are a myriad of causes of facial palsy. Identifying the etiology in each case is
of vital importance to the choice of management pathway, either as an emergency
or in terms of long-term intervention. Most patients at the time of presentation are
convinced that they are suffering from either a stroke (50%), an intracranial tumor
(25%), or do not know but are nonetheless anxious (25%) (Peitersen 2002). In a
review of the literature, Schaitkin and May identied over 100 possible diagnoses
but the overwhelming majority (5066%) of cases were Bells palsies (Schaitkin
et al. 2000). The difculty of this diagnosis of idiopathic paralysis is that it is one of
exclusion. Any case of new onset palsy must be thoroughly examined, and the history, as always, is vital in ascertaining the cause. The onset, progression, concurrent
symptoms, and localization all assist the physician in deciding what further investigations are required.
Whatever the cause of the facial palsy, this is a devastating condition. The complete or partial loss of function of the seventh cranial nerve results in a spectrum of
both functional and esthetic problems that plague the lives of sufferers. The
American Medical Association Guide to the Evaluation of Permanent Impairment,
which rates disabilities on a scale of percentage of whole body impairment, scores
unilateral facial palsy as 1015% and bilateral as 3045% (Cocchiarella and
Andersson 2001). Communication, social interaction, vision, eating, and drinking
can all be affected. In children, it is a detrimental to their development and leaves
them introverted and shy. The lack of subcutaneous muscular tension exacerbates
the aging process such that the affected side of the face falls, causing long-term
problems with eye and mouth closure. Tears can run from the loose lower lid and
A.O. Grobbelaar (*) A.C.S. Woollard

Institute for Plastic Surgery Research and Education, Royal Free Hospital,
Pond Street, London NW3 2QG, UK
e-mail: aog@talk21.com
265
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A.O. Grobbelaar and A.C.S. Woollard
the loss of oral continence results in dental caries and drooling. Alternatively the
patient may suffer from reduced lacrimal or salivary production and complain of a
dry eye and mouth. Corneal ulcers arise once the ocular sphincter is unable to effectively protect the eye, especially where there is a loss of corneal sensation and the
normal blink reex. The sense of taste can be diminished or absent and the lack of
oral tone can make it difcult to keep dentures in place. A loss of stapedial reex
can lead to hyperacusis, and any concurrent eighth nerve involvement leads to auditory and balance disruption. A partial paralysis (or partial recovery) may not involve
all the branches of the nerve. Unilateral paralysis results in asymmetry, bilateral in
a completely static, expressionless affect.
15.2 Anatomy
The nucleus of the facial nerve lies in the lower third of the pons under the fourth
ventricle, just caudal to the trigeminal nerve nucleus. It receives input regarding
voluntary facial expression from the pre- and postcentral gyri of the cerebral cortex.
Here the homunculus is laid out with the forehead most superior. A cortical lesion
will often produce a facial palsy associated with weakness of the tongue, thumb, or
hand ipsilateral to the facial palsy.
Impulses are carried in the corticobulbar tract, through the internal capsule, the
upper mid-brain, and lower brainstem to synapse with the seventh nerve nucleus.
The upper face receives relatively little in the way of cortical input in comparison
with the lower face which may explain why the forehead and eyelid closure are not
as severely affected with focal central lesions (Jenny and Saper 1987).
Resting tone, emotional, and involuntary movements are thought to arise in the
thalamus, globus pallidus, and basal ganglia of the extrapyramidal system.
Supranuclear lesions will tend to leave emotional movements and reexes intact.
The lack of facial movement in Parkinsons and Meiges syndromes is due to a dysfunction of the extrapyramidal system. The seventh nerve also receives input from
the trigeminal and vestibulocochlear nerves as the basis of corneal and stapedial
reexes. A lower mid-brain lesion may result in a contralateral facial and extremity
paresis but an ipsilateral abducens defect due to the close association of the sixth
and seventh nerve nuclei.
The facial nerve (CNVII) exits the brain at the cerebropontine angle as a motor
and a sensory component (nerve of Wrisberg). It is in close proximity to the eighth
nerve (CNVIII, vestibulocochlear) and its bers pass around the nuclei of the sixth
nerve (CNVI, abducens) and the superior salivatory nerve. Pontine lesions can be
associated with a number of syndromes that are characterized by a spectrum of
involvement of these nerves (Jemec et al. 2000). Examples include Moebius syndrome (congenital VIth and VIIth cranial nerve palsies) and pseudobulbar palsy
(bilateral facial paralysis and other cranial nerve decits, a hyperreactive gag reex
and hyperreexia associated with hypertension). The sensory component of CNVII
carries the afferent taste bers from the chorda tympani nerve (taste to the anterior
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two-thirds of the tongue), the taste bers from the soft palate via the palatine and
greater petrosal nerves, and the preganglionic parasympathetic innervation to the
lacrimal, submandibular, and sublingual glands. The lesser petrosal nerve carries
secretomotor bers to the parotid gland. There is also a small cutaneous sensory
component arising from the posterior auricular area.
The facial nerve has the longest bony course of any nerve as it traverses the
facial canal of the petrous temporal bone and then the lateral canal of the mastoid
bone, some 2030 mm in all. This extended encased section is vulnerable to both
swelling through edema or inammation, and fractures. The labyrinthine segment
in particular is especially narrow and lacks arterial cascades making it susceptible
to ischemia. Between the labyrinthine and tympanic segments lies the geniculate
ganglion where the petrosal branches are given off. Lesions prior to the geniculate ganglion result in more severe ocular complications due to the lack of lacrimal
secretions (Mavrikakis 2008). In the tympanic segment, the nerve passes behind the
cochleariform process against the medial wall of the cavum tympani, above and
posterior to the oval window. The bony wall is commonly thin or dehiscent here,
and the nerve may lie directly against the middle ear mucosa making it particularly
vulnerable to iatrogenic injury and middle ear infections. Between the external
auditory meatus and the horizontal semicircular canal the nerve makes a second
turn into the lateral canal of the mastoid bone. Three branches exit in this segment:
the chorda tympani, the nerve to stapedius, and the nerve from the auricular branch
of the vagus nerve (CNX).
Base of skull fractures can result in a facial palsy as a result of transection or
tension accompanied by entrapment of the nerve in its bony course. The presence of
a facial palsy in the setting of head and neck trauma is an indication that urgent
further assessment is essential with CT and MRI scans.
The facial nerve exits the skull through the stylomastoid foramen, supplies a
branch to the posterior auricular muscle, passes between and innervates the posterior
belly of digastric and the stylohyoid muscle before entering the parotid gland. In the
substance of the parotid, it divides into upper and lower trunks, which subdivide
into ve main branches: temporal, zygomatic, buccal, marginal mandibular, and
cervical.
The temporal branch innervates the upper eyelid and forehead. Paralysis results
in a ptosis of the brow and upper lid that in the elderly can be severe enough to
obscure vision. In addition, the upper eyelid is responsible for blinking and distributing the watery tear lm that protects the cornea. Ulceration of an unprotected
cornea is a serious risk, and assessment of an adequate Bells reex is an essential
part of any examination. Xeropthalmia (i.e., dry eye syndrome) is extremely uncomfortable for patients and a dry eye can paradoxically elicit excessive tear production
that overwhelms the lacrimal duct resulting in epiphora.
The zygomatic and buccal branches innervate the muscles of the midface and
experience signicant cross-innervation. Paralysis results in ptosis of the lower
eyelid and increased scleral show, exacerbating the eye problems alluded to above.
In combination with the two inferior branches, they control the movements of the
mouth and are responsible for oral continence, smiling, and speech.
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Table 15.1 Distribution and function of the facial nerve (CNVII)

Branch of CN VII
Muscle
Action
Posterior auricular
Posterior auricular
Pulls ear back
Occipitofrontalis
Moves scalp back
Direct branch
Stylohyoid
Retracts and elevates oor of mouth
Direct branch
Posterior belly digastric
Raises hyoid bone in swallowing
Temporal
Anterior auricular
Pulls ear forward
Superior auricular
Raises ear
Frontalis
Raises brow
Corrugator supercilli
Pulls eyebrows medially and down
Procerus
Pulls medial eyebrow down
Temporal and zygomatic Orbicularis oculi
Closes eyelids
Zygomatic and buccal
Zygomaticus major
Elevates corners of mouth
Buccal
Zygomaticus minor
Elevates upper lip
Levator labii superioris
Elevates upper lip and mid nasolabial fold
Levator labii superioris
Elevates nasolabial fold and nasal ala
alaeque nasi
Risorius
Assists lateral vector of smile
Buccinator
Deates cheeks
Levator anguli oris
Pulls corners of mouth up and medially
Orbicularis oris
Purses lips
Nasalis, dilator naris
Flares nostrils
Nasalis, compressor naris Closes nostrils
Buccal and marginal
Depressor anguli oris
Depresses corner of mouth
mandibular
Depressor labii inferioris Depresses lower lip
Marginal mandibular
Mentalis
Pulls skin of chin up
Cervical
Platysma
Tightens skin of neck and depresses
corner of mouth
The marginal mandibular and cervical branches innervate the platysma and the
depressor anguli oris. Paralysis of the lower lip depressors impairs depression of the
lower lip on the affected, giving a snarl-like appearance especially during crying
(Tulley et al. 2000). See Table 15.1 for a complete list of the muscles innervated by
each branch.
15.3
Etiology
Evidence for facial palsy dates back as far as 4000 BCE with an Egyptian statue
exhibiting a left-sided facial palsy (Resende and Weber 2008). Avicenna (9791037
CE) identied the difference between a central lesion affecting the body and face,
and an isolated nerve lesion affecting only the face (Kataye 1975). Freidrich was the
rst to describe three cases of idiopathic facial palsy in 1797 in Germany (Bird and
Nicolaus 1979). However, it was Charles Bell (later knighted) who demonstrated
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Table 15.2 Possible causes of facial nerve palsy and related conditions
Cause
Example
Congenital
Moebius syndrome, myotonic dystrophy
Trauma
Birth trauma, basal skull fracture, facial injuries, barotrauma, middle ear injury
Neurological
MillardGubler syndrome, WernickeKorsakoff syndrome
Infectious
Viral: Herpes simplex, herpes zoster, measles, mumps, cytomegalovirus,
infectious mononucleosis, HIV/AIDS
Bacterial/parasitic: Lyme disease, acute/chronic otitis media, osteomyelitis,
suppurative parotitis, scleroderma, botulism, tuberculosis, leprosy, malaria,
syphilis, aspergillosis, leptospirosis, cat scratch fever, trichinosis
Metabolic
Diabetes mellitus, hyper- and hypothyroidism, hypertension, acute porphyria,
vitamin A deciency
Neoplastic
Cholesteatoma, leukemia, sarcoma, carcinoma, acoustic schwannoma,
brosarcoma, neural lesions (astrocytoma, glioma, etc.), parotid lesions,
facial nerve tumor
Toxic
Tetanus, diphtheria, arsenic, lead, alcohol, carbon monoxide
Iatrogenic
Local anesthesia, surgery (parotid, temporal bone, carotid endartectomy,
temporomandibular joint)
Idiopathic
Bells, Familial, MelkerssonRosenthal syndrome, CharcotMarieTooth
disease, temporal arteritis, GuillainBarre syndrome, multiple sclerosis,
myasthenia gravis, Kawasaki disease, amyloidosis, sarcoidosis, Wegeners
granulomatosis, scleroderma, StevensJohnson syndrome, osteogenesis
imperfecta, Pagets disease, osteopetrosis
that the CNVII was responsible for movement of the facial muscles devoted to
expression. The eponymous Bells palsy bears his name despite the earlier description by Bell (1821).
As already alluded to, the number of possible causes of facial palsy can make a
denitive diagnosis elusive. Pathology specimens are only available in the case of
neoplasms and to biopsy the nerve in most circumstances would violate primum
non nocere. All that palsies is not Bells and a thorough clinical assessment can
diagnose those cases where the underlying condition merits a more interventionist
approach (Cawthorne 1965). In the series reported by May, over 300 of the 2,256
cases which had been referred as an acute Bells palsy turned out to have a treatable
progressive or life-threatening disorder (Schaitkin et al. 2000). Table 15.2 gives
examples of etiologies taken from the comprehensive list given by Bonnet (2005).
A systematic understanding of some of the key presenting features helps to guide
diagnosis. It is important to appreciate that very few features are explicit, and it is
an overall picture of the presentation that leads the clinician. Table 15.3 gives a list
of key diagnostic signs and symptoms to be evaluated.
Onset and completeness alone cannot determine the cause of the paralysis. In the
setting of trauma, a complete sudden palsy indicates a likely transection of the nerve
and warrants exploration. An incomplete palsy suggests that the nerve is likely to be
intact and deserves observation. An incomplete paralysis can progress for up to
10 days with a Bells palsy, after external blunt trauma or surgical trauma in the
parotid, temporal bone, or posterior cranial fossa. In herpes zoster, it may progress
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Table 15.3 Diagnostic signs

Date of onset
Rate of onset
Incomplete vs. complete
Recurrence (ipsilateral or contralateral)
Family history
Pregnancy
Systemic illness (including any indications
of immunocompromise)
Malignancies
Medications
Trauma
Fasciculations
Mass lesion in head and neck
Recent viral episode or exposure
Pain or parasthesia
Otitis media or externa, tinnitus, ear surgery
Alteration in hearing or taste
Dizziness
Xerophthalmia or excessive tearing
Vesicles (and location)
for up to 21 days. An incomplete paralysis that is progressive for longer than 3 weeks
is almost certainly due to a tumor. In these cases, the nerve is slowly compressed by
the expanding mass resulting in progressive axonal destruction. Seventy six percent
of the tumors in Mays series presented in this fashion, 24% presented with sudden
onset complete palsy with approximately equal proportions of benign and malignant disease in both groups.
Recurrence can occur with a Bells palsy (incidence 6.813%). In Mays series,
he describes the majority as contralateral (62%) and interestingly notes that whilst
it is a common nding with herpes simplex, it is very rare in herpes zoster infections. Without explicitly attributing it to HSV, May believes recurrent contralateral
palsy to be virtually diagnostic of Bells palsy. A rare condition, Melkersson
Rosenthal syndrome, is characterized by recurring, alternating facial palsy. This is
identied by having 2 of 4 features: recurrent alternating facial palsy, recurrent orofacial edema, chelitis, ssuring of the tongue. Of the ipsilateral recurrences 30%
were associated with a tumor, and May advises a full tumor workup be carried out
in any case of ipsilateral recurrence (Schaitkin et al. 2000).
Bilateral facial palsy, outside of the congenital presentations, can represent a
medical emergency. In cases of incomplete palsy, it can be difcult to appreciate the
less-affected side. GuillainBarre syndrome (GBS) and Lyme disease are probably
the commonest causes. GBS is an acute, inammatory demyelinating polyradiculopathy characterized by an ascending parasthesia, weakness, and areexia. It is
believed to be an autoimmune hypersensitivity reaction to peripheral myelin. The
evolution of symptoms occurs over 24 weeks and recovery takes 46 months in
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85% of cases, though the majority of cases show some permanent loss of function.
The ascending motor paralysis can range from mild to total paralysis and may
progress rapidly to respiratory failure. The facial nerve is the most commonly
affected cranial nerve, occurring in approximately 50% of cases and is frequently
bilateral (Asbury and Cornblath 1990). Urgent hospital admission for observation
and support of failing systems is essential. Lyme disease is caused by the spirochaete Borrelia burgdorferei, which is transmitted via a tick host. It is characterized
by a localized erythematous rash that expands and lasts 3 weeks. This is associated
with generalized prodromal symptoms and occasionally neurological symptoms
including meningitis, cerebellar ataxia, and facial palsy, which can be bilateral
(Goldfarb and Sataloff 1994). The disease occurs in three distinct stages: erythema
chronicum migrans, the development of neurological symptoms (when most patients
will present to a clinician), late onset arthritic changes and psychiatric disorders,
fatigue, and permanent paralysis. Treatment is with a long course of doxycycline,
(1 month), and inadequate duration can dampen the antibody response whilst still
allowing disease progression.
Bilateral facial palsy can rarely occur with Bells and with a number of other
conditions such as infectious mononucleosis, cytomegalovirus, sarcoidosis, acute
porphyria, amyloidosis, and botulism. Of the congenital conditions causing bilateral
palsy, Moebius is the commonest but still rare with approximately 1:500,000 live
births (Verzijl et al. 2003). Most other cases fall into the spectrum of incomplete
Moebius-like syndromes.
15.4
Examination and Investigation
The history should be followed by a clinical examination. Cranial nerves VXII

pass through or close to the temporal bone. Nerves VI and VIII both have their
nuclei adjacent to the nerve VII in the brainstem and deserve particular attention.
A full cranial nerve examination is vital as part of a facial palsy work up. Topognostic
testing relies on the sequential branching of the seventh nerve to identify the site of
the lesion. Anatomy can be variable, which reduces the validity of this method, but
does allow for complete assessment of the nerve and identies specic areas such as
eye function that may require prophylactic intervention.
Ear pain is a common complaint in Bells palsy. Pain, transmitted by the chorda
tympani, is likely to be associated with an inammatory reaction and may be caused
by a viral infection. The chorda tympani also carries taste from the anterior twothirds of the tongue. Papillae atrophy occurs with denervation, and this can be
observed under magnication after 510 days.
Denervation of the greater petrosal nerve results in loss of tearing. Tearing is an
important aspect of corneal protection. It can be tested using Schirmers test with
the unaffected eye used as a control. A dry eye accompanied by loss of corneal
sensation and a poor Bells phenomenon places the eye at risk of ulceration and
272
long-term loss of visual acuity. Disordered reinnervation of the lacrimal gland can
lead to excessive tearing; however, this should not be confused with reactive
excessive tearing from incomplete eye closure.
Testing of salivation and the stapedial reex are not reliable indicators of the
level of the lesion, but the stapedial reex may have some role in prognosis if the
result is positive.
Clinical testing of auditory system and otoscopy is important particularly in the
presence of unilateral symptoms. These may suggest a mass lesion and warrant an
MRI. Dizziness is uncommon in facial palsy but can occur in Bells and with brainstem lesions or herpes zoster cephalicus infection. Patients complaining of dizziness should undergo vestibular testing and investigation of nystagmus.
There is some controversy over the value of electrophysiological testing in facial
palsy. There are three main tests that have been used: electromyography (EMG), the
maximal stimulation test (MST), and evoked electromyography (EEMG). In EMG,
a needle electrode is placed in the muscle and measurements taken of the electrical
activity due to the insertion of the needle itself, of the muscle at rest, and during
voluntary contraction. At insertion there is a normally a spike of activity. This is
characteristically increased in a denervated muscle, but decreased once brosis has
occurred due to atrophy. In the normal muscle, there is no signal at rest. Fibrillation
is indicative of denervation and occurs within 1020 days after nerve injury (May
et al. 1983). A normal voluntary contraction produces a reproducible bi- or triphasic
wave pattern. A polyphasic (>3 waves) signal is an indicator of regeneration or
myopathy; however, in reinnervation the signals tend to be prolonged.
The electrical signal in MST is measured in the muscles during maximal articial
stimulation of the entire facial nerve at the level of the parotid and at each subsequent branch in the mid face. The response is compared with the normal control
side. Results are graded as equal, minimally decreased (less than half the normal
side) or markedly decreased (less than a quarter) and the test is repeated regularly
until there is return of function or no response. May believes this to have a strong
prognostic value in predicting recovery, with 92% of patients with an equal result
at 10 days having a complete recovery and 100% of those with no response at 10
days having an incomplete recovery (May et al. 1971).
EEMG is similar to MST except that the muscle twitch is recorded on a graph
and the latency and amplitude of the response can be measured. Idiopathic palsies
show a progressive decrease in amplitude while tumors will display an increased
latency (Schaitkin et al. 2000). A drawback of all these techniques is patient compliance, especially in children. They can be painful and require the patient to remain
still during the course of the procedure. Also, in an ideal nerve stimulation test the
stimulus and the measurement should be either side of the nerve lesion. Due to
the anatomy of the facial nerve, it is not possible to stimulate the nerve cranial to the
stylomastoid foramen despite many of the lesions occurring proximal to this point.
Peitersen feels that the EEMG is useful in eliciting degeneration and that the EMG
has some use in demonstrating regeneration, but that the MST is not a reliable tool
in predicting recovery (Peitersen 2002).
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15.5
273
Bells Palsy
The natural history of Bells palsy is fascinating yet frustrating. It is the most
common cause of facial paralysis, and yet there is considerable uncertainty as to its
underlying pathology. Despite being a diagnosis of exclusion, it is a convenient
place to start to think about facial palsy as a whole. The theories to explain the cause
of idiopathic palsy began in the 1800s with the concept of rheumatism as the
condition seemed to be associated with fevers, chills, and localized pain and swelling in the neck region. In fact, Freidrich initially published his account as the paralysis musculorum faciei rheumatica. The idea of swelling, combined with the
anatomical knowledge that the nerve had a signicant petrous course in the temporal bone gave rise to the hypothesis that the nerve might become thickened and
edematous, resulting in compression around the stylomastoid foramen. This compression was believed to have secondary ischemic effects due to disturbance of the
vasa nervorum accompanying the nerve. This gave rise in the 1930s to the school of
thought advocating mastoid decompression surgery, which was in vogue for some
30 or more years (Cawthorne 1951; Jonkees 1957). In 1972, McGovern postulated
that an immunological source may be responsible for the inammation and edema
causing the nerve damage; later that year McCormick suggested herpes simplex
(HSV-1) as a possible culprit (McGovern et al. 1972; McCormick 1972). There is
still no conclusive evidence that HSV-1 is the denitive cause, but polymerase chain
reaction techniques seem to be supportive (Murakami et al. 1996).
Peitersen began a very thorough prospective study of the natural course of facial
palsy in the early 1970s, following over 2,500 patients around Copenhagen for 30
years (Peitersen 2002). Emphasis was placed on the specic details surrounding the
onset of the condition (e.g., time, other cranial nerve symptoms, pregnancy, comorbidities, trauma, ocular, and auricular symptoms, etc.), any previous or familial episodes, completeness vs. incomplete and the nature of branch involvement, as well
as the timing and completeness of remission. At the rst visit this was coupled to a
full ENT and cranial nerve examination, acoustic and vestibular tests, taste, nasolacrimal and stapedial reex examination, and baseline laboratory tests to rule out
diabetes, hypertension, serum antibodies to HSV, HZV, and borreliosis. Patients
were then seen weekly until function was observed to be returning. After 6 months,
this reduced to monthly and then discontinued after full recovery or after 1 year. If
patients suffered a second episode or had not recovered in 4 months, they underwent
further testing with CSF analysis and CT and MRI scanning. The Copenhagen
Facial Nerve Study is particularly useful in both its size and completeness of follow
up (98%). Of 2,570 cases, 1,701 were idiopathic or Bells palsies, an incidence of
32/100,000 per year. Seventy percent of these were complete paralyses. There was
a 6.8% recurrence rate and 4.1% represented familial cases. There was no indication
of a seasonal or decade variation, and there was no statistical connection with gender or laterality. Bells palsy was uncommon under the age of 15 and above 60 years
with a maximum incidence between 15 and 45 years (P < 0.001 in comparison with
the underlying population).
274
Eighty ve percent of patients recovered some movement within 3 weeks and the
remaining within 35 months. Complete remission occurred in week 1 for 6%,
week 2 for 33%, and week 3 for 16%. Interestingly, no patients achieved remission
between 3 weeks and 35 months, indicating that in the latter group there was total
degeneration of the nerve. Ten percent reached remission at 35 months and 5% at
56 months.
Overall, 71% of patients achieved a full recovery with 58% occurring within the
rst 2 months, though there was signicant difference between those who initially
had an incomplete or complete paralysis (94% vs. 61%, P < 0.001). No patient who
still had abnormal movement 6 months after onset of paralysis regained full function. The speed of onset of recovery was a critical prognostic indicator as was the
age of the patient. Ninety percent of children under 14 years achieved a full recovery, 84% of those 1529, 75% of those 3044, and less than 33% of those over 60.
Whilst Bells palsy was no more common in pregnant women, it did result in a
poorer prognosis (61% vs. 80% complete recovery, P < 0.001) (Peitersen 2002).
Eight hundred and sixty nine patients had facial palsies with identiable causes
(i.e., not idiopathic/Bells palsies). It is worth expanding on cases in the context of
diabetes mellitus, those caused by HZV, and pediatric cases. Approximately 3% of
cases occurred in patients with diabetes mellitus (diabetes has an estimated incidence of 34% in the Danish population). Two-thirds of these were incomplete
paralyses but did poorly, with only 25% achieving full recovery, in contrast to the
normal picture with incomplete palsy. It is thought that this is explained by the
underling diabetic neuropathy. Herpes zoster (HZV) oticus, or Ramsay-Hunt syndrome, is associated with a very poor prognosis (Hunt 1908) and tends to afict an
older subset of patients. Most of the time, it caused a complete paralysis (88%) and
was often associated with vestibular disturbances and irreversible hearing loss typically of the higher tones. The diagnosis of HZV is based on clinical observations of
vesicles, which may not locate around the ear, necessitating a thorough examination
of the head, neck, and mucosal surfaces. The vesicles may appear before, with, or
after the palsy. Diagnosis can be conrmed by the detection of antibodies in serum
and CSF. Prognosis was also poor in this group with 46% achieving a fair recovery
and 54% a bad one. In addition, Peitersen feels that treatment with acyclovir does
not affect outcomes markedly (Peitersen 2002).
The pediatric cases (349 cases, 13.5% overall) were dominated by neonatal cases
(169 cases) and Bells palsy (138 cases). The remaining cases were congenital bilateral palsies, trauma, or infectious causes (Peitersen 2002). There has been considerable discussion over whether neonatal paralysis is congenital or due to birth trauma.
Congenital causes can be as a result of teratogenesis, aplasia of the facial nerve
nucleus or as part of a syndrome such as Treacher-Collins or Moebius. Of the neonatal cases, the majority (80%) are due to birth trauma (Smith et al. 1981).
One of the most difcult aspects of evaluating facial palsy is the lack of a
common tool for measuring recovery that allows comparison between groups. The
complexity of normal facial movement and the variety of homeostatic functions that
the muscles of expression also encompass makes a succinct scale of total decit
impossible. There have been several attempts to classify facial palsies according to
15 Facial Nerve Innervation and Facial Palsies
275
global, regional, or specic decits, and each has its advantages and disadvantages.
The ideal system needs to be simple to use, reproducible, and yet still manage to
usefully categorize a condition that is very complex in its manifestations. The
HouseBrackmann system is probably the one most commonly used and provides
a global decit measure that includes contraction and synkinesis (House 1983).
Adours elegant regionally based system provides a facial paralysis recovery prole
(FPRP) from which subtractions can be made for symptoms of contracture, synkinesis, ptosis, etc., to generate a facial paralysis recovery index (FPRI) (Adour 2002).
This gives a numeric score for each patient, but it is complicated and requires calculations that make it unwieldy as a general tool for the clinician. The grading
system presented by Ross et al. is probably the most useful (Ross et al. 1996).
It combines the regional approach with a simple numerical grading system and
includes synkinesis.
15.6
Management Approach
The importance of understanding both the possible etiology and the natural history
of a Bells palsy is demonstrated in the rst consultation with a patient suffering an
acute onset facial palsy. The history and examination systematically rules out any
treatable, traumatic, or possible neoplastic causes. The palsy is recorded as complete
or incomplete and given a Ross or HouseBrackmann score. Further tests can be
ordered as required at this juncture. There is normally a slight delay in presentation,
which gives clues as to any progression or recovery. If the picture is compatible with
a Bells palsy, reassurance can be given that recovery is usually excellent and a
framework of the timing or return of function mapped out. Attention must be paid to
prophylactic measures with respect to sequelae, particularly eye care. Regular follow up in this period aids accurate estimation of recovery and reassures the patient.
Opinion varies as to the value of electrophysiological testing during this time.
There is no indication that surgical decompression of the facial nerve in
inammatory conditions improves outcome. If the palsy is as a result of an ongoing
process such as a cholesteatoma or suppurative otitis media then surgical intervention to arrest the underlying condition is warranted. This is particularly important if
rapid progression of the severity of the palsy is noted. Grogan et al. performed a
meta-analysis of the evidence for early medical treatment. Oral steroids are thought
to probably have a benecial effect on facial functional outcomes, acyclovir only
possibly (Grogan and Gronseth 2001).
In all cases where progressive or life-threatening causes have been excluded,
patience is essential. Most patients with facial palsies will recover at least some
function, and the return of natural expression is more esthetic than any reconstruction. Interventions to improve on any residual decit should only be considered
1218 months after there has been no further recovery of movement. At that stage
the original cause of the palsy has little impact on the reconstructive approach,
which will be guided by the residual decit and the physiological assessment of the
276
patient. The nal plan must be tailored through detailed discussion between surgeon
and patient as to the desired end point. The overall aims focus on protection of the
cornea, resting symmetry and tone, and a dynamic symmetrical smile.
15.7
Nonsurgical Management
The nonsurgical approach really centers around prophylactic measures to reduce the
incidence of sequelae around the eye, predominantly corneal abrasions. Articial
tears such as hydroxypropyl methylcellulose can help to lubricate the eye. At night
a more viscous, petrolatum-based ointment in combination with taping down of the
upper lid can reduce the chances of a corneal ulcer.
Chemodenervation of the active facial muscles with botulinum A toxin can be
used to create a more symmetrical face. This must be administered 23 times per
year. It can help both with the static position and to reduce the twitching of synkinesis. It is also possible to improve the symmetry of a smile in a partial paralysis
through careful denervation of small muscle groups around the mouth to inuence
the vector of the smile (Bulstrode and Harrison 2005). Some physicians offer neuromuscular retraining with specialist physiotherapists to improve dynamic motion,
but this is more usually in association with a functional muscle transfer.
15.8 Acute Surgical Management

Early repair of a nerve after transection improves the nal outcome. In a trauma scenario with a grossly contaminated wound, the ends should be tagged and repaired as
soon as adequate debridement and infection control has been established, ideally
within 30 days. A nerve that has been accidentally divided during surgery should be
repaired immediately. If a segment of the nerve is invaded by a tumor, proximal and
distal ends can be sent for fresh frozen section and once conrmed clear can be
repaired or bridged with a cable graft (usually sural). A more distal division tends to
be compensated for by the cross-arborization of the buccal and zygomatic branches.
More proximal injuries also suffer from increased incidence of synkinesis as they
recover (Coker et al. 1987). In cases where the proximal facial nerve is not suitable
for repair it is possible to perform an immediate mini-hypoglossal transfer to the
distal branches of the facial nerve at the same time as a cross-facial nerve graft that
can be coapted at a later date to augment the axonal load (Terzis and Tzafetta 2009).
15.9
Chronic Surgical Management
As previously mentioned the goals of surgical reconstruction are tailored to the

needs of the individual patient. The procedures can be divided into static vs. dynamic
and by which area of the face they are trying to improve: the forehead; the upper and
15
277
lower eyelids; the midface and mouth; and lower lip. In general, we have found that
patients under 10 years get the best results with functional muscle transfer reconstructions. They often achieve spontaneous smiles, and we believe this correlates
with their nerve regeneration capacity. In patients over the age of 55 years, the
benet from a free-functioning muscle transplant procedure may be less predictable. In these cases, we opt for either a simpler muscle transfer procedure or a static
sling that restores the ocular or oral continence and balances the face at rest but does
not provide movement.
15.9.1
The Forehead
The forehead undergoes a natural ptosis with age as it loses its natural elasticity.
In paralysis, this is more pronounced and more noticeable when unilateral. In extreme
cases, the brow can obscure vision. There are a number of procedures to correct
forehead ptosis, all of which are static. There is no option for recreating a useful
dynamic brow.
Brow lifts can be performed directly or endoscopically. Endoscopic lifts tend to
produce subtle adjustments as opposed to robust support and therefore produce disappointing results in facial palsy patients. Direct lifts can be performed to address
either the eyebrow or the whole forehead. An eyebrow lift, or dermodesis, requires
the excision of an ellipse of superciliary skin and frontalis muscle and the pexy of
orbicularis oculi to the periosteum of the forehead (Ueda et al. 1994). The main
risks of this procedure are scarring and damage to the supraorbital nerve which can
give rise to numbness on that side of the forehead.
In an open brow lift the forehead is usually approached via a bi-coronal incision
5 cm posterior to the hairline and the entire brow is elevated to the level of the
supraorbital ridge in the sub-galeal plane. The forehead is re-draped, and the excess
skin posterior is excised in an asymmetric fashion to compensate for the ptosis of
the paralyzed side. The scar is well hidden but can be problematic in male-pattern
baldness and in cases of incisional alopecia. Patients also often complain of parasthesia posterior to the scar.
15.9.2
The Eyelids
The aim in eyelid surgery is to achieve adequate closure to protect the cornea whilst
minimizing ptosis. This can be achieved through both static and dynamic procedures tailoring the management to the upper or lower lid depending on the nature of
the decit. The upper eyelid is primarily responsible for eye closure. Gold weights
inserted under the skin of the upper lid to improve lid ptosis were originally described
in the 1960s (Smellie 1966). Gold is an inert metal that triggers little in the way of
an inammatory response. However, there can occasionally be problems with skin
erosion and extrusion of the weight. Test weights can be taped to the outside of the
278
lid in clinic to evaluate the required mass. The aim is to achieve approximation of
the lids to within 24 mm with the lightest possible weight which is then sutured in
a supratarsal position approximately 4 mm from the lid margin to reduce the possibility of extrusion (Misra et al. 2000). It is important to stress the need to avoid
inadvertent injury to the levator as this will result in ptosis. Sometimes the weights
have to be adjusted at a secondary procedure to ne tune lid approximation. More
recently, there has been some interest in platinum chains which allow better contouring along the lid margin (Berghaus et al. 2003). Lengthening of the levator has
a similar effect in lowering the upper lid but with the advantage of no articial prosthesis or unaesthetic contour deformity that accompanies a gold weight. It is usually
performed by the interposition of a segment of temporalis fascia equal to the gap in
the orbital ssure during forced closure (Piggot et al. 1995). It is possible to implant
a dynamic device to assist closure. A palpebral spring can be inserted between the
superior orbital rim and the upper lid margin. This is loaded by the opening action
of the levator and actively closes the eye as the muscle relaxes. Its advantage is that
it works even when the patient is lying down, but results are highly dependent on
the skill and experience of the surgeon (Levine and Shapiro 2000).
The lower lid can be used to provide greater inferior support. Krastinova
described the insertion of an ellipse of conchal cartilage to improve the contour of a
paralyzed lower eyelid (Krastinova et al. 2002). It is important to crush the cartilage
to reduce the incidence of extrusion through the subciliary incision. A McLaughlins
lateral tarsorrhaphy procedure provides static support by double-breasting the
lateral canthus through resection of the posterior lamella of the upper lid and a corresponding portion of the anterior lamella of the lower lid (McLaughlin 1952). This
raises the lower lid, narrowing the aperture of the eye and effectively lowering the
upper lid. It is a simple and effective procedure, especially useful in the elderly
where it also improves any ectropion of the lower lid. However, it can give the
appearance of a smaller eye and interfere with lateral gaze. The lower lid tension
can be augmented by a fascial or palmaris sling. This can be tunneled through the
lower lid and xed to the medial canthal ligament and the lateral supraorbital margin. It is vital that the position of the sling relative to the lid margin does not exacerbate or create ectropion (too low) or entropion (too high). A canthopexy alone
tends to loosen with time and therefore provides insufcient support in facial palsy
cases. Where there is laxity of the medial canthal ligament and ectropion, it can be
addressed with a medial canthopexy or medial tarsal strip and suture xation to the
deep periosteum (McLaughlin 1951; Lee et al. 2004; Collin 1993). This can also
help to address epiphora.
Gilles described a dynamic eyelid closure where by a pedicled transfer of a slip
of the temporalis muscle is turned over and extended across the upper and lower
eyelids via fascial strips to the medial canthal ligament (Gillies 1934). The action of
chewing then causes blinking and lubrication of the cornea. Alternatively the muscle can be used exclusively for the upper lid as it constitutes the main action of eye
closure, and the lower lid supported with a simple sling. Patients frequently complain of a bulge at the lateral border of the orbit, a slit-like eye, and of the irritation
caused by eye closure whilst eating. More recently Terzis has reported a free
15
279
functional transfer of a segment of platysma with a cross-facial nerve graft

(CFNG) to restore the blink reex, though the numbers are still small (Terzis and
Karypidis 2010).
15.9.3
The Midface and Mouth
As with the forehead and the eye the reconstruction of the function of the midface
can also be approached through static and dynamic procedures. A loss of symmetry
and animation around the mouth is particularly noticeable and causes considerable
concern to patients with a facial paralysis. Young patients with facial palsy retain
good symmetry at rest due to the natural elasticity of the soft tissues. The aim of
reconstruction here is to restore the movement of the midface. These dynamic procedures will provide additional static support as the new muscle is in effect also a
sling. In older patients with paralysis, the natural aging process gives a ptotic droop
to the cheeks and corner of the mouth, even in repose. These patients are bothered
by this static asymmetry and the appearance of instability in the face with contraction of the non-paralyzed side. It causes drooling, difculties with eye closure, and
affects their ability to mix comfortably in public situations. They tend to seek symmetry at rest and a stable platform with which to use the expression of contralateral
mobile face, more than a broad smile. As a result of this, coupled with the reduced
capacity for nerve regeneration with increasing age, we have decided on an articial
cutoff of 55 years for dynamic transfers in our patients.
A static sling of autologous (palmaris longus, tensor fascia lata) or synthetic
(Goretex) material can address symmetry at rest and improve both the esthetic
appearance and functional aspects such as drooling. In our unit, we divide the medial
aspect into three slips that are rmly anchored to the ipsilateral philtral column and
commissure and the midline of the lower lip. In addition, resuspension of the suborbicularis oculi fat pad (SOOF lift) can correct static ptosis of the midface (Horlock
et al. 2002).
Early attempts at dynamic reanimation were based on a pedicled translation of
the temporalis muscle. Gilles in 1934 detached its posterior attachment and turned
it down over the zygomatic arch to insert into the corner of the mouth (Gillies 1934).
There have been modications since then. MacLaughlin detached the temporalis
from the coronoid process and extended it to the corner of the mouth using fascial
grafts rather than folding it over the zygoma (McLaughlin 1952). Labb avoided the
need for the fascial grafts by partially detaching the origin of the temporalis allowing the muscle to rotate and slide far enough to reach the mouth (Labb 1997).
Initially this was facilitated by an osteotomy of the zygomatic arch which was subsequently plated, but modications mean it is no longer required. This procedure
reduces the main patient complaint of a bulge in the lateral cheek, but does require
intense physiotherapy to retrain the muscle to be used for smiling instead of mastication. We use this procedure in older patients who are keen on a dynamic reconstruction but where the results of a cross-facial nerve graft and free muscle prove
280
Fig. 15.1 First stage facial

reanimation: The cross-facial
nerve graft is coapted to a
buccal branch of the facial
nerve on the functioning side
and tunneled across the upper
lip to the paralyzed side of
the face. The regeneration of
the axons through the graft
can be traced by a positive
Tinels sign
unreliable. We also use a Blair type facelift incision to avoid the need for the
nasolabial inset incisions as described by Labb.
CFNG were rst described by Scaramella in 1970. The arborization between the
zygomatic and buccal branches of the facial nerve is sufcient to allow minimal
donor decit and provide synergistic nerve impulses to power the paralyzed side of
the face. Originally this was used to attempt reinnervation of native muscles
(Scaramella 1975; Anderl 1976). In 1976, Harii performed the rst successful free
transfer of a gracilis into a paralyzed face. This was anastomosed to the deep temporal vessels and coapted to the existing ipsilateral facial nerve stump. In 1979, he
described the two-stage procedure of a CNFG to contralateral facial nerve and subsequent free muscle transfer (Harii et al. 1976). This has become accepted as the
gold standard for dynamic reanimation (Figs. 15.1 and 15.2). Many muscles have
since been suggested as potential donors (gracilis, latissimus dorsi, extensor digitorum brevis, pectoralis minor) in an attempt to improve the vector of the recreated
smile and to minimize the bulky contour that resides in the reconstructed cheek.
The two stages can be performed 912 months apart and in congenital palsy
cases results are better in children under 10 years. Long-term studies show a wide
variation in improvements with most authors claiming good to excellent results in
5194% of patients (Terzis and Noah 1997; OBrien et al. 1990; Harrison 2002;
15
281
Fig. 15.2 Second stage

facial reanimation: Once
there is adequate length of
functioning graft the donor
muscle is transferred. This is
anastomosed to the facial
artery and vein and a
neurorraphy performed
between the graft and the
muscles native nerve. The
muscle is secured to the
zygomatic fascia proximally
and divided into slips distally
to insert into the nasal alar
and the upper and lower lip
Kumar and Hassan 2002). All centers declare that a signicant minority of patients
required further revisional operations (Takushima et al. 2005). We rely on the
pectoralis minor and a CFNG from the sural nerve. We feel that the fan shape of this
muscle conforms well to the dimensions of the cheek providing a good, complex
vector to the smile. In addition, the muscle does not have the bulk of gracilis, which
gives an unusual hamster appearance especially noticeable in a unilateral reconstruction. The harvest of pectoralis minor is more technically demanding than gracilis but the anatomy has been well described, and there is negligible donor site
morbidity (Scevola et al. 2003; MacQuillan et al. 2004).
A one-stage reanimation has been described whereby the long pedicle of gracilis
can be coapted directly to the contralateral facial nerve at the time of free muscle
transfer (OBrien et al. 1990; Kumar 1995). This reduces the number of operations
and the recovery time by some 10 months since there is no need to wait for the
CFNG to grow across the face. However, results show that whilst the dynamic
results were comparable (93% vs. 90%), a good static appearance at rest is better in
the two-stage group (67% vs. 20%) (Kumar and Hassan 2002). An experimental
rabbit model has conrmed that the axonal morphometry and tetanic force produced
by transferred muscles are comparable in one- and two-stage procedures (UrsoBaiarda and Grobbelaar 2009). Bae et al. described free gracilis transfer with direct
coaptation to the ipsilateral masseteric branch of the trigeminal nerve which provided good excursion of the oral commissure but lacked the synchronous movement
282
achieved with a CFNG (Bae et al. 2006). This option may be of benet in older
patients or in recovery operations where a previous standard approach has failed.
15.9.4
Lower Lip
The lower lip depressors are innervated by the marginal branch of the facial nerve.
Paralysis is especially apparent during speech when the lower lip is retracted only
on the functioning side. The simplest treatment is aimed at reducing the movement
of the functioning side through regular Botulinum A toxin. A more permanent
approach is possible through surgical division of marginal branch or selective myectomy of the unparalyzed side.
The main reconstructive option for the paralyzed lower lip is a transfer of the
anterior belly of the digastric muscle. This is innervated by the trigeminal nerve and
thus spared in most cases of facial palsy. It can be transferred on its pedicle and
inserted into the margin of the lower lip (Tulley et al. 2000). Terzis advocates this in
conjunction with a CFNG to increase the synchronicity but this is a technically
difcult procedure (Terzis and Kalantarian 2000). We preoperatively image patients
to ensure the presence of the anterior belly since it can be absent, particularly in
congenital facial hypoplastic complexes (MacQuillan et al. 2010). Alternatives
include the transfer of a segment of platysma or coapting the marginal branch in
an end-to-side fashion to the hypoglossal nerve (Terzis and Kalantarian 2000).
A CFNG and free functioning muscle transfer may be suitable in severe cases.
15.10
Bilateral Facial Palsy
In cases of bilateral facial palsy there is no functioning contralateral facial nerve to

power the CFNG or new muscle. These patients require a full cranial nerve exam to
ascertain which other nerves are involved and therefore by extension which nerves
may be available to use as a donor (Terzis and Noah 2002, 2003). Bilateral palsy is
usually caused by a congenital defect, such as Moebius syndrome where there is a
paralysis of CNVI and CNVII. It is part of a spectrum of disorders where there can
be involvement of other cranial nerves, the thorax, limbs, and face (Abramson et al.
1998). Bilateral temporalis transfers can be performed, though these patients frequently have problems with speech and mastication and removing the major muscle
for chewing can be debilitating. Potential nerve donors for a free muscle transfer are
the masseteric branch of the trigeminal nerve, the accessory nerve, and a proportion
of the hypoglossal (end-to-side anastomosis) allowing for preservation of tongue
function. Each has advantages and disadvantages. Provided there is good temporalis function, mastication is not affected by the loss of some power in masseter.
15
283
As with unilateral reconstructions there is variation in the choice of donor muscle,

which can be inuenced further by any peripheral involvement of the patients
underlying syndrome.
We utilize the masseteric branch of the trigeminal nerve to power a segmental section
of latissimus dorsi. We alter the muscle donor from our unilateral reconstructions as
the length of nerve required to perform a neurorraphy within the muscle bulk of
masseter cannot be provided by pectoralis minor. Gracilis has a long enough pedicle
and in bilateral cases its excess bulk is less distracting due to its symmetry (Zuker
et al. 2000). We prefer to operate in a single stage in children under 10 years of age
as this drastically reduces the overall recovery time, and we believe the plasticity of
the brain in this age group allows them to adapt and learn to smile spontaneously in
response to emotion (Woollard et al. 2010).
15.11
Summary
The muscles innervated by the facial nerve have a very different function from
those of the axial skeleton. They facilitate the sophisticated and subtle ballet of
facial expression and communication, a vital part of human social interaction. They
provide protection to the eye and dentition. The movement and tone of the lips
allow for oral continence, clarity of speech, and of course smiling. These actions
comprise an interaction of many small muscles of variable strengths and vectors
acting in concert, perhaps rivaled only by the movements of the hand. Reconstruction
of a decit in this nervemuscle complex is still a crude science, and one in which
it is hard to remain faithful to Gilles maxim of replacing like with like. However,
its importance to a patients quality of life cannot be underestimated.
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Chapter 16
Spastic Facial Muscle Disorders

Juwan Park, Andrew R. Harrison, and Michael S. Lee
16.1
Introduction
Facial muscles are a group of striated muscles that, among other things, control
facial expression and are innervated by the facial nerve (CNVII). In contrast, the
nearby eyelid retractor muscles and masticator muscles are innervated by the oculomotor (CNIII) and mandibular branch of trigeminal nerve (CNV), respectively.
Beside facial expression, facial muscles around the eyes are in charge of controlling eye blink and eyelid closure. A blink is a temporary closure of both eyelids and
normally does not interfere with the continuity of vision. Physiologic blinking helps
keep the cornea moist to maintain a smooth refractive surface for clear vision. Reex
closure of the eyelids is a spontaneous reaction to a corneal irritant. The normal
average spontaneous blink rate is 16 9 times per minute.
Various dystonic or non-dystonic movement disorders, or dyskinesias, in the
facial region cause involuntary contractions of the facial muscles (Table 16.1),
which may be debilitating functionally and esthetically. In this chapter, we discuss
the more common facial muscle dystonias, including blepharospasm, hemifacial
spasm, and diverse conditions that cause facial spasms.
J. Park, M.D.
Department of Ophthalmology, University of Minnesota, Minneapolis, MN, USA
A.R. Harrison, M.D. (*) M.S. Lee, M.D.
Department of Ophthalmology, University of Minnesota,
420 Delaware Street SE, Minneapolis, MN 55455, USA
e-mail: harri060@umn.edu
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Table 16.1 Disorders of overactive facial muscles

Bilateral
Unilateral
Benign essential blepharospasm
Hemifacial spasm (rarely bilateral)
Aberrant regeneration of facial nerve (Facial
Reex blepharospasm; ocular, eyelid disease,
synkinesis, facial nerve misdirection,
foreign body
post-Bells palsy syndrome)
Apraxia of eyelid opening
Ocular/facial myokymia
Other idiopathic craniocervical dystonias
Focal motor seizure
Meige syndrome (Brueghel syndrome)
Tics, Tourettes syndrome (can be bilateral)
Spasmodic dystonia
Eyelid myokymia (only one eyelid involved)
Torticollis
Drug induced
Acute dystonic reaction
Tardive dystonia
Tardive dyskinesia
Neurologic disorders
Parkinsons disease
Progressive supranuclear palsy
Wilsons disease
Huntingtons disease
Post-encephalitic syndrome
Midbrain infarction
Demyelination
Seizure
Psychogenic
16.2
Blepharospasm
Dystonia is a neurologic movement disorder (dyskinesia) characterized by involuntary muscle contractions, which can vary from brief spasm to sustained contractions
and cause slow repetitive movements, twisting, or abnormal postures. There are
several different types of dystonia based upon the regions of the body which they
affect: most or all of the body (generalized dystonia), a specic part of the body
(focal dystonia), two or more unrelated body parts (multifocal dystonia), two or
more adjacent parts of the body (segmental dystonia), or the arm and leg on the
same side of the body (hemidystonia) (Dystonia fact sheet).
Among its common forms, cranial dystonia involves eyelid, facial, mandibular,
oral, lingual, and laryngeal muscles. Blepharospasm, which is the most frequent feature of cranial dystonia and the second most common focal dystonia after cervical
dystonia (spasmodic torticollis or torticollis), is the bilateral intermittent involuntary
forceful contraction of the protractor muscles of the eyelids. The protractor muscles
controlling eye blinks consist of the orbicularis oculi (main), procerus, and corrugator supercilii muscles, which are all innervated by branches of the facial nerve
(CNVII). If blepharospasm is limited to the eyelids in the absence of other adnexal
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disease, it is termed essential blepharospasm. Benign essential blepharospasm (BEB)

is dened as an essential blepharospasm without a known underlying cause.
Blepharospasm is associated with additional abnormal dystonic movements of
the lower face, neck, or extremities in more than 50% of patients. Blepharospasm
accompanied by involuntary spasm of the lower face (oromandibular dystonia) is
termed Meige syndrome (idiopathic orofacial dystonia, idiopathic oromandibular
dystonia, or idiopathic cranialcervical dystonia) named after the French neurologist Henry Meige. In 1910, he described a condition characterized by blepharospasm and facial, mandibular, oral, lingual, and laryngeal spasms and called it spasm
facial median. Its alternative eponym is Brueghel syndrome named after a Flemish
artist in the sixteenth century. De Gaper, one of his paintings of a woman showing
apparent blepharospasm with face and neck involvement, is regarded as one of the
earliest suspected documentations of blepharospasm. The term, Brueghels syndrome is used especially when extensive mandibular involvement is a major
component of the disease, and sometimes Meige syndrome and Brueghel syndrome
are differentiated as idiopathic orofacial dystonia and idiopathic oromandibular
dystonia, respectively.
16.2.1
Epidemiologic Features
BEB affects an estimated 20,00050,000 people in the United States, with 2,000
new cases diagnosed annually and a prevalence of 1.25 per 100,000 compared to
the prevalence rate of overall cranial dystonia, which is estimated at 510 per
100,000 population (Patel and Anderson 1995; Hallett 2002; Bradley et al. 2003).
Blepharospasm usually begins in the fourth to sixth decades, with its peak onset in
the sixth decade of life. Women are affected more frequently than men with the ratio
of 1.52:1 (Castelbuono and Miller 1998; Defazio and Livrea 2002).
The disorder is usually sporadic, but there are a few reports of familial occurrence, some of which suggest an autosomal dominant pattern with incomplete penetrance (Defazio et al. 1993, 2003a, 2006b). Approximately one third of the patients
have at least one rst- or second-degree relative with a movement disorder, such as
blepharospasm, Meige syndrome, Parkinsonism, or essential tremor, suggesting a
genetic predisposition in some patients. Various medical problems, including
depression, thyroid disease, and autoimmune disorders, have been reported in
patients with cranial dystonia (Cavenar et al. 1978; Diamond et al. 1984; Wenzel
et al. 2000; Nishikiori et al. 2005; Grandas et al. 1990; Jankovic and Patten 1987).
16.2.2
Clinical Features
Essential blepharospasm is typically a slowly progressive disorder. Symptoms may

stabilize in mild cases. Some patients have a uctuating course, with exacerbations
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Table 16.2 Jankovic Rating Scale (JRS) severity score

Blepharospasm severity
0 = None
1 = Minimal, increased blinking present only with external stimuli (e.g., bright light, wind,
reading, driving, etc.)
2 = Mild, but spontaneous eyelid uttering (without actual spasm), denitely noticeable, possibly
embarrassing, but not functionally disabling
3 = Moderate, very noticeable spasm of eyelids only, mildly incapacitating
4 = Severe, incapacitating spasm of eyelids and possibly other facial muscles
Blepharospasm frequency
0 = None
1 = Slightly increased frequency of blinking
2 = Eyelid uttering lasting less than 1 second (s) in duration
3 = Eyelid spasm lasting more than 1 s, but eyes open more than 50% of the waking time
4 = Functionally blind due to persistent eye closure (blepharospasm) more than 50% of the
waking time
and partial remissions. Remission rates of 1.211.4% have been reported (Castelbuono
and Miller 1998; Grandas et al. 1988).
The involuntary movement ranges from increased blink frequency to severe,
sustained spasms of the protractor muscles causing the eyelids to clamp tightly shut.
It is very helpful in evaluating the effect of treatments for blepharospasm to grade
the symptoms based on the severity and frequency. The Jankovic Rating Scale (JRS)
is probably the most widely used current clinical scale which differentiates the
severity and frequency of blepharospasm into grades of 04 (Jankovic and Orman
1987). As seen in Table 16.2, the JRS primarily focuses on the objective signs of
blepharospasm but does incorporate subjective symptoms such as whether the
increased blinking and spasms affect quality of life.
Rarely, only one eyelid is affected in blepharospasm patients, but eventually in
almost all cases both eyelids are involved within weeks to months. However, the
degree of involvement may remain asymmetric. Most patients present with sensory
complaints of dry eye symptoms (ocular irritation, foreign body sensations, grittiness, photophobia, and tearing) that may precede or occur simultaneously with the
development of the eyelid spasms (McCann et al. 1999). The initial motor sign may
be an increased frequency in blinking, particularly in response to a variety of common stimuli including wind, sunlight, and air pollution. Many blepharospasm
patients wear sunglasses, even inside and on cloudy days, and have difculty with
reading and driving.
As the disease progresses, excessive blinking is seen early and late due to overaction of the eyelid protractor muscles, particularly the orbital portion of the orbicularis oculi and the corrugators. Once the contractions are well established they may
be tonic and sustained, brief and clonic, or regular and rhythmic. Patients frequently
complain of retro-orbital discomfort at the time of the spasms (Shorr et al. 1985).
Spreading of the spasms to midfacial and lower facial muscles is often seen.
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Additional dystonias are found in the body other than eyelids in 78% of patients
(Grandas et al. 1988). For example, some patients progress to a more generalized
facial dystonia: Meige syndrome. Other muscle groups that may also be affected by
dystonic movements include muscles of the larynx and pharynx (laryngealpharyngeal dystonia) (Alappan Spring 2008; Kahn 2001). The voice may become
harsh, hoarse, and strained, a condition termed spasmodic dysphonia. (Zwirner
et al. 1997; Brin et al. 1998). Cervical muscle involvement, typical of spasmodic
torticollis, may accompany cranial dystonia; less often distal muscles, such as of
the hand (as in writers cramp), may be affected (Gordon 2005). A postural tremor
similar to benign essential tremor often accompanies cranial dystonia, and occasionally Parkinsonian symptoms are present which should be differentiated from a
complication of levodopa therapy (Tolosa and Compta 2006).
Symptoms vary during daily activities. Spasms are typically absent during sleep
and often for the rst 1 or 2 h after awakening in the morning. Patients may develop
and adopt sensory tricks to keep their eyes open. Reported conditions that might
relieve the spasms are sleep (75%), relaxation (55%), inferior gaze (27%), articial
tears (24%), traction on eyelids (22%), talking (22%), singing (20%), and humming
(19%) (Anderson et al. 1998a). In addition, many patients adopt yawning, extending the neck, whistling, coughing, walking, wearing dark glasses, or pressing the
supraorbital notch or temple in an attempt to reduce or hide the manifesting symptoms. Increased attention or concentration, such as occurs in the physicians ofce,
can temporarily reduce and mask the severity of blepharospasm. As a result, the
severity can be grossly underestimated even in a severely affected patient. Patients
who are severely affected may be rendered functionally blind even though their
vision is normal. Sudden involuntary eyelid closure can occur while a patient is
driving or crossing the street and thus can lead to serious injury. Many such patients
cannot keep their normal daily and social activities and become socially isolated
and often have psychiatric problems including depression (Patel and Anderson
1995; Hallett 2002; Grandas et al. 1988).
There can be anatomic changes associated with long-standing blepharospasm.
Besides elevating their brows against contractions of the orbital part of orbicularis
oculi, patients with severe spasms have to manually pry their eyes open and keep
pressure on the upper eyelids to prevent the spontaneous closure. It may result in
elongation and dehiscence of the eyelid tissues and cause brow ptosis, blepharoptosis, and dermatochalasis. Furthermore, entropion and ectropion may develop due to
medial and lateral canthal tendon laxity (Bodker et al. 1993).
In blepharospasm, the most common ocular comorbidity is dry eye (49%), followed by other neurologic diseases (8%) (Anderson et al. 1998a). Usually the patient
has no apparent underlying cause for blepharospasm, but secondary blepharospasm
may occur in Parkinsonism (e.g., Parkinsons disease, progressive supranuclear
palsy), (Golbe et al. 1989) months or years following an episode of Bells palsy,
(Baker et al. 1997) and in association with a lower pontine lesion (Aramideh 1996).
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16.2.3
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Pathophysiologic Features
The etiology of blepharospasm is not clear but appears to be multifactorial, with a

genetic background factor (a predisposing factor such as reduced central nervous
system inhibition) and an environmental trigger factor (a precipitating factor such
as ocular irritation). Historically, patients with blepharospasm received the misdiagnoses of a psychiatric illness, but today blepharospasm is considered to be a neuropathologic disorder rather than a psychopathologic disorder. Given that 30% of
patients with essential blepharospasm have a family history, genetic predisposition
is thought be involved in the pathophysiology. It is believed to be related to
degenerative changes in the basal ganglia, diencephalon, corpus striatumbrainstem
extrapyramidal system, and/or the cerebellum. A small number of patients with
lesions in the caudal diencephalon or rostral midbrain were reported to have abnormal movements similar to those in cranial dystonia (Herrero et al. 2002; Kulisevsky
et al. 1988). No consistent pathological features in the basal ganglia or brain stem
have been found in postmortem specimens. Enhanced blink reex excitability, perhaps due to supranuclear disinhibition of the facial nucleus and brain stem reexes,
denervation supersensitivity of the facial nuclear complex, sprouting of surviving
axons, or some combination of the three has been proposed as possible predisposing
factors for developing blepharospasm (Hasan et al. 1997).
A relationship between blepharospasm and dopamine insufciency has been recognized in animal models and suspected from clinical observations in patients with
dopamine-related disorders (Patel and Anderson 1995; Hotson and Boman 1991;
Schicatano et al. 1997). Similar movements may be caused by levodopa therapy in
Parkinsons disease and by dopamine receptor antagonists (e.g., neuroleptic, antipsychotic drugs, and metoclopramide hydrochloride), both suddenly (acute dystonic
reactions) and after long-term therapy (tardive dystonia). This suggests that the
neurotransmitter dopamine may play an important role in the development of the
abnormal movements.
16.2.4
Diagnosis and Differential Diagnosis
There are no particular criteria for the diagnosis of essential blepharospasm.

Diagnosis is made based on the patients history and clinical ndings. A family
history of blepharospasm or dystonia further aids in the diagnosis.
It is helpful to divide the face into four quadrants and recognize the involved
areas to determine the diagnosis (Nerad et al. 2008). Spasm in essential blepharospasm involves both eyes although during a transient initial period it might present
unilaterally. If bilateral eyelid spasms are associated with twitches or spasms of the
lower face, then Meige syndrome is the diagnosis. If spasm is restricted to only one
side of the face, the proper diagnosis is likely to be hemifacial spasm. If spasm is
observed in only a single group of orbicularis oculi muscle bers on the unilateral
side, the patient probably has eyelid myokymia.
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Essential blepharospasm can be divided into three categories depending on its

causes: BEB which is idiopathic; reex blepharospasm associated with irritating
ocular or eyelid diseases; and atypical blepharospasm or apraxia of eyelid opening.
Many patients with blepharospasm often present with additional dystonic movement abnormalities in other body parts beyond the eyelids, and thus rather than
BEB, Meiges syndrome and/or apraxia of eyelid opening should be considered to
make the diagnosis. The diagnosis of BEB is one of exclusion. Several ocular and
non-ocular disorders which may lead to similar symptoms must be ruled out for the
diagnosis of BEB.
16.2.4.1
Reflex Blepharospasm
Reex blepharospasm occurs in response to provocative, irritating mechanical or

light stimuli. Reex blepharospasm may be misdiagnosed as BEB, resulting from
lack of recognition of a potentially treatable underlying disorder. Any cause of
reex spasm must be ruled out before BEB is diagnosed. A thorough ophthalmologic examination is indicated for various ocular or eyelid problems including dry
eye, ocular surface disease, blepharitis, eyelid or eyelash malposition, anterior
uveitis, and posterior subcapsular cataract, which render the patient abnormally sensitive to light and cause ocular irritation. Foreign bodies on the internal surface of
the eyelids must be evaluated using magnication and lid eversion. Once the underlying causes of the excess blinking are eliminated, the spasms will be relieved in
patients with reex blepharospasm.
16.2.4.2 Apraxia of Eyelid Opening (Atypical Blepharospasm)

Difculty in opening the eyelids when the orbicularis oculi is not in forceful contracture indicates that the patient is suffering from apraxia of eyelid opening
(Jankovic et al. 1982). It is the inability to initiate voluntary opening of the eyes,
resulting from a combination of varying degrees of orbicularis oculi spasm and
inhibition of levator function. Patients with this condition have difculty initiating
eyelid opening, resulting in prolonged periods of bilateral eyelid closure.
Some patients with blepharospasm often have a component of apraxia of eyelid
opening superimposed on top of the eyelid spasm; purely isolated apraxia of eyelid
opening can also occur. The estimated incidence of apraxia of eyelid opening among
patients with blepharospasm is 7% (Jordan et al. 1990). It also occurs with neurodegenerative diseases such as Parkinsons disease, progressive supranuclear palsy,
and Shy-Drager syndrome (multiple system atrophy) (Vissenberg et al. 1993).
One potential mechanism involves persistent contraction of the pretarsal orbicularis oculi muscle with attempted lid opening. Electomyographic studies have shown
the inappropriate persistence of pretarsal orbicularis oculi activity during attempted
eyelid opening. This is often not clinically evident on examination. Patients with
apraxia of eyelid opening fail to open the eyelids even in the absence of clinically
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evident eyelid squeezing (Tozlovanu et al. 2001). The eyelids appear relaxed, and
the eyebrows are often raised as a result of prominent use of the frontalis to elevate
the upper eyelid (Krack and Marion 1994). In contrast, the spasms in BEB usually
involve all the subparts of the orbicularis oculi muscles, causing characteristic lowering of the eyebrows.
Injections of paralytic agents into the preseptal orbicularis oculi only are generally unsuccessful in treating apraxia (Lepore et al. 1995). Injection of 45 units of
botulinum toxin A into several sites around the pretarsal orbicularis oculi muscle
has been shown to elicit an improvement in eyelid opening, with the sites of most
effectiveness being between the preseptal and pretarsal portions of the orbicularis
oculi (Vissenberg et al. 1993; Forget et al. 2002). On average, symptoms improve
for 2 months, with retreatment necessary after this time period to maintain improved
eyelid control. Limited myectomy with complete removal of the pretarsal orbicularis
and a frontalis sling operation should be considered for patients who are visually
disabled by the apraxia.
16.2.4.3
Meige Syndrome
Meige syndrome consists of blepharospasm plus oromandibular dystonia, characterized by dystonic movements of the lower face, jaw, and neck. The most frequent
presenting complaint is blepharospasm, although it is not always present. The full
syndrome can take years to develop. It is estimated that as many as 50% of patients
with blepharospasm may have Meige syndrome (Bradley et al. 2003; Defazio
et al. 2001). Eyelid involvement may predate or follow midfacial, oral, mandibular,
or pharyngeal involvement which includes facial grimacing, frowning, aring of the
nostrils, yawning, retraction and forced opening of the mouth, contractions of the
soft palate and oor of the mouth, pursing and tightening of the lips, jaw clenching,
tongue protrusion, head titubation, tensing of the platysma, torticollis, and spastic
dystonia.
Its earliest symptom is usually action dystonia with involuntary dystonic
movements appearing only when the involved muscles are used, such as in talking
or chewing. Typically one action may precipitate the dystonia; at the beginning
other actions may not be involved at all. As the disorder worsens, more and more
actions are affected, and the spasms become more intense. Eating, swallowing, and
speaking all may become impaired. Forced jaw closure may damage the lips, gums,
tongue, and teeth. Temporomandibular joint pain may occur, along with recurrent
jaw dislocation.
16.2.4.4
Eyelid Myokymia (Ocular or Orbicularis Myokymia)
Eyelid myokymia is a relatively common condition, and is a localized form of facial

myokymia characterized by benign episodes of continuous brillary twitching or
quivering of one or more bers or fascicles of the orbicularis oculi muscle lasting
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seconds. It is unilateral, usually involving a single orbicularis oculi ber or small

fascicle of bers in lower eyelid. It does not close the eyelid ssure, even though it
is occasionally forceful enough to cause oscillopsia. Men and women are equally
affected. Its onset is acute and usually correlates with stress, fatigue, caffeine, or
alcohol consumption. Treatment is usually not necessary, since it is self-limiting
and usually lasts for less than a week. The longest reported case of eyelid myokymia
is 13 years.
16.3
Hemifacial Spasm
Hemifacial spasm affects the entire side of the face and neck unilaterally, and is
related to facial nerve irritation mainly at its exit from the brainstem. Hemifacial
spasm differs from blepharospasm and other features of cranial dystonia in that the
spasms remain unilateral in hemifacial spasm, whereas in blepharospasm there is
nearly always bilateral involvement. Rarely, hemifacial spasm is bilateral; in such
cases the movements on the two sides of the face are asynchronous, in contrast to
the simultaneous bilateral movements of cranial dystonia. In hemifacial spasm,
spontaneous contraction is often more of a spasm than a twitch. It may persist during sleep unlike blepharospasm and, in general, cannot be altered by sensory tricks.
However, emotion and stress frequently aggravate the condition (Castelbuono and
Miller 1998; Defazio and Livrea 2002).
16.4 Aberrant Regeneration of Facial Nerve (Facial

Synkinesia or Facial Nerve Misdirection
A history of facial paralysis or facial nerve injury as well as electrophysiologic studies, might be helpful in revealing signs of synkinesis. As a simple test for aberrant
regeneration, patients can be asked to pucker their lips to see if the eyelid ssure
becomes narrow because of increased orbicularis muscle tone (Nerad et al. 2008).
Like hemifacial spasm, these spasms persist during sleep.
16.5
Neurologic Disorders
Neurodegenerative disorders, especially those affecting the basal ganglia, such as

Parkinsons disease, progressive supranuclear palsy, Huntingtons disease and
Wilsons disease, can produce various combinations of spontaneous blepharospasm,
reex blepharospasm, and apraxia of eyelid opening, in addition to involuntary
movements of the lower face. Patients with these lesions typically have additional
neurologic signs.
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Focal motor seizures can include paroxysmal eyelid movements, such as

uttering, which occurs during the seizure. Unilateral facial movements or eyelid
closure which is repetitive, brief, and followed by weakness (Todds paralysis)
would suggest a focal motor seizure involving the face. Spread to the hands or
limbs, or generalization to involve the other side of the face or body with loss of
consciousness, would make this diagnosis obvious. Evaluation consists of an electroencephalogram (EEG) and neuroimaging to detect a structural seizure focus,
followed by treatment with anticonvulsants.
16.6
Psychological Problems
Depression, anxiety, and personality disorder are often associated with

blepharospasm, but it is generally regarded that blepharospasm can cause or aggravate the psychological problems. The variability in severity of symptoms, the
unusual aggravating and relieving factors, and the discrepancy between the history
of the disorder and objective signs seen by the physician have often resulted in the
condition being misdiagnosed as hysteria or other psychiatric disorders.
Blepharospasm used to be considered a psychological disorder but is now thought
only rarely to be due to psychogenic factors. However, sudden onset spasms in
young patients under 30 may represent psychological blepharospasm.
16.7
Drug-Induced Facial Dyskinesias (Tardive Dyskinesia)
The classic form of tardive dyskinesia, caused by long-term treatment with neuroleptics (anti-dopaminergics), involves the buccallingualmasticatory area, most
frequently and usually spares the eyelids; tardive dyskinesia may consist of rapid,
continuous, stereotyped, writhing movements of the orofacial region, and may
involve either bilateral or unilateral blepharospasm.
Commonly used drugs that are implicated in tardive dyskinesia include antidopaminergics or neuroleptics (e.g., haloperidol), dopaminergics or anti-Parkinsons
agents (e.g., levodopa), antidepressant and anxiolytics (e.g., alprazolam), antiepileptics (e.g., carbamazepine, phenytoin), antiemetics (e.g., metoclopramide), nasal
decongestants containing histamine, and anticholinergics (Levin and Reddy 2000).
The reported duration of exposure that incites tardive dyskinesia ranges from 3 days
to 11 years, with an average of about 3.7 years, and onset of the dyskinesia can
occur up to 1 year after cessation of the offending drug (Jankovic 1985).
The movements associated with this disorder differ from those of cranial dystonia
in that the movements are choreic rather than sustained or dystonic and are often
quite stereotypic (Tarsy 2000). However, neuroleptics can also cause a chronic form
of dyskinesia that mimics cranial dystonia (tardive cranial dystonia) which is difcult
to differentiate from essential blepharospasm. It is most important to check to see if
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the drug history includes drugs which can cause tardive dystonia (Mauriello et al.
1998a). Treatment consists of withdrawing the offending agent, sometimes combined with the use of botulinum neurotoxin (BoNT) injections in refractory cases.
16.8 Treatment
Specic treatment may be not necessary until patients with blepharospasm or other
cranial dystonia are disabled by the abnormal movements. Any potentially exacerbating ocular disease such as dry eye or blepharitis must be treated rst. Dry eye
symptoms can be treated symptomatically with articial tears and punctal occlusion.
Tinted lenses also have been recommended to ameliorate photophobia in patients
with blepharospasm (Adams et al. 2006; Herz and Yen 2005).
The treatment of choice in patients with debilitating blepharospasm, Meiges
syndrome, and hemifacial spasm is localized injections of botulinum neurotoxin
type A (BoNT/A) around the eyelids to weaken the orbicularis oculi and other muscles involved in eyelid closure and facial movements (Aramideh 1996; Aramideh
1995; Osako and Keltner 1991; Price and ODay 1994; Defazio et al. 2002; Dutton
and Fowler 2007). Greater than 90% of patients report a marked decrease in the
squeezing action of the eyelids and twitching in lower part of the face (Osako and
Keltner 1991; Elston 1987; Engstrom et al. 1987; Dutton and Buckley 1988;
Kennedy et al. 1989; Mauriello et al. 1996; Anderson et al. 1998b). Some patients
with apraxia of eyelid opening benet from BoNT injection depending on how
much of their eyelid closure is spastic. Most need higher doses of toxin and more
frequent injections.
16.8.1
BoNT Injection
BoNT injections were rst used to treat strabismus in 1977 by Alan Scott, a pediatric
ophthalmologist, (Dressler 2000) and subsequently used to treat blepharospasm in
the early 1980s by Frueh et al. (1984) and Scott et al. (1985). Since then, BoNT has
been highly effective and well tolerated in the symptomatic treatment of a very
broad range of conditions involving either muscle hyperactivity such as blepharospasm and hemifacial spasm, or cholinergic hyperactivity such as hyperhidrosis and
hypersalivation (Jankovic 2009. Recently, BoNT has been approved for the treatment
of glabellar rhytids and chronic migraine headaches (Harrison 2003).
The various strains of the anaerobic bacteria Clostridium botulinum produce
seven distinct serotypes of BoNT, of which ve are pharmacologically active in
humans (A, B, E, F, and G) and two are inactive (C and D) (Brin and Blitzer 1993).
In all naturally occurring serotypes of BoNT (types A~G) and commercially available BoNT preparations, the active neurotoxin (150 kDa; 100 kDa of a heavy chain;
and 50 kDa of a light chain) is noncovalently associated with a set of nontoxic and
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J. Park et al.
Fig. 16.1 Contents of botulinum neurotoxin preparation
inactive complexing proteins (hemagglutinins (HA) and nonhemagglutinins (NHA))

and thus forms high molecular toxin complexes (Hasegawa et al. 2007; Hambleton
1992) (Fig. 16.1). The molecular weight of the toxin complex ranges between 230
and 900 kD, depending on the serotype (Daniele Ranoux 2007).
Today, two serotypes are used in therapeutics, BoNT type A (BoNT/A) and type
B (BoNT/B). Among the seven distinct exotoxins, BoNT/A is the most powerful,
followed by type B and type F (Huang et al. 2000). BoNT/A has been most commonly used in the studies of eye movement disorders because this bacterial strain
retains its toxigenicity well, and it can be crystallized in a stable form. Compared
with BoNT/A, BoNT/B seems to have a quicker onset and greater diffusion in the
tissues. Also, its dosage is signicantly different from that of type A, and its duration of action is shorter. Patients treated with BoNT/B generally experience more
discomfort at injection, and their ultimate satisfaction rates are lower. Therefore,
BoNT/B is considered as an alternative only for patients who show decreased clinical response or who fail to respond to initial treatment with BoNT/A (Baumann and
Black 2003; Alster and Lupton 2003).
There are 3 type A and 1 type B brands of BoNT preparations currently available
in the United States (Table 16.3): Botox (onabotulinum toxin A; Allergan Inc,
Irvine, CA, USA), Dysport (abobotulinum toxin A; Ipsen Ltd, Slough, Berks, UK),
Myobloc (rimabotulinum toxin B; Solstice Neurosciences Inc, Malvern, PA, USA),
and newly FDA approved Xeomin (incobotulinum toxin A; Merz Pharmaceuticals
GmbH, Frankfurt, Germany) (Albanese 2011; Frevert 2009). The potency (toxicity)
of the BoNT preparations is expressed in units, but each preparation has its own
measurement. For example, 1 unit of Botox is dened as the weight of intraperitoneally injected toxin required to kill 50% of a group Swiss-Webster mice weighing
1820 g (Harrison 2003; Schantz and Johnson 1990). The mean lethal dose of
3648 months
7.4
28C for 24 h
Lactose 2.5 mg
1/3
40
28C
24 months
7.4
28C for several hours 4 h
if stored at room temperature
NaCl 0.9 mg
1
20
28C
3648 months
7.4
28C for 24 h
For a few hours
24 months
5.6
75125
28C
Myobloc is the brand name in Canada, the United States, and Korea. Neurobloc is the brand name in the European Union, Norway, and Iceland
HSA human serum albumin
167
Room temperature
Sucrose 4.7 mg
1
Freeze drying (lyophilization)

150
X
100 units/vial; HSA 1 mg
RimabotulinumtoxinB
Solstice Neurosciences Inc.
(USA)
B
VAMP (synaptobrevin)
2,500 (0.5 mL), 5,000 (1 mL),
10,000 (2 mL)
Ready-to-use solution
(5,000 U/mL)
pH reduction
700
O
HSA 0.5 mg/mL
NaCl 0.1 M
Disodium succinate 0.01 M H2O
Hydrochloric acid
1/40
Myobloc/Neurobloca
Biological activity in
relation to Botox
Specic activity (units/ng)
Storage of packaged
product
Shelf life
pH of reconstituted
preparation
Storage once reconstituted
Freeze drying (lyophilization)

300900
O
HSA 0.125 mg
Vacuum drying
900
O
HSAb 0.5 mg
Powder
Powder
Powder
Pharmaceutical
Preparation
Stabilization
Complex size (kDa)
Complexing proteins
Excipients (per vial)
A
SNAP-25
500
A
SNAP-25
100
IncobotulinumtoxinA
Merz Pharmaceuticals GmbH
(Germany)
A
SNAP-25
50, 100
Serotype
Target SNARE
Packaging (units/vial)
AbobotulinumtoxinA
Ipsen Ltd. (UK)
OnabotulinumtoxinA
Allergan Inc. (USA)
Xeomin
Generic name
Manufacturer
Table 16.3 Properties of different botulinum neurotoxin preparations

Brand name
Botox
Dysport
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299
300
J. Park et al.
Botox in humans is estimated as 39 units/kg and 2,5003,000 units for a person

weighing 70 kg (Osako and Keltner 1991; Harrison 2003; Cather and Menter 2002).
Based on several studies and our own personal experience, it seems that 100 units
of Botox or Xeomin are bioequivalent to 300 units of Dysport with a conversion
factor of 1 Botox or Xeomin unit to 3 Dysport unit and 50100 Myobloc (Jost
et al. 2007; Odergren et al. 1998; Ranoux et al. 2002; Dressler 2009).
BoNTs act on the peripheral nervous system where they interrupt calcium-mediated exocytosis of acetylcholine-containing vesicles at the motor endplate within
the neuromuscular junction. It is mediated by inhibition of the proteolytic cleavage
of different proteins of the acetylcholine transport protein cascade (soluble
N-ethylmaleimide-sensitive fusion attachment protein receptor (SNARE) proteins).
BoNT/A hydrolyses synaptosomal-associated protein 25 (SNAP-25), which is
located on the presynaptic cell membrane, whereas BoNT/B acts on synaptobrevin
or vesicle-associated membrane protein (VAMP), which is embedded in the
membrane of the acetylcholine vesicles. By cleaving these target proteins, BoNT
prevents the fusion of the synaptic vesicle with the presynaptic membrane, thereby
blocking the release of acetylcholine into the synaptic cleft (chemodenervation).
BoNT/A consists of a heavy chain (100 kDa) and a light chain (50 kDa) of neurotoxin, but only the light chain is responsible for the pharmacological action of BoNT
(Daniele Ranoux 2007; Dressler 2010).
The neurotoxin acts on individual motor neuron terminals, and its effects occur
within hours of binding to the nerve cell membrane. The onset of action is gradual
and continues until the end-plate potential is reduced to an extremely low level.
Muscle weakness might become clinically evident in 27 days after the injection
because of the continued release of acetylcholine from vesicles that have not been
blocked by the toxin. Some reports indicate that Dysport has a quicker onset of
action, and can be as short as 1 day.
The local weakening effect is dose related and with a peak effect at 12 weeks
after injection, and the symptom-free duration lasts for 23 months in 90% of
patients (Dutton and Buckley 1988). More than 5% of treated patients experience
relief for longer than 6 months, whereas some patients require injections as often as
monthly. Restoration of muscle activity is usually complete by 34 months after the
injection, and results from sprouting of the axon and the formation of additional
motor endplates de novo (Harrison 2003). Histopathologically, the nerve terminals
show a mild degree of demyelinating changes after toxin. Subsequent regeneration
is seen at the neuromuscular junctions in the form of onion bulb formations and
nerve sprouting (Osako and Keltner 1991). Patients should be aware that the aim of
treatment is to control rather than cure their symptoms, and the injection must be
repeated indenitely because of its transient effect.
BoNT/A preparations should be rehydrated with preservative-free physiologically normal saline, which should be introduced slowly into the wall of the vacuumsealed vial to prevent frothing. Most physicians reconstitute Botox (100 units/vial)
in 2 mL of non-preserved saline so as that 0.1 mL solution contains 5 units of
Botox. The manufacturers recommend discarding the BoNT solutions after 424 h
of reconstitution, but many studies have shown clinical activity that persists for
several weeks after reconstitution.
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301
The sites of injection for blepharospasm treatment include upper and lower eyelids, brow and, in some cases, forehead. The exact sites of the injections vary from
patient to patient depending on the areas where the patient has spasms. In general,
the central portion of both upper and lower eyelids is avoided because of the risk of
upper lid ptosis, lower lid entropion, and diplopia. It is said that Dysport has a
greater dispersion area compared with Botox.
The effectiveness and side effects of BoNT injection using four different treatment site applications (standard, brow, inner orbital, or outer orbital treatment
group) were evaluated. Standard injection sites were compared to injection sites
further from the eyelid margin and in the brow (Price et al. 1997). This study found
that the further the treatment is away from the eyelid margin, the lower the risk of
ocular side effects and that in patients with blepharospasm, standard injections produced the longest duration of effect but were associated with the most transient
ocular side effects such as irritation and epiphora. In patients with hemifacial spasm,
the brow treatment has an equally long duration of effect as that of the standard
treatment and has fewer side effects.
BoNT should be injected subcutaneously over the orbicularis oculi, without
being intradermal, to allow diffusion in a subcutaneous plane and to decrease deeper
penetration; the thicker corrugator and procerus muscles require intramuscular
injections.
The dosing of BoNT preparation also should be individualized based on previous
BoNT treatment. If the patient has no history of BoNT treatment or the previous
information is not available, the starting dose for blepharospasm treatment is 2.5
5.0 units/injection site usually resulting in injection of 12.525 units/eye. Few
patients with blepharospasm received a total dose of greater than 75 units in the controlled clinical trials and less than 70 units (35 units/eye) is recommended for the
initial total dose by the manufacturer (Xeomin (incobotulinumA) injection package
insert. It is necessary to adjust the dose, position, and/or number of injection sites for
the next treatment, depending on the therapeutic efcacy and side effects.
There is some debate regarding the proper dosing of BoNT. Some authors reported
a doseresponse relationship for efcacy and its duration, in which the greatest
benets for BoNT were observed with the highest dose and maximum therapeutic
dose up to 840 units of both Botox and Xeomin in a variety of muscle hyperactivity disorders without producing clinically detectable systemic adverse effects
(Dressler and Mander 2008). It was also reported that in BEB patients undergoing an
upper eyelid surgical procedure that includes limited myectomy, upper blepharoplasty, or levator advancement, the duration of the effect of botulinum toxin injections might be increased. In 14 patients, the average duration of the effect increased
from 122 days preoperatively to 210 days after orbicularis oculi myectomy (Mauriello
et al. 1999b). Although various authors have reported increased duration of effect
with larger doses as well as increased efcacy of BoNT injection in patients previously
operated on for blepharospasm, these ndings are inconsistent and still controversial
(Osako and Keltner 1991; Dutton and Buckley 1988; Kraft and Lang 1988; Ainsworth
and Kraft 1995; Perman et al. 1986; Garland et al. 1987).
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J. Park et al.
Long-term effect and loss of efcacy with repeated injections is also debated in
the literature. Although some studies have failed to demonstrate a reduced effectiveness or shorter duration of treatment with time, (Ainsworth and Kraft 1995; Jankovic
and Schwartz 1993) it is sometimes clinically observed that initial treatments are the
most successful and, with time, the effect of each injection may be less or tends to
last for a shorter period.
Reduced efcacy may be the result of antitoxin antibody development and binding of the nonactive large protein chain. Careful consideration should be given
before labeling a patient as a failure due to antibody induction. Immunity to BoNT
is uncommon, and some authors reported that despite the observed development of
antibodies to BoNT/A in the serum of some patients receiving repeated multiple
injections; their presence did not appear to weaken its therapeutic effect (Ainsworth
and Kraft 1995; Siatkowski et al. 1993; Choi et al. 2007).
The loss of efcacy might be a result of disease progression rather than a true
resistance to the toxin. To differentiate a loss of pharmacological effect of the BoNT
from disease progression, affected patients should be evaluated 2 weeks after a
larger amount of BoNT treatment and should be tested for objective weakness of the
orbicularis oculi muscle. If they fail to develop weakness after injection, such immunized patients are good candidates for myectomy.
Failure of treatments including BoNT and myectomy is often due to apraxia of
eyelid opening. These patients still struggle to open their eyes after BoNT or myectomy but have little or no spasm. Jordan et al. estimated that almost 50% of patients
in whom BoNT treatment is considered a failure suffer from apraxia of eyelid
opening (Jordan et al. 1990).
Reduced efcacy after repeated BoNT injection may be the result of a nerve
sprouting and the formation of new motor end plates on the paralyzed muscle bers
(Holds et al. 1990; Alderson et al. 1991, Harrison et al. 2011). Paralysis of the neuromuscular junction is irreversible, so repeated injections cause the development of
collateral nerve bers, with a resulting increase in the number of axon terminals.
This may explain the development of tolerance after repeated BoNT injections.
Some microscopic pathology studies show that long-term exposure to the BoNT
can cause denervation atrophy of some skeletal muscles, which might reduce the
frequency and amount of BoNT treatment needed. Others observed only mild
degenerative muscle changes including changes in myobril size and increased distribution of anticholinesterase. These studies imply that repeated BoNT injection
does not appear to result in irreversible changes such as brosis or scar formation
that is secondary to neurogenic muscle atrophy (Borodic and Ferrante 1992; Horn
et al. 1993).
The most common side effect of BoNT injections is erythema or swelling of the
eyelid, sometimes accompanied with bruising. It is known that signicant systemic
complications do not occur, since clinical doses of BoNT in cranial dystonia or
hemifacial spasm are relatively small in amount, and moreover, it is injected locally
into the muscle or subcutaneous plane and very little enters the systemic circulation
(Siatkowski et al. 1993). Local complications related to BoNT treatment for
blepharospasm include transient blepharoptosis (711%), exposure keratopathy or
16
303
lagophthalmos (512%), dry eye (710%), entropion, ectropion, epiphora, photophobia (2.5%), and, less likely, diplopia (<1%) (Osako and Keltner 1991; Dutton
and Buckley 1988; Wutthiphan et al. 1997; Kalra and Magoon 1990). These are all
due to the paralytic effects of the toxin and its deep penetration. They resolve spontaneously as the effects of the BoNT wear off.
Contraindications for BoNT injections include pregnancy and lactation, allergies
to the drug, human serum albumin, or cow milk (due to lactose in Dysport), uncooperative patients, neuromuscular diseases, coagulopathies, infection in the injection site, and use of medications such as quinine, calcium channel blockers, and
penicillamine or aminoglycoside antibiotics (Dutton and Buckley 1988; Hexsel and
Dalforno 2003).
16.8.1.1
Complications During Injection
(a) Pain: Slow injection with a ne, 30-gauge needle on a tuberculin syringe and
injection volume less than 0.1 mL per site are fairly helpful in reducing the
discomfort associated with injections. Some physicians prefer using a topically
applied anesthetic, such as Betacaine gel or EMLA cream before injection, or
ice compress before and after injection, while others do not use any sedatives or
local anesthesia (Soylev et al. 2002; Linder et al. 2002).
Some patients feel more pain with injections around the corrugator supercilii
muscle because the skin at this location is thicker, and the supratrochlear nerve
is compressed by drug inltration. Patients with a previous history of eyelid
surgery including myectomy tend to complain of more pain since the brotic
scar tissue is more difcult to penetrate with a needle and is less expandable
compared to normal tissue. Slow injection of less volume with a higher concentration is helpful in this situation.
(b) Ecchymosis/Hematoma: Any visible vessels underneath thin eyelid skin must
be avoided to reduce hematoma formation. If a hematoma occurs, compression
at the injection site should be applied for several minutes.
(c) Eyeball Perforation: Injection into the eyelids of controlled patients who move
their head vigorously and uncontrollably risk eyeball perforation. It is always
necessary to stabilize and hold the patients head still during the procedure.
16.8.1.2
Complications After Injection
(a) Erythema, Swelling: Erythema and swelling typically last for several days after
injection and slowly resolve.
(b) Blepharoptosis: Injections spreading from the upper eyelid injection sites to the
levator muscle can cause one of the most concerning complications, blepharoptosis. In patients treated more than four times, the reported incidence of ptosis
304
J. Park et al.
is as high as 50%. It is recommended to inject the toxin into orbicularis oculi

muscles in a supercial, subcutaneous plane and spare the central portion of
upper eyelid to prevent blepharoptosis. The tip of the needle should be directed
outwards, not towards the median portion of upper lid. This complication also
can be avoided by using a lower concentration and/or a lower volume, which
reduces the risk of spreading to adjacent areas.
The use of less toxin (<25 units/eye) might be helpful, but there is controversy about the relationship between volume and dose of each set of injections
and the incidence of blepharoptosis. Dutton and Buckley (Dutton and Buckley
1988) reported that the incidence of blepharoptosis will be more than double if
more than 25 units of BoNT are injected per eye. On the other hand, Osako and
Keltner (Osako and Keltner 1991) reported no signicant difference in dosage
of BoNT or volume of injections between the patients who developed ptosis
and those who did not.
The blepharoptosis is transient as is the effect of toxin, but if needed, the a2adrenergic agonist Iopidine (apraclonidine 0.5%) eye drops can be applied to
correct the ptosis temporarily. This causes Mllers muscles to contract and
temporarily elevate the upper eyelid up to 2 mm.
(c) Dry eye, Lagophthalmos, Exposure keratopathy: Patients with blepharospasm
often have dry eye. BoNT injection also may induce dry eye secondary to either
exposure keratopathy with lagophthalmos or meibomian gland dysfunction.
This generally lasts several days to weeks and can be treated with lubricants,
taping, and punctal occlusion. Rarely, a temporary tarsorrhaphy may be necessary in severe patients.
(d) Diplopia: Diplopia secondary to BoNT injections is rare, and the inferior
oblique is the most commonly affected muscle due to the anterior site of its
origin (Wutthiphan et al. 1997). As the toxin may spread deep into the orbit,
thus reaching the inferior oblique muscle, Frueh et al. (1988) recommended
avoiding injecting into the medial portion of the lower eyelid. Once diplopia
occurs, an eye patch or prism lens can be applied to reduce the discomfort until
the effects of the toxin wear off. In patients with puffy lower eyelids, the dose
injected into the lower lid should be reduced, as the risk of diffusion of BoNT
is greater increasing the risk of diplopia due to inadvertent treatment of the
inferior oblique muscles.
(e) Antibody Formation: One of the main potential long-term side effects of BoNT
use is the development of an immunologic resistance due to the production of
neutralizing antibody to the neurotoxin after repeated injections. This, however,
is still controversial (Jankovic and Schwartz 1993; Kalra and Magoon 1990).
Antibody formation is more likely to occur in patients with torticollis than in
those with blepharospasm or hemifacial spasm because the amount of toxin
used is much higher in torticollis patients. The reported incidence of this sensitization is 310% (Greene et al. 1994).
Several risk factors for sensitization to BoNT have been identied: (Greene
et al. 1994; Dressler and Benecke 2007) injection of over 100 units of Botox
16
305
or 300 units of Dysport per session; an interval of less than 3 months between
two injections; using the Booster technique where another dose is injected
23 weeks after the rst injection; and use of a BoNT drug with a low intrinsic
activity. Cumulative dose, treatment time, and patient age have been excluded
as risk factors. Antibody-induced therapy failure usually develops within the
rst 23 years of BoNT therapy (Dressler 2002).
The intrinsic activity of BoNT drugs is dened as the number of toxin units
per amount (nanograms) of clostridial proteins (i.e., toxin complex). At each
injection of toxin, the administered protein mass will be greater when using a
toxin with a low intrinsic activity. The toxins antigenic potential is probably
related to the total protein concentration injected (protein load). This may be a
much more relevant parameter in the development of resistance than the number of units injected (Borodic et al. 1996). In patients with cervical dystonia, the
original formulation of Botox (100 units/25 ng protein) was six times more
likely to elicit the production of neutralizing antibodies than the newer formulation of Botox (100 units/5 ng protein). The authors conclude that the low risk
of antibody formation after newer Botox treatment is related to lower protein
load (Jankovic et al. 2003).
The newly FDA approved BoNT/A drug Xeomin may reduce antibodyinduced therapy failure, since it contains only the pure neurotoxin (150 kDa)
produced by a manufacturing process that separates it from complexing proteins such as hemagglutinins and other proteins in the neurotoxin complex
(Frevert 2009; Park et al. 2011). Long-term comparative trials in nave patients
between Xeomin and conventional BoNT/A drugs are required to conrm the
lower immunogenicity of Xeomin (Park et al. 2011).
(f) Systemic Toxic Effects: The LD50 in humans is approximately 390,000 unit/kg,
and single injection of more than 500 units may cause acute systemic toxicity.
Systemic toxic effects have not been reported in the treatment of cranial dystonia
because the amount for each treatment is relatively small.
(g) Excessive Facial Weakness: In the patients with Meiges syndrome or hemifacial spasm, injections in the mid- and lower facial muscles may induce excessive facial weakness. Careful toxin injection of appropriate drug levels can
reduce this side effect.
16.8.2
Psychotherapy
Psychotherapy such as behavior modication and biofeedback has been used to

decrease the frequency and amplitude of spasm. The principle is based on teaching
patients to control their muscle contractions using an electromyographic recording.
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J. Park et al.
Table 16.4 Drugs used for treatment of blepharospasm

Antipsychotics
Affective disorder drugs
Anxiolytics (Antianxiety drugs)
Stimulants
Sedatives
Muscle relaxants (Gamma aminobutyric acid, GABA)
Parasympathomimetics
Antimuscarinics
Anticholinergics
Anticonvulsants (Benzodiazepines)
Serotonin antagonists
Antihistamines
16.8.3
Phenothiazine, butyrophenone,
reserpine
Lithium carbonate, tetrabenazine
Meprobamate
Amphetamine
Phenobarbital
Baclofen
Lecithin, choline, physostigmine
Tincture of belladonna, scopolamine,
catecholamine synthesis inhibitors
Orphenadrine, trihexyphenidyl
Diazepam, clonazepam, lorazepam,
oxazepam
Cyproheptadine
Diphenhydramine hydrochloride
Oral Medications
Many drugs have been used for the treatment of blepharospasm and cranial dystonias (Table 16.4) on the basis of three hypothetical pharmacological paradigms:
(1) cholinergic excess, (2) gamma-aminobutyric acid (GABA) hypofunction, and
(3) dopamine excess. Even though some drug studies have reported high percentages of favorable patient responses, including lorazepam (67% of patients), donazepam (42%), and trihexyphenidyl HCl (41%), in general, their effects are temporary
and only useful in a small number of patients. The side effects, which include sedation, may be dangerous in older individuals. Oral medications control symptoms on
a long-term basis in only 25% of patients with cranial dystonia, and their long-term
use is usually limited by side effects. Thus, they are usually reserved as a second
line of treatment or adjuvant therapy for spasms that respond poorly to BoNT and
in patients with middle and lower face spasms, which are difcult to treat with
BoNT injection.
16.8.4
Surgery
Surgery is not usually necessary and should be reserved for patients with severe
symptoms that have failed to respond to other forms of treatment. Options include
orbicularis myectomy, during which the orbicularis oculi and other muscles used in
eyelid closure are excised either surgically (Anderson et al. 1998b) or chemically
(Wirtschafter and McLoon 1998), and neurectomy, a procedure in which branches
of the facial nerve are cut (Kennedy et al. 1989). However, signicant numbers of
patients who undergo surgeries for blepharospasm need to continue BoNT injection
treatment after the surgery.
16
16.8.4.1
307
Myectomy
(a) Surgical Myectomy: Surgical myectomy can be divided into limited and
extended myectomy depending on the extent of muscle removal. To determine
which surgical method should be used, the strength of the orbicularis oculi
muscle should be objectively tested 2 weeks after BoNT injection. In patients
with a partial response to BoNT, limited surgical myectomy can be considered,
whereas in patients with no response to BoNT, extended myectomy is more
likely to be benecial. Up to 75% of patients obtain signicant subjective and
objective relief for at least 12 months.
(b) Limited Myectomy: Limited myectomy includes the pretarsal, preseptal, and
orbital portions of orbicularis oculi muscle.
(c) Extended Myectomy: In extended myectomy, there is surgical extirpation of all
the eyelid protractors, including the procerus and corrugators muscles as well
as orbicularis oculi muscle.
Myectomy can be performed through a lid crease incision, suprabrow incision, coronal incision, or a combination. Mid-forehead or hairline incisions can be considered in patients with brow ptosis. In most cases, the procedure can be approached
with a lid crease incision, and dermatochalasis and blepharoptosis should be corrected simultaneously if necessary. Limited myectomy should be performed by
resecting the orbicularis muscle in three en bloc sections. First, the pretarsal orbicularis between the eyelid crease incision and a position 2.5 mm superior to the lashes
is dissected away. At least 12 mm of muscle strip from the eyelid margin should be
left for to allow for normal blinking. Second, the preseptal and orbital orbicularis
muscle from the superior edge of the incision to the inferior edge of the eyebrow is
dissected away. Finally, the orbicularis muscle over the temporal raphe is resected.
For extended myectomy, visualization of the corrugators and lateral procerus can
be enhanced by a suprabrow incision but good exposure of these structures can often
be obtained through the eyelid crease incision without making a suprabrow scar.
Complications of orbicularis myectomy surgery
(a) Button-hole skin defect: During resection of the muscles, the skin over the muscles can be damaged.
(b) Orbital hemorrhage: This can occur from incomplete hemostasis before wound
closure.
(c) Skin necrosis: Eyelid skin or scalp ap necrosis can develop if the subdermal
plexus underneath the dermis is signicantly damaged.
(d) Inclusion cyst formation: In closing the upper lid crease incision, it is important
to evert the thin wound edges, as there is a tendency for the edges of the thin
skin aps to roll under and cause inclusion cyst formation.
(e) Alopecia: A thin band of muscle should be left beneath the eyebrow to prevent
alopecia.
(f) Multiple eyelid creases: Adhesion between the dermis and levator palpebrae
superioris muscle or aponeurosis may cause multiple eyelid creases. The orbital
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J. Park et al.
septum should be preserved to avoid this deformity.

(g) Visible scar: Suprabrow incisions provide better visualization for corrugator
supercilii and procerus muscle removal, but a visible scar above the brow limits
its use.
(h) Hypoesthesia: Removal of the lateral corrugator muscle has a risk of supraorbital neurovascular bundle damage and consequent hypoesthesia of the forehead. It can recover within 1 year, but sometimes can be permanent.
(i) Dry eye, lagophthalmos, exposure keratopathy: Dry eye and exposure keratopathy can be caused or aggravated by orbicularis myectomy as it attenuates eyelid closure.
(j) Chronic lymphedema: Lymphedema may last for longer than 1 year until new
lymphatic channels begin to function. Upper and lower eyelid myectomy should
be staged to avoid chronic lymphedema that is caused by extensive damage to
lymphatic vessels as a result of simultaneous surgery to both upper and lower
eyelids.
(k) Irregularity of eyelid skin, periorbital contour deformity: Subcutaneous scar
tissue and long standing lymphedema can result in an irregular skin surface.
(l) Recurrence of blepharospasm: Although the resected muscles do not appear to
regenerate, blepharospasm can recur presumably due to incomplete removal of
the orbicularis oculi muscle. In such cases, BoNT injection is necessary after
the surgery. Subcutaneous brotic scar tissue from the surgery prevents diffusion of BoNT and causes the injections to be more painful.
16.8.4.2
Chemomyectomy
Doxorubicin (Adriamycin), a cytotoxic anthracycline used to treat disseminated

neoplasms, is a potent method for the permanent removal of muscle via local injection and is under investigation as a treatment of patients with BEB and HFS
(Wirtschafter and McLoon 1998; Wirtschafter 1991; Wirtschafter 1994). It has a
relatively selective effect in damaging muscle bers by altering intracellular calcium hemostasis. Doxorubicin opens calcium channels in internal cisternae and
activates calcium release from the sarcoplasmic reticulum. In animal experiments,
there is loss of muscle mass, which is greatest near injection sites. The drug causes
degeneration of the treated muscles and permanent muscular weakness. One favorable outcome is a resulting blepharoplasty and reduced wrinkling of the eyelids
skin that is normally caused by the underlying muscle bers. Skin erythema and
ulceration at injection sites are frequent complications and are dose-dependent
(Wirtschafter 1994).
Doxil (Sequus Pharmaceuticals, Menlo Park, CA) is a liposome-encapsulated
form of doxorubicin (Harrison 2003). In monkeys, the chemomyectomy effect of
Doxil was similar to that of doxorubicin. The benet of the liposome-encapsulated
form of doxorubicin was the reduced incidence of skin injury; however, its myotoxicity and therefore its efcacy were also reduced compared to doxorubicin alone
(McLoon and Wirtschafter 2001).
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309
Another agent that has been investigated for chemodenervation is ricin-mAb35

(Hott et al. 1998; Christiansen et al. 2003). Ricin, a potent ribosomal toxin, is conjugated to a monoclonal antibody to the alpha subunit of the nicotinic acetylcholine
receptor. The agent has been extensively studied in extraocular muscles, with excellent results. The toxin paralyzes the extraocular muscles for at least 6 months with
no histologic evidence of long-term muscle damage.
16.8.4.3
Selective Facial Nerve Ablation (Neurectomy or Reynolds

Procedure, Differential Section of the Seventh Nerve [CNVII])
Selective facial nerve (CNVII) ablation may be considered in cases refractory to

BoNT and myectomy (Fante and Frueh 2001a). Among the branches of the facial
nerve, temporal, and zygomatic branches are selectively ablated. This also can be
done by percutaneous thermolysis of the nerve. Recurrence rate is high, and 50% of
patients treated with this technique require more than one operation to control their
spasms. Even in these patients, 50% of the patients have a recurrence of spasms 2
or more years after surgery (Fante and Frueh 2001b). Its use has declined with the
introduction of BoNT injection as well as the high incidence of complications.
Hemifacial paralysis frequently results from facial nerve dissection. Consequently,
the patients may permanently suffer from difculty in controlling facial expression
and in eating and speaking. Other complications include transient parotid stula and
recurrent spasm (Frueh et al. 1992; Gillum and Anderson 1981; McCord 1984).
16.8.4.4
Superior Cervical Ganglion Block
In some patients in whom BoNT treatment fails, the reason for failure may be the
persistence of severe photophobia (photooculodynia) despite weakening of the
orbicularis muscle. It suggests that the sympathetic nervous system may play a role
in maintaining the afferent loop of the disease.
Photooculodynia can be identied using a simple clinical test. If patients complain of signicant spasm and pain with a 25-W light bulb at a distance of 3 ft, a
diagnosis of photooculodynia can be made. These patients are not likely to respond
to myectomy and are referred to a pain clinic for a superior cervical ganglion block
to chemodenervate the orbital sympathetic nerves. It was reported that two-thirds of
patients with photooculodynia had a symptomatic improvement with this treatment
(McCann et al. 1999; Fine and Digre 1995).
In summary, although the pathophysiology of blepharospasm is unclear, and there
is no known cure for it, several effective modes of treatment, including botulinum
toxin injection, oral medication, and surgery are currently available. Cumulative success
rates for the treatment of BEB are approximately 85% with BoNT/A injections, 97%
for BoNT/A in conjunction with protractor myectomy, and 98% for a combination of
BoNT/A, myectomy and selective facial nerve ablation (Mauriello et al. 1996; Fante
and Frueh 2001a). Ultimately, most patients (70%) continue to receive BoNT
injections, while 711% of the patients spontaneously improve.
310
16.9
J. Park et al.
Hemifacial Spasm
Hemifacial spasm is an involuntary intermittent synchronous contraction of the

facial muscles of the whole face on one side. These facial muscles are innervated by
the facial nerve (CNVII). Hemifacial spasm is not truly a dystonia because it is
generally recognized as resulting from compression of the CNVII by a blood vessel
most commonly, or a tumor, which is rare, as the nerve exits the brainstem. This
nerve compression can result in the common hyperactive (spasm) form or the less
appreciated hypoactive (palsy) form.
Hemifacial spasm may be less debilitating than BEB in that the contralateral side
is not affected; however, it is still disguring and a socially embarrassing disorder.
16.9.1
Epidemiologic Features
The typical form of hemifacial spasm occurs in the third to the seventh decade, with
a peak in middle age. Like BEB, it is more frequent in women with a ratio of 23:1.
Incidence rates in the United States are 8 out of 100,000 men and 15 out of 100,000
women. For unknown reasons, hemifacial spasm tends to affect the left side of the
face slight more often than the right. The disorder usually occurs in isolation.
However, occasionally it is associated with trigeminal neuralgia or other concomitant cranial nerve dysfunction.
16.9.2
Clinical Features
This disorder is characterized by muscle spasms in the ipsilateral hemiface with

eyelid closure and elevation of the corner of the mouth. The onset pattern is variable
but usually is insidious or subacute. In the typical form of the disease, the spasms
usually start in the orbicularis oculi where the twitches are mild and mainly clonic
at its onset. Patients progress over a period of months to years from quick apparent
twitching (clonic contractions) around one eye to repetitive synchronous, sustained
spasms (tonic contractions) of all the facial muscles including the zygomatic, orbicularis oris, mentalis, and platysma on the affected side (Nerad et al. 2008). The
spasms may become tonic as the disease worsens and cause persistent closure of the
eye and tensing of other affected muscles with deviation of the mouth on the spastic
side (Castelbuono and Miller 1998).
Hemifacial spasm is often associated with ipsilateral facial nerve weakness.
A small proportion of cases of hemifacial spasm represent a post-paralytic form that
develops as a sequelae of facial nerve palsy (Bells palsy) or injury. Many patients
show evidence of aberrant innervation by CNVII caused by abnormal reinnervation
as motor function recovers following injury of the nerve.
16
16.9.3
311
Pathophysiologic Features
The pathogenesis of hemifacial spasm is not yet fully understood. Any compressive
lesions along CNVII may cause axonal damage and stimulate ephaptic impulses,
which cause the involuntary muscle contractions (Ishikawa et al. 1997). The most
frequent location is the exit of CNVII from the brainstem, within the cerebellopontine (CP) angle, and less commonly at its entry into the internal auditory meatus.
The most common nding is vascular pulsatile compression of the nerve by a
dolichoectatic artery; typically the offending vessel is the anterior inferior cerebellar
artery, the posterior inferior cerebellar artery, or the internal auditory artery. A dilated,
tortuous, atherosclerotic basilar artery may cause similar compression as well as
compressing additional cranial nerves simultaneously. Rarer causes include aneurysms and CP angle tumors (Rahman et al. 2002).
The post-paralytic form of hemifacial spasm may be caused by aberrant reinnervation of the facial musculature from branches of the functioning facial nerve that
are proximal to the site of nerve injury. Other theories include ephaptic transmission
at the site of injury and spontaneous discharge from the deafferented facial nerve.
16.9.4
Diagnosis and Differential Diagnosis
Patient interview and examination help differentiate hemifacial spasm from blepharospasm or cranial dystonia, facial myokymia, tic disorders, focal seizures and, rarely,
hysterical conversion reaction. The typical and post-paralytic forms of hemifacial
spasm are differentiated by a history of facial nerve palsy or injury and clinical
examination. In the post-paralytic form, there is residual facial weakness on the
affected side. Spasms in the typical form of hemifacial spasm are brief, stereotyped,
but not synkinetic, unlike post-paralytic facial spasm.
The identication of associated neurological signs helps differentiate secondary
hemifacial spasm from a primary (idiopathic) hemifacial spasm. Any additional
cranial nerve dysfunction (e.g., in hearing or facial sensation) should prompt a
detailed search for a denable cause. However, even if all ndings point towards a
primary hemifacial spasm, imaging studies of the brain must be performed systematically. Magnetic resonance angiography (MRA) is necessary to demonstrate vascular compression of facial nerve, which is present in 88% of patients and also
sometimes present on the asymptomatic side. MRI is helpful to rule out any other
intracranial pathology, including a cerebellopontine angle tumor (e.g., pontine
glioma) and tumor or swelling around the temporal bone or stylomastoid foramen,
which may be the cause of 1% of cases (Adler et al. 1992; Ho et al. 1999).
312
16.9.5
J. Park et al.
Treatment
BoNT injection into the orbicularis oculi muscle and other affected muscles is now
the most widely used treatment. In cases with obvious compression at the exit zone of
the facial nerve root or refractory hemifacial spasm, a second line of treatment might
be provided by microvascular decompression (MVD) (Kemp and Reich 2004).
16.9.5.1
BoNT Injection
Since Elston rst reported the use of BoNT in the successful treatment of patients
with hemifacial spasm, various publications report that BoNT injections reduce
symptoms in 8090% of patients with hemifacial spasm (Park et al. 1993; Soulayrol
et al. 1993; Chen et al. 1996; Elston 1986, 1992; Jedynak et al. 1993). Periodic
BoNT injection is now considered the treatment of choice for hemifacial spasm.
Interestingly, the effect of BoNT injection tends to persist longer in hemifacial
spasm patients, often 46 months, than in essential blepharospasm or Meiges syndrome patients.
The dose and injection sites of BoNT should be individualized based on the
symptoms and response to BoNT treatment. The treatment regimen is similar to that
of blepharospasm. BoNT can be injected unilaterally or bilaterally into the eyelids
to reduce iatrogenic facial asymmetry. Additional injections may be given to lower
facial muscles using low doses; however, the orbicularis oris muscle should be
avoided because of the risk of causing problems with eating and drinking. Sometimes
the platysma muscle, whose abnormal contractions are often unsightly, is injected
with higher doses. This muscle is easily identiable by asking the patients to clench
their teeth keeping the lips open. As long as the anterior bers are not injected, the
injections do not cause swallowing problems.
The typical BoNT/A dose injected into each treatment site is 2.55 units, and the
total dose for the rst session should range between 17.5 and 45 units. In the second
session, if the patient is not satised with the duration of efcacy or complains of
persisting spasms, doses can be increased to a maximum of 50 units.
Like in BEB, a relatively low dose of BoNT for hemifacial spasm does not appear
to lead to systemic side effects. Local side effects are often caused by the toxins
diffusion to other muscles. In addition to the complications described for BoNT in
the treatment of BEB, excessive lower facial weakening especially the orbicularis
oris muscle is a problem. These adverse effects are not common, and more importantly, they are short-lived.
16.9.5.2
Oral Medication
Antiseizure or antianxiety drugs were used in the past with limited effectiveness and
poorly tolerated side effects, especially drowsiness. Some oral medications including
16
313
carbamazepine, baclofen, and clonazepam have been found to be useful in small

numbers of patients, but have generally proven much less effective than BoNT
injections or surgical decompression in controlling the spasms in both the typical
and post-paralytic form.
16.9.5.3
Surgery
(a) Neurosurgical decompression (MVD, Janetta i): Placing a sponge prosthesis

such as expanded polytetrauoroethylene (ePTFE, Gore-Tex), between the
facial nerve and the offending vessel to prevent future compression was rst
successfully demonstrated by Janetta (1983). The reported success rate for this
procedure varies and ranges from 5090%. Other surgical options, such as
orbicularis myectomy, CNVII neurectomy, crushing the facial nerve at its exit
from the stylomastoid foramen, percutaneous fractional thermolysis, alcohol
injections, and anastomosis of the facial nerve with the CNXI or CNX11 are
rarely indicated because of high complication rates, limited benet, and only
provide temporary relief.
Although MVD of CNVII may be curative in hemifacial spasm and produce better
spasm reduction compared to other surgical treatments, there is always an operative risk. This was estimated at 2% (Jannetta 1983; Jannetta et al. 1977) with permanent sequelae: facial paralysis, deafness, or vestibular disorders, which are
more debilitating than the facial spasm. Reported potential complications include
infection in 1%, hematoma in 0.5%, CSF leak in 3%, facial nerve palsy in 1.4%,
ipsilateral hearing loss in 0.86%, and stroke in less than 0.5% (Kalkanis et al.
2003). Therefore, it seems reasonable to treat patients rst with BoNT injections
and resort to surgery only if these injections fail or if the patient is not satised
with the results.
16.9.6
Other Precipitating Factors
Aberrant Regeneration of the Facial Nerve (Facial synkinesia, Facial nerve misdirection, Post-Bells palsy syndrome): If the facial nerve is damaged, it might regenerate aberrantly, with misdirection to other facial muscles on the ipsilateral side or
with cross-innervation to the contralateral side. The abnormal regeneration of CNVII
can result in synkinesis of facial muscles, which in turn can cause unwanted facial
movements during normal facial expressions (Osako and Keltner 1991). The abnormal synkinetic innervation can develop after facial palsy or facial nerve injury. It
causes unilateral synkinetic facial movements mimicking blepharoptosis, orbicularis
myokymia, or hemifacial spasm. Hemifacial spasm is often accompanied by aberrant
314
J. Park et al.
regeneration because the irritation at the facial nerve root causing hemifacial spasm
can evoke nerve injury and consequently aberrant regeneration (Nerad et al. 2008).
The aberrant regeneration also can result, albeit rarely, as a primary phenomenon
from a slow-growing tumor compressing or inltrating the facial nerve.
The abnormal movements in hemifacial spasm are seen most commonly in the
middle-aged but can occur in childhood. Abnormal reinnervation patterns can begin
several months after an acute facial palsy as motor function recovers. It is most
commonly manifested as ipsilateral narrowing of the palpebral ssure with movements of the mouth such as smiling, chewing, and speaking. In addition, uncontrolled tearing when eating or in anticipation of food (crocodile tears) occurs when
nerve bers destined to supply the salivary glands are misdirected to the lacrimal
gland. Abnormal sweating of face while eating (gustatory sweating or Frey syndrome) can be seen in the parotid gland area, which is caused by aberrant bers
innervating sweat glands.
BoNT injection provides reasonably effective control for synkinetic facial
spasms, and the treatment regimen is similar to that of the typical form of hemifacial
spasm (Putterman 1990; Armstrong et al. 1996). BoNT injection into the lacrimal
gland may help reduce or prevent involuntary tearing (Boroojerdi et al. 1998).
16.10
Myokymia and Neuromyotonia
Myokymia is the spontaneous, ne fascicular contractions of muscle in the absence

of muscular atrophy or weakness. Facial myokymia is characterized by small, continuous unilateral contractions of the facial muscles. When associated with ipsilateral facial contracture and weakness (spastic-paretic facial contracture), a pontine
lesion rostral to the facial nerve nucleus in the brainstem should be considered.
Multiple sclerosis and brain stem tumors are also typical etiologies (Jacobs et al.
1994). Other causes of facial myokymia include stroke, hypoxic injury, meningitis,
hydrocephalus, acoustic neuroma, syringobulbia, and GuillainBarre syndrome.
Eyelid myokymia (ocular or orbicularis myokymia), which is small, annoying
twitches of an eyelid unilaterally, mainly affect the lower lid, and are very common
in young adults. It tends to be precipitated by fatigue, stress, alcohol, nicotine, or
excessive caffeine consumption.
It is benign and usually idiopathic. Contractions may last for seconds and recur
several times daily over a period of weeks or months. Most patients require only
reassurance and avoidance of precipitating factors because eyelid myokymia usually resolves spontaneously. Neuroimaging may be necessary only if the twitches
spread to involve other facial muscles. Benzodiazepines or BoNT injection into the
affected parts of twitching muscle can be applied for persistent cases (Pane et al.
2007; Banik and Miller 2004).
Facial neuromyotonia, which is similar to myokymia but is dened as a delay in
muscle relaxation after a voluntary contraction, has been reported as a complication
of radiation and responds to carbemazepine (Marti-Fabregas et al. 1997).
16
16.11
315
Eyelid/Facial Tics
Eyelid tics are brief, stereotyped, repetitive, and involuntary eyelid blinks, winks, or
blepharospasm (Evidente and Adler 1998). Tics may be preceded by a premonitory
urge to perform the movement, which increases until the movement is nished. This
premonitory urge may be an unpleasant feeling, such as burning, tension, or a contraction. A tic may be temporarily suppressed by willpower, but the next time it
occurs, it will often be more violent and explosive.
Tics can be classied as motor or phonic. Motor tics usually reproduce a normal
movement such as blinking or raising the shoulders. Any muscle can be involved,
but mostly tics occur in the muscles of the face, neck, and shoulders. Phonic tics are
involuntary sounds produced by moving air through the nose, mouth, or throat (e.g.,
grunting) or words, sometimes obscene (coprolalia)
Tics are often idiopathic and considered benign. They also can be associated with
encephalitis, drugs, toxins, stroke, and head trauma. In some instances, eyelid tics
are a rst manifestation of Tourettes syndrome. This is a childhood disorder, affecting boys more than girls, in which multiple motor tics in eyelid, face, limbs, or body
are combined with one or more phonic tics. Characteristic behavioral manifestations
include obsessive-compulsive disorder, grunting, throat clearing, barking, coprolalia,
and echolalia (Jankovic 1992; Jankovic and Stone 1991; Jankovic 2001). Facial tics
are treated with reassurance, and BoNT injections are hardly ever recommended.
16.12
Summary
Various movement disorders cause involuntary or rarely voluntary contractions of

the facial muscles and subsequently lead to both esthetic and functional problems.
Although symptomatic therapy including BoNT injection is available, better
approaches are needed and will likely become available as the understanding of the
genetics and pathophysiology improves.
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Part VIII
Summary and Conclusions
Chapter 17
Comparison of the Craniofacial Muscles:

A Unifying Hypothesis
Linda K. McLoon and Francisco H. Andrade
17.1
Introduction
In the eld of skeletal muscle research, most research has been performed using limb
skeletal muscle, whether studying myogenesis or the anatomy, cell biology, biochemistry, and physiology of normal, diseased, or aging muscle. Early studies of limb muscle
led to the description of four basic ber types with specic biochemistry and physiological properties assigned to each. Evidence in the past decade has revealed that this
is an oversimplied view of the true heterogeneity amongst the myobers within limb
muscles (Caiozzo et al. 2000, 2003; Pette and Staron 2000; Stephenson 2001).
When one considers the craniofacial muscles, it is apparent that there is an
exponential increase in the complexity of these muscles compared to limb skeletal
muscle. These muscles are responsible for basic life processes: maintaining an open
airway, controlling the intake of food and liquid, ne calibration that ensures clearest
vision, and controlling the patency of the apertures of the face. Thus, normal function of
the craniofacial muscles is essential for sustaining the most basic functions of life.
The specialized phenotypes of each group of craniofacial muscles form the basis
of their unusual physiological properties and allow them to (1) produce extremely
rapid yet prolonged contractions, (2) perform highly complex patterns of movement,
(3) respond rapidly to physical injury and changes in innervation, (4) display few
changes normally associated with aging skeletal muscle, and (5) show differential
susceptibility to systemic neuromuscular diseases.
L.K. McLoon, Ph.D. (*)

e-mail: mcloo001@umn.edu
F.H. Andrade, Ph.D.
325
L.K. McLoon and F.H. Andrade
326
17.2
Embryology
One of the most striking differences between limb and craniofacial muscles relates
to the genetic programs that control their early embryologic development. As
described in Chap. 2, while somite-derived skeletal muscles depend on early expression of Pax3 to develop (Tajbakhsh et al. 1997), non-somite-derived craniofacial
muscles develop normally in the absence of Pax3. Over the last decade, the genetic
networks that control differentiation of craniofacial muscles have been illuminated,
and are quite divergent from each other as well as from limb skeletal muscles
(Table 17.1; for review, see Chap. 2; Sambasivan et al. 2011; Bothe et al. 2011).
The muscles derived from the pharyngeal arches have some overlapping early
gene control, with Tbx1 being important in the formation of muscles derived from
pharyngeal arches 2 and 3, and partially controlling masticatory muscle formation.
The extraocular muscles represent the most distinct of this group of muscles, and
depend on Pitx2 expression for their formation (Diehl et al. 2006). The importance
of these early genetic differences is underlined by examination of a Pitx2 conditional knockout, where over time the extraocular muscles from these mice show
decreased expression of slow-tonic and EOM-specic myosin heavy chain (MyHC)
isoforms, as well as decreased numbers of en grappe neuromuscular junctions (Zhou
et al. 2009, 2011), resulting in extraocular muscles that have increased similarity to
limb muscle.
17.3
Fiber Types and Contractile Properties
Limb and body skeletal muscles express four main MyHC isoforms, types IIA, IIB,
IIX, and type I; while these can be co-expressed in a variety of patterns, they still
only express these four isoforms. As we have seen, all the craniofacial muscles
included in this book, as well as muscles within the soft palate and associated with
the ear (Sthl and Lindman 2000; Jung et al. 2004), are predominantly fast twitch
muscles. With the possible exception of the muscles of facial expression, the craniofacial muscles express unusual myosins. These include the alpha-cardiac and
the fetal MyHC isoforms (Stl et al. 1994; Korfage et al. 2005). In addition individual subsets of craniofacial muscles express muscle-specic myosins such as the
Table 17.1 Development
Muscle type
Genetic control
Mesodermal source
Limb muscles
Tongue
Laryngeal muscles
Facial muscles
Masticatory muscles
Extraocular muscles
Somitic mesoderm
Somitic mesoderm
Pharyngeal arch 3
Pharyngeal arch 2
Pharyngeal arch 1
Non-segmented cranial mesoderm
Pax3
Pax3
Tbx1
Tbx1
Tcf21 (partial loss,Tbx1), Pitx2
Pitx2
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Comparison of the Craniofacial Muscles: A Unifying Hypothesis
Table 17.2 Myosins and muscle contractile properties

Unloaded shortening
Muscle type
Myosins
velocities (Vo) (ML/s)
4
2.23.7a
8, but majority are same
?
as limb
Laryngeal
6
45a
Facial
4
Masticatory
8 including masticatory
2.2e
specic
Extraocular
9 including EOM specic
19f
ML/s muscle lengths per second
? indicates no one has published this measurement in tongue muscle
a
Larsson and Moss (1993) and Sciote et al. (2003)
b
(Sokoloff (2000)
c
Hinrichsen and Dulhunty (1982)
d
Lindquist (1973)
e
Toniolo et al. (2004)
f
Asmussen et al. (1994) and McLoon et al. (2011)
Limb
Tongue
Twitch contraction
times (ms)
1422
833b
37c
8.533d
1332
5.27
superfast MyHC in the jaw-closing muscles (Hoh 2002) and the EOM-specic
MyHC in the EOM and variably in the laryngeal muscles (Wieczorek et al. 1985;
Shiotani and Flint 1998; Toniolo et al. 2005). These diverse MyHCs are combined
in single bers, and this complexity of MyHC isoform co-expression results in
myobers with a greater range of shortening velocities (Morris et al. 2001; Sciote
et al. 2002; McLoon et al. 2011). There is also a mismatching of myosin light chains
(MLC) with the various MyHC isoforms (Stl et al. 1994; Bergrin et al. 2006; Bicer
and Reiser 2009). Thus, the craniofacial muscles demonstrate that one motor neuron does not connect to myobers of only one MyHC or MyLC isoform, but rather
controls the contraction characteristics of groups of myobers with different MyHC
compositions (Kwa et al. 1995). This is hypothesized to result from their distinct
embryological origins.
The masticatory, laryngeal, and extraocular muscles in particular display
extremely fast shortening velocities, the fastest of any mammalian skeletal muscles
(Table 17.2; Close and Luff 1974; Asmussen et al. 1994), although it should be
pointed out that the masticatory muscles also have myobers that are slower than
those seen in limb muscle (Morris et al. 2001). EOM and laryngeal muscles also
contain slow tonic MyHC along a portion of their length (Jacoby et al. 1989; Hoh
2005). As a group, the craniofacial muscles are fatigue resistant (Asmussen and
Gaunitz 1981; Fuchs and Binder 1983; Prsa et al. 2010). Fatigue resistance in these
muscles is associated with the unusual co-expression of succinic dehydrogenase
(SDH) and glycerophosphate dehydrogenase (GPDH) in single myobers, enzymes
involved in oxidative and glycolytic energy pathways, respectively (Asmussen et al.
2008). These complex ber types and specialized contractile characteristics increase
the functional repertoire of these muscles, presumably critical for their ability to
adapt quickly to changing physiological needs.
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17.4 Adaptability
Another explanation for the diversity of myober types is that it is a sequella of their
rapid adaptability in response to local changes in muscle activation and stretch,
hormones, and the like (Korfage et al. 2005). The craniofacial muscles respond
rapidly to perturbations such as functional denervation (Ugalde et al. 2005; Spencer
and McNeer 1987), yet still maintain relative overall normalcy relative to ber types
and function (Wu et al. 2004). This ability may be due, in part, to their myogenic
precursor cell populations which retain the ability to express craniofacial musclespecic properties when placed in vitro (Kang et al. 2010). In addition, at least
extraocular, laryngeal, and pharyngeal muscles contain a population of myogenic
precursor cells which continue to divide and fuse into normal myobers continuously throughout life (McLoon and Wirtschafter 2002, 2003; McLoon et al. 2004;
Goding et al. 2005). We have postulated that this ability may play a role in their
differential sparing in aging and skeletal muscle disease (Kallestad et al. 2011).
How these myogenic precursor cell populations affect muscle function is illustrated
by the demonstration that even 2 years after denervation, human laryngeal muscles
contain activated myogenic precursor cells (Donghui et al. 2009), in contrast to the
atrophy that is seen after similar lengths of denervation in limb skeletal muscle
(Borisov et al. 2005), and allows successful reinnervation of denervated laryngeal
muscles even 2 years later (Tucker 1978). We and others have shown that there is
minimal atrophy in the denervated laryngeal muscles, except for the vocalis muscle,
even at 24 weeks (Wu et al. 2004; Shinners et al. 2006). The ability of extraocular
and facial muscles to maintain relative normalcy after injections of local anesthetics, known to be myotoxic in limb skeletal muscles (Porter et al. 1988; McLoon and
Wirtschafter 1993), also suggests a rapid capacity to respond to injury such that
relatively normal muscle morphology is maintained. As these muscles are required
for basic functions of life, maintaining an open airway for example, this ability
would allow these functions to be minimally affected.
17.5
Disease Sparing
One area that is particularly striking, but not well understood, is the differential
ability of various craniofacial muscles to be spared from select skeletal muscle
diseases. While some small degree of change from normalcy often can be seen in
these muscles, they are generally comparatively spared relative to the degeneration
seen in limb skeletal muscle in animal models and patients suffering from these
degenerative diseases. Several specic examples will be used as illustration, but this
chapter is not meant to be a complete review of this topic (Table 17.3).
In the continuum of skeletal muscle allotypes, extraocular muscles appear to
represent the far end of the continuum. They are spared in a myriad of skeletal
17
329
Table 17.3 Susceptibility of muscle types to disease and aging

Muscle type
Disease sparing
Aging
Limb muscles
Tongue
Laryngeal muscles
Yes
No
Some evidence of weakness
Facial muscles
Masticatory muscles
Extraocular muscles
No
?
DMD, congenital muscular dystrophy
type 1A
Myotonic dystrophy
Delayed compared to limb

muscle
Critical illness myopathy,
Delayed compared to limb
spinocerebellar ataxia type 3
muscle
DMD, Becker, congenital muscular
Few to none; some evidence
dystrophy, a-sarcoglycan deciency,
of mitochondria decits
merosin-decient muscular dystrophy,
with aging
actin myopathies, dermatomyositis
? sparing propensity unknown
muscle diseases, including Duchenne and Becker muscular dystrophy (Khurana

et al. 1995; Kaminski et al. 1992), laminin alpha2-chain-decient congenital muscular dystrophy (Kjellgren et al. 2004), sarcoglycan-and merosin-decient dystrophies (Porter and Karathanasis 1998; Porter et al. 2001), alpha-actin diseases
(Ravenscroft et al. 2008), and even dermatomyositis (Scopetta et al. 1985). The
laryngeal muscles are also morphologically and functionally spared in Duchenne
muscular dystrophy (DMD) (Marques et al. 2007; Thomas et al. 2008), as well as
congenital muscular dystrophy type 1A (Hger and Durbeej 2009). Reports differ as
to the morphologic sparing or involvement of the masticatory muscles in DMD
(Muller et al. 2001; Spassov et al. 2010). Functionally, the masseter in particular
becomes weaker as the disease duration increases (Botteron et al. 2009), although
the extent of loss in force production is not as dramatic as seen in the limb muscles.
The tongue becomes hypotonic and shows morphologic signs of muscle degeneration (Kiliaridis and Katsaros 1998; Spassov et al. 2010); however, the orbicularis
oris is less affected than either the tongue or the masticatory muscles (Kiliaridis and
Katsaros 1998). These complex patterns of sparing and/or involvement of the craniofacial muscles in DMD vary according to the age of the mdx mouse or patient, but
generally their overall pathology is less than seen in limb skeletal muscles (Muller
et al. 2001).
Myotonic dystrophy 1 results in some saccadic slowing, but other aspects of eye
movements are normal (Di Constanzo et al. 1997). While laryngeal muscles are
spared in congenital muscular dystrophy type 1A (Hger and Durbeej 2009), the
tongue, masticatory, and facial muscles show reduced strength as the disease progresses (Odman and Kiliaridis 1996; Eckardt and Harzer 1996; Sjgreen et al.
2007). Thus, there appears to be a continuum within the different groups of craniofacial muscles relative to disease sparing. It is hypothesized that this may be due to
the different genes that control their early development and the maintenance of the
adult phenotype in each of these muscles.
330
17.6 Aging
Aging also affects the craniofacial muscles differently than limb skeletal muscles.
Again, while some alterations from normal have been described, relative to the
signicant atrophy that can be seen in aging skeletal muscle, the craniofacial muscles remain relatively normal. We will give some examples (Table 17.3), but this is
not meant to be a complete summary of the work in this eld.
As might be expected from the differential susceptibility to disease, aging affects
each craniofacial muscle group differentially. Extraocular muscles again show the
fewest age-related changes both morphologically and functionally (Yang and
Kapoula 2008; Valez et al. 2012), although some changes in connective tissue density and an increase in mitochondrial defects occur (McMullen et al. 2009). Masseter
also shows constancy in muscle structure and function during aging (Norton et al.
2001). Laryngeal muscles display fewer age-related changes compared to limb
muscle, but still show elevation in connective tissue, some increased variation in
myober cross-sectional area, changes in neuromuscular junction structure (Connor
et al. 2002), plus less force and slower shortening velocity (Kersing and Jennekens
2004; McMullen and Andrade 2006, 2009). In facial muscles, while the skin undergoes signicant loss of elastin, the facial muscles themselves are normal (Lee et al.
2011). Aging changes in tongue muscles are quite interesting; aging retrusive tongue
muscles do not show a decrement in overall contractile speed or force production,
but signicant changes in forces is seen in aging protrusive tongue muscles (Nagai
et al. 2008; Connor et al. 2009). The basis for this difference in unclear. However,
all of the changes in craniofacial muscles are relatively minor compared to those
seen in aging limb skeletal muscle where signicant atrophy, fat conversion, brosis,
and denervation changes can occur.
17.7
Conclusions and Future Studies
It is clear from the collective chapters in this book that one cannot draw conclusions
about structure and function of craniofacial muscles from the study of limb skeletal
muscles. Their behavior cannot be predicted by studies of limb skeletal muscle;
often they change in diametrically opposed ways in the presence of myogenic signaling factors (Tzahor et al. 2003) or during aging (Monemi et al. 1999). The craniofacial muscles appear to represent one end of the continuum of skeletal muscle
types in the body, with the relatively more homogeneous soleus at one end and
extraocular and laryngeal muscles at the other. Except for tongue muscles, from
their onset craniofacial muscles are derived from non-segmented, non-somitic
cranial mesoderm, with different genes controlling their formation compared to
those that direct the formation of somitic muscle. The mature muscles each display
a relatively unique set of contractile and metabolic proteins, which are mirrored in
the collective physiological and contractile differences seen in the craniofacial
17
331
muscles compared to those in limb skeletal muscle. From a clinical viewpoint, they
represent both challenges and opportunities in their differential propensity for or
sparing from limb skeletal muscle diseases and pathology.
There is a great deal more work that needs to be done before we understand the
basis for the molecular, cellular, and physiological differences between the craniofacial and limb skeletal muscles. They are complex muscles, difcult to study, and
few laboratories are studying them. This, however, provides for opportunity, as the
clinical potential for understanding how these muscles function and the mechanism(s)
for their preferential sparing from or involvement in skeletal muscle diseases should
yield important new approaches for the treatment of limb skeletal muscle pathology
as well as ways to treat craniofacial muscle pathology.
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Index
A
Abducens nucleus
vs. lateral rectus motoneurons, 64
neuroanatomy, 5859
neurophysiology
eye movements, neural response, 6162
eye position sensitivity, 62
motoneuron discharge, 62
saccadic eye movement and eye
velocity, 6264
and oculomotor nuclei, anatomical
connection, 5961
Adenosine triphosphate (ATP), 147148
Adnexal disease, 288
Alopecia, 307
a-glycerophosphate dehydrogenase, 43
Amyotrophic lateral sclerosis (ALS), 6
extraocular muscles, 8284
laryngeal muscle response, 190192
Anterior cingulate cortex (ACC), 232, 233
Apraxia, 293294
B
Benign essential blepharospasm (BEB), 289
b-catenin, 18
Bilateral facial palsy, 270, 282
Blepharoptosis, 303304
Blepharospasm
adnexal disease, 288
clinical features
anatomic changes, 291
dry eye, 291
excessive blinking, eye, 290
JRS score, 290
parkinsonian symptoms, 291
retro-orbital discomfort, 290

spasmodic dysphonia, 291
CNVII facial nerve, 288
cranial dystonia, 288
differential diagnosis
eyelid myokymia, 294295
eyelid opening apraxia, 293294
Meige syndrome, 294
reex blepharospasm, 293
epidemiologic features, 289
oromandibular dystonia, 289
pathophysiologic features, 291
Bony orbit, 33
Botulinum neurotoxin (BoNT) injection
anaerobic bacteria strains, 297
antitoxin antibody, 302
Botox, 300
botulinum neurotoxin preparation,
298, 299
cholinergic hyperactivity, 297
complications
after injection, 303305
during injection, 303
contraindications, 303
Dysport, 301
erythema, eyelid, 302
neurotoxin acts, 300
SNAP-25, 300
type A, 298
type B, 298
Xeomin, 301
Brain-derived neurotrophic factor
(BDNF), 197
Brueghel syndrome, 289
Bruxism, 134
Button-hole skin defect, 307
DOI 10.1007/978-1-4614-4466-4, Springer Science+Business Media New York 2013
337
Index
338
C
Central pattern generator
(CPG), 115, 233, 235
Cerebral cortex, masticatory muscle
intracortical microstimulation, 122124
movements types, 121122
neuronal recording and ablation
nding, 124125
Cervical dystonia, 288
Chronic lymphedema, 304, 308
Chronic progressive external ophthalmoplegia
(CPEO), 7981
Ciona intestinalis, 22
Conjugate horizontal eye movements
abducens nucleus
anatomical connection, 5961
neuroanatomy, 5859
neurophysiology, 6164
horizontal recti, 58
oculomotor nucleus
neuroanatomy, 6466
neurophysiology, 66
Corneal ulcers, 266
Cortical masticatory area (CMA), 115
Cranial dystonia, 288
Cranial nerves
EOM innervation, 34, 51
facial nerve (see Facial nerve)
hypoglossal nerve, motor
activation, 230232
motor nuclei, 116, 117
sucking rhythm generators, 237
tongue sensation, 232233
Cranial neural crest cells
head muscle development, 1920
masticatory muscles, 132
Craniofacial muscles
adaptability, 328
aging, 330
disease sparing, 328329
embryology, 326
extraocular muscle (see Extraocular
muscle (EOM))
facial muscles (see Spastic facial muscle
disorders)
ber types, 326327
future aspects, 330331
head (see Head muscle development)
head and neck evolution, 4
larynx (see Laryngeal muscle)
masticatory muscle (see Masticatory muscle)
mesodermal origin, 12
muscle function, 5
neuromuscular disease, 56
pharynx (see Pharyngeal muscle)

physiological properties, 325
tongue (see Tongue)
Cyclovertical eye movements
agonistantagonist pair, 67
superior rectus and oblique
muscles, 6667
trochlear motoneurons, 68
trochlear nuclei, 6768
D
Diplopia, 79
BoNT injections, 304
EOM, thyroid disease, 82
Dizziness, 272
Dorsal medullary reticular column
(DMRC), 233
Doxorubicin, 308
Dry eye, 304
Duchenne muscular dystrophy
(DMD), 6, 16, 329
extraocular muscles, 8485
laryngeal muscle response to
clinical characteristics, 187
cricothyroid (CT) muscle, 188190
extracellular and intracellular
calcium, 187188
lateral cricoarytenoid muscle, 188
medial and lateral thyroarytenoid
muscle, 188
muscle weakness, 188
Dyskinesias, 287288
Dysport, 301
E
Ear pain, 271
Electromyography (EMG)
brainstem reexes, 119
cricopharyngeus (CP) muscle, 160
facial palsy, 272
jaw movement, 248
laryngeal muscle
amyotrophic lateral sclerosis, 190
cricothyroid muscle, 145
myasthenia gravis, 193
sternothyroid muscle, 155
swallowing, 146147, 157
masticatory muscles
aged masticatory muscles, 135136
DMD and ALS, 133
jaw-opening and jaw-closing
muscles, 119
Index
Embryonic myosin heavy chain, 95
Endomysial collagen, 102
Entactin, 97
Erythema, 302, 303
Essential blepharospasm. See also
Blepharospasm
clinical features, 289290
denition, 288289
diagnosis and differential
diagnosis, 292293
pathophysiology, 292
Evoked electromyography (EEMG),
facial palsy, 272
Exposure keratopathy, 304, 308
Extraocular muscle (EOM), 12
anatomy
agonist/antagonist pairs, 33
bony orbit, 33
cranial nerves, 34
eye movements, 32
levator palpebrae superioris
muscle, 3132
yoked muscles, 33
embryological origins, 3435
mitochondrial disorders
chronic progressive external
ophthalmoplegia, 7980
cytochrome-c-oxidase loss, 8081
MELAS, 80
mtDNA mutations, 7980
molecular expression
Krebs cycle, 43, 44
myosin-binding protein, 41
SERCA content, 4243
motor control
conjugate horizontal eye movements
(see Conjugate horizontal eye
movements)
cyclovertical movements, 6668
vergence movements, 6869
motor innervation, 3638
muscle bers, 36, 37
myonuclear turnover and
regeneration, 4445
myosin heavy chain isoforms
hybrid bers, 4142
limb and body skeletal muscle, 39
mismatched ber, 41, 42
orbital and global layers, 39
single ber segments, 42
neuromuscular diseases
Miller Fisher syndrome, 7678
339
oculopharyngeal muscular
dystrophy, 81
thyroid disease, 8182
Eye. See also Extraocular muscle (EOM)
biomechanical characteristics
eye-pull study, 5253
Maxwell element, 53
ocular biomechanics, 5356
plant modeling, 52, 5557
Voigt elements, 5253
conjugate horizontal movements
movements)
Eyelid creases, 307
Eyelid tics, 315
F
Face primary motor cortex (face MI), 121
Face primary somatosensory area
(face SI), 121
Facial nerve
aberrant regeneration of, 295
ablation, 309
anatomy
facial nerve (CNVII) function, 268
lacrimal secretions, 267
marginal mandibular and cervical
branches, 268
pontine lesions, 266
temporal branch, 267
voluntary facial expression, 266
zygomatic and buccal
branches, 267
palsy (see Facial palsy)
Facial palsy
acute surgical management, 276
Bells palsy
age, 273374
Copenhagen Facial Nerve
Study, 273
FPRI, 275
herpes simplex virus, 273
HouseBrackmann system, 275
HZV diagnosis, 274
natural history, 273
pediatrics, 274
rheumatism, 273
bilateral facial palsy, 282
chronic surgical management
eyelids, 277278
forehead, 278
Index
340
Facial palsy (cont.)
lower lip, 282
midface and mouth, 279281
clinical examination and investigation
auditory system and otoscopy, 272
denervation, 271272
dizziness, 272
ear pain, 271
electrophysiological testing, 272
salivation and stapedial reex, 272
corneal ulcers, 266
etiology, 268271
idiopathic paralysis, 265
life-threatening causes, 275
nonsurgical management, 276
subcutaneous muscular tension, 265
Facial paralysis recovery index (FPRI), 275
Facial tics, 315
G
Global (GLOB) layer, 36, 37
Glottic closure reex, 177
Goldenhar-Gorlin syndrome, 132
Graves disease, 81
Growth hormone (GH)IGF axis, 100
GuillainBarre syndrome (GBS), 270
H
Head muscle development
cellular and molecular parallels, 12
EOM, 12
extrinsic regulation, 1819
genetic programs, 1617
hypobranchial muscles, 12
mesodermal origins, 1314
patterning and differentiation, 1920
pharyngeal arch-derived muscles
clonal analysis, 21
LIM-homeodomain protein Islet1, 21
pharyngeal mesoderm evolution, 22
PM-derived cardiogenesis, 2021
satellite cells, 1416
somites, 12
tongue muscles, 12
Hemifacial microsomia, 132
Hemifacial spasm
clinical features, 310
CNVII facial nerve, 310
differential diagnosis, 312
pathophysiologic features, 311
treatment
BoNT Injection, 312

neurosurgical decompression, 313
oral medication, 312313
precipitating factors, 313314
Heparan sulphate proteoglycans (HSPG), 97
High-resolution manometry (HRM), 160
HouseBrackmann system, 275
Hyoid positions, tongue, 230
Hyo-laryngeal complex elevation, 175
Hypobranchial muscles, 12
Hypoesthesia, 308
Hypoglossal (cranial nerve XII)
motor neurons, 230
Hypoxia, 235
I
IGF binding proteins (IGFBPs), 100
Insulin-like growth factor (IGF), 100
Intracortical microstimulation (ICMS), 122
Intrinsic laryngeal muscles
(ILMs), 147, 151
breathing, 145146
canine larynx, 143, 144
classication, 141143
denervation and reinnervation effects
morphology, 196
MyHC isoforms, 197
PCA samples, 198
RLN nerve section, 197198
TA muscle biology, 197
bers energy supply, 147
LCA muscle, 145
mitochondrial density, 148149
MyHC, 149151
nervemuscle connections, 151153
permanent rhythmic activity, 145
phonation movements, 143
slow tonic bers, 150151
slow vs. fast muscle ber types, 147148
swallowing, 146147
TA muscle
activition, 146
components, 144145
vocal fry, 145
J
Jawtongue coordination, 233
K
Krebs cycle, 43, 44
Index
L
Lagophthalmos, 304, 308
Laminin, 97
Laryngeal adductor response (LAR), 177
Laryngeal mechanoreceptor stimulation, 235
Laryngeal muscle
anatomical and physiological differences,
185
biological and functional diversity, 186
extrinsic muscles
swallowing, 156157
voice production and modulation,
154156
ILMs (see Intrinsic laryngeal muscles
(ILMs))
limb vs. craniofacial muscles
neuromuscular disease and injury, 187
unique phenotypes, 186187
motor control and biomechanics
automatic motor control, 168169
central nervous system control,
170171
central neural control, 178
innervation, 170171
neurological diseases, 178179
sensory-motor interactions control,
177178
neuromuscular disease
limb and craniofacial muscle
response, 187
muscular dystrophy, 187190
peripheral paralysis, 194
recurrent laryngeal nerve paralysis
bilateral, 194195
unilateral, 194
superior laryngeal nerve paralysis,
195196
Lateral cricoarytenoid (LCA), 143
Lateral pterygoid muscle, 93
Levator palpebrae superioris muscle, 3132
LIM-homeodomain protein Islet1 (Isl1), 21
Listings law, 5455
Lyme disease, 270
M
Masseter muscle, 99
anatomy, 93
craniofacial skeletal parameters, 94
Frankfort horizontal plane, 94
MRI scans, 9394
vs. non-cranial muscles, 102
341
satellite cell nuclei, 99
TIMP-1 expression, 98
type II bres in, 96
Masticatory muscle
aging
animal studies, 135
EMG activity, 135136
ber type and MyHC isoform, 135
myosin composition and synapse
remodeling, 134135
anatomy
lateral pterygoid muscle, 93
masseter muscle (see Masseter muscle)
medial pterygoid muscle, 9293
temporalis muscle, 92
biochemistry, 9798
biomechanics
jaw movement, 113
motor function, 113, 115
multi-axis force transducer and axes
orientation, 113, 114
bruxism, 134
characteristics, 131
cortical neuroplasticity and control
ICMS-evoked tongue motor
response, 126127
jaw-opening and tongue-protrusive
muscles, 123, 126
pain adaptation model, 127
structure and function, 125126
developmental anomalies, 132
motor function
chewing, 116
cyclic jaw movements, 116
voluntary movements, 115
myosin heavy chains
embryonic and neonatal, 95
extraocular MyHC, 96
gene expression, 9697
isoforms, 94
jaw-closing mechanism, 96
jaw-opening mechanism, 96
masticatory, 95
neural process
brainstem reexes, 118119
cerebral cortex process, 121125
CNVII and CNXII motor nuclei,
117118
descending modulatory inuences, 115,
119120
peripheral mechanisms, 117
subcortical processes, 115, 120121
oromandibular dystonia, 134
pain, 134
342
Masticatory muscle (cont.)
primary pathology
DMD, 133
Parkinsons disease, 134
regeneration and adaptation
animal models, 99
broblasts, 102
growth factor, 100
macrophages, 101102
satellite cells (see Satellite cells)
stem cell niche, 101
sparing in
critical illness myopathy, 133
DMD and ALS, 133
SCA forms, 132
trismus, 134
Matrix metalloproteinases (MMPs), 97, 98
Maximal stimulation test (MST), 272
Maxwell element, 53
Medial pterygoid muscle, 9293
Meige syndrome, 289, 294
Miller Fisher syndrome (MFS), 7678
Mitochondrial disorders, EOM
chronic progressive external
ophthalmoplegia, 7980
cytochrome-c-oxidase loss, 8081
MELAS, 80
mtDNA mutations, 7980
Motor activation, hypoglossal nerve, 230232
Motor control
extraocular muscle
conjugate horizontal eye movements
movements)
laryngeal muscle
central nervous system control,
170171
innervation, 170171
177178
masticatory muscle (see Masticatory
muscle)
pharyngeal muscle
genioglossus, 172
innervation, 175177
Index
inspiration dilator muscles, 173, 175
177178
swallowing constrictor muscles, 174,
175
tongue (see Tongue)
Motor unit potential (MUP) reinnervation, 133
Muscle-specic kinase (MuSK), 78
Muscular dystrophy, 187190. See also
Duchenne muscular dystrophy
(DMD)
Myasthenia gravis (MG)
extraocular muscle, 7779
laryngeal muscle, 193
masticatory muscle, 133134
Myectomy, 307308
Myoblasts, 13, 19
Myogenic regulatory factor (MRF), 11
Myokymia, 294295, 314
Myosin heavy chain (MyHC), 37, 38, 147,
196, 234
extraocular muscle
hybrid bers, 4142
limb and body skeletal muscle, 39
mismatched ber, 41, 42
orbital and global layers, 39
single ber segments, 42
isoforms, 96, 236, 327
masticatory muscle
embryonic and neonatal, 95
extraocular MyHC, 96
gene expression, 9697
isoforms, 94
jaw-closing mechanism, 96
jaw-opening mechanism, 96
masticatory, 95
Myotonic dystrophy, 329
N
Neonatal myosin heavy chain, 95
Nerve growth factor (NGF), 197
Neurodegenerative disorders, 295296
Neuromuscular disease, 56
extraocular muscle
Duchenne muscular dystrophy, 8485
Miller sher syndrome, 7678
OPMD, 81
laryngeal muscle
limb and craniofacial muscle
response, 187
Index
muscular dystrophy, 187190
muscular hydrostat, 242
sensational disorders, 241
tongue kinematics (see Tongue kinematics)
tongue musculature, 241, 259
volumetric reduction and motor function
(see Volumetric reduction, tongue)
Neuromyotonia, 314
Nico-tinic acetylcholine receptor, 38
Nucleus tractus solitarius (NTS), 233
O
Ocular biomechanics, 5356
Oculomotor nucleus, 6466
Oculopharyngeal muscular dystrophy
(OPMD), 6, 81
Orbital hemorrhage, 307
Orbital (ORB) layer, 3638
Oromandibular dystonia, 134, 289
P
Paralysis, 267
Paralysis musculorum faciei rheumatica, 273
Parkinsons disease, 292
Periorbital contour deformity, 304, 308
Pharyngeal arch, 132
Pharyngeal mesoderm (PM)
domains, 13
evolution, 22
progenitors, 20
Pharyngeal muscle
motor control and biomechanics
genioglossus, 172
innervation, 175177
inspiration dilator muscles, 173, 175
177178
swallowing constrictor muscles,
174, 175
muscle ber types, 142143, 158
pharyngeal movement, 142143, 157
structure and function, 142143, 158
UES
CP innervation, 159160
CP muscle dysfunction, 160161
cricopharyngeus muscle, 159
HRM, 160, 161
343
manometry measurements, 158
muscle ber properties, 159
Pharyngoesophageal segment (PES), 158
Photooculodynia, 309
Pontine lesions, 266
Posterior cricoarytenoid muscle (PCA), 143
R
Rapsyn, 78
Respiration, tongue, 218, 234235
Rhythmic activity bursts, tongue, 247
Ryanodine, 78
S
Sarcolemma, 98
Satellite cells
animal models, 99
classic quail-chick chimera
experiments, 99
FGF and IGF-I, 100
bre type distribution, 98
head vs. trunk-derived muscles, 16
lineage tracing techniques, 15
masseter muscle, 99
myonuclear turnover and regeneration,
4445
Pax3 expression, 16
sarcolemma, 98
self-renewal mechanism, 15
Skin necrosis, 307
Somatic sensation, tongue, 232233
Somites, 12
Sonic hedgehog (Shh), 18
Spasmodic dysphonia, 291
Spasmodic torticollis, 291
Spastic facial muscle disorders
blepharospasm (see Blepharospasm)
drug-induced facial dyskinesias, 296297
dyskinesias, 287, 288
eyelid/facial tics, 315
facial nerve synkinesia, 295
hemifacial spasm (see Hemifacial spasm)
myokymia, 314
neurologic disorders, 295296
neuromyotonia, 314
psychological problems, 296
superior cervical ganglion block, 309
treatment
BoNT injection (see Botulinum
neurotoxin (BoNT) injection)
chemomyectomy, 308309
Index
344
Spastic facial muscle disorders (cont.)
myectomy, 307308
neurectomy, 309
oral medications, 306
psychotherapy, 305306
selective facial nerve (CNVII)
ablation, 309
superior cervical ganglion block, 309
Suc-cinic dehydrogenase, 43
Superior cricoarytenoid (SCA), 188
Swallow expansion device (SED), 161
T
Tardive dyskinesia, 296297
Temporalis muscle, 92
Temporomandibular disorders (TMD), 112
Thyroarytenoid muscle (TA), 143
Thyroid-associated ophthalmopathy
(TAO), 8182
Thyroid disease, 8182
Tissue inhibitors of the metalloproteinases
(TIMPs), 97, 98
Titin, 78
Tongue, 207208
biomechanics, 230, 242
functions
food manipulation, 235237
protrusion, 233234
respiration, 234235
retrusion, 233234
speech, 237238
suckling and swallowing, 235237
hypoglossal nerve, motor activation
dorsal compartment, 232
hypoglossal nucleus, 230, 231
innervation, 230
motoneuron projections, 230, 231
kinematics
chewing, 245
crystal pairs locations, 244, 245
drinking cycle, 245246
expansioncontraction, 246
hypoglossal motor system, 243244
ingestion cycles, 245
jaw movement and muscle
activity, 248250
mastication, 245
pharyngeal constrictor, 245
post-injury adaptations, 251
respiration, 246247
rhythmic activity bursts, 247
spatio-temporal coupling, 247248
swallowing, 245
ultrasonic crystal array, 242, 243

volumetric mass reduction
(see Volumetric reduction, tongue)
mastication, 218
movement, neuromuscular basis
anatomy and localization, 217218
MEP morphology and muscle ber
innervation, 216
physiology, 215216
theoretical considerations, 215216
muscle ber biochemistry
aging, 222223
capillarization and oxidative
metabolism, 221222
MyHC composition, 220221
MyHC isoform, 219220
speech production, 218
muscular anatomy
deformable solid, 209211
muscle anatomy and
innervation, 208210
primarily longitudinal
orientation, 214215
primarily transverse
orientation, 213214
respiration, 218
somatic sensation, 232233
type II tongue, animals, 229
Tonic-positive myobers, 43
Tourettes syndrome, 315
Transcranial magnetic stimulation
(TMS), 121, 172
Trismus, 134
Trunk muscle-associated satellite
cells, 16
U
Upper esophageal sphincter (UES), 158
V
Vagal nerve injury, 171
Vergence eye movements, 6869
Vestibulo-ocular reex, 55
Visible scar, 308
Voigt elements, 5253
Volumetric reduction, tongue
craniofacial growth and dentition
formation, 257259
mass reduction and tongue kinematics
food leaking, 252
functional modication, 252
genioglossus, 251
Index
hydrostat mass reduction, 251
maladaptation, 253
muscular mass reduction, 252
morphological and histologic
consequences
immunohistochemical study, 256
mandibular dentition, 253, 254
partial brosis, 257
sham tongues comparison, 255
surgical incisions, 254
surgical injury, 257
345
W
Wallenberg syndrome, 171
X
Xeomin, 301
Xeropthalmia, 267
Y
Yoked muscles, 33

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Craniofacial Muscles

Linda K. McLoon Francisco H. Andrade

1 The Craniofacial Muscles: Arguments for Uniqueness .......................

Head Muscle Development .....................................................................

Extraocular Muscle Structure and Function........................................

Motor Control of Extraocular Muscle ..................................................

Extraocular Muscles Response to Neuromuscular Diseases

Part IV Masticatory Muscles

Masticatory Muscle Structure and Function........................................

Motor Control of Masticatory Muscles ................................................. 111

Masticatory Muscle Response to Neuromuscular Diseases

Part V Laryngeal and Pharyngeal Muscles

Structure and Function of the Laryngeal and Pharyngeal

Motor Control and Biomechanics of Laryngeal

Laryngeal Muscle Response to Neuromuscular Diseases

Part VI Tongue Musculature

Facial Nerve Innervation and Facial Palsies ........................................ 265

Spastic Facial Muscle Disorders ............................................................ 287

Summary and Conclusions

Comparison of the Craniofacial Muscles: A Unifying

Index ................................................................................................................. 337

Francisco H. Andrade Department of Physiology, University of Kentucky,

Mark Lewis School of Sport, Exercise and Health, Loughborough University,

The Craniofacial Muscles: Arguments

F.H. Andrade, Ph.D. (*)

F.H. Andrade and L.K. McLoon

Origin of Head and Neck Musculature

The Craniofacial Muscles: Arguments for Uniqueness

Craniofacial Muscle Function

Craniofacial Muscles and Neuromuscular Disease

F.H. Andrade and L.K. McLoon

The Craniofacial Muscles: Arguments for Uniqueness

Head Muscle Development

Skeletal Muscle Formation

I. Harel E. Tzahor (*)

I. Harel and E. Tzahor

2 Head Muscle Development

Head Muscles Are Heterogeneous in Terms of Their

Head muscles are highly heterogeneous in their structure, function, anatomical

I. Harel and E. Tzahor

Head Muscle Satellite Cells

Recent studies have begun to uncover an unexpected heterogeneity in head muscles

2 Head Muscle Development

I. Harel and E. Tzahor

Distinct Genetic Programs in Trunk and Head Muscles

2 Head Muscle Development

I. Harel and E. Tzahor

Extrinsic Regulation of Head Muscle Development

2 Head Muscle Development

Cranial Neural Crest Cells Affect Head Muscle

I. Harel and E. Tzahor

2.8 The Link Between Heart and Pharyngeal-Arch Derived

2 Head Muscle Development

I. Harel and E. Tzahor

Evolution of Pharyngeal Mesoderm: From Pharyngeal

2 Head Muscle Development

I. Harel and E. Tzahor

2 Head Muscle Development

I. Harel and E. Tzahor

2 Head Muscle Development

I. Harel and E. Tzahor

Extraocular Muscle Structure and Function

L.K. McLoon, Ph.D. (*)

L.K. McLoon et al.