Gazzetta Medica Italiana – Archivio per le Scienze Mediche 2023 mese;182(0):000–000
DOI : 10.23736/S0393-3660.23.05091-X
OSAS: Obstructive Sleep Apnea : Between myth and reality.
Dott. Antonio Ferrante
Medico Chirurgo, Spec. In Odontostomatologia
Docente Master ”Posturologia clinica” Univ. Pisa, Napoli
Autore di contatto: dott. Antonio Ferrante I trav. Luigi Angrisani, 23 84014 Nocera Inferiore (Sa) Italia e-mail dott.antonioferrante@gmail.com
Key words
OSAS, Trigeminal Nose-Palatine Nerve, Tongue Spot, Surface Electromyography, Neuro-transmitters, Concentration, Memory.
Abstract
The article aims to shed light on an aspect too little considered: the true causes of apnea, purifying it of unverified statements, and referring to clinical, scientific data and linking various information to consider Apnea in a new light, and to outline new courses of treatment. BACKGROUND: Obstructive apnea is a sleep disorder increasing constantly and involves both adult and children. Many causes have been hypothesized, but none of them have been fully validated. The discovery that the nose-palatine nerve (second branch of the trigeminal nerve), presents a huge amount of all five types of postural receptors present in the human body, led us towards a different interpretation. AIM OF WORK: To prove that the Obstructive Sleep Apnea is a consequence of an improper posture of the tongue and of the hypertone from this determined, debunking of the false myths METHODS: We measured the diameter of the faring in profile teleradiographies. RESULTS: we appreciated a steady increase in diameter. CONCLUSIONS: Apnea in many cases is not caused by hypertonicity, but, on the contrary, by linguo-pharyngeal hypotonia, which is treatable by myofunctional re-education.
Background Obstructive apnea is a sleep disorder increasing constantly and involves both adult and children. It brings with it a number of effects on the nervous, metabolic and vascular systems (1). Many specialists have tried to find explanations and treatments, but they are incomplete and unable to explain the complexity of signs and symptoms that this disease presents. A doctor trys to prevent Apnea but desn’t why this disorder appears. So, for example, the biochemical aspect, considering the amount of vitamin D in serum is analyzed (2.3), but without questioning whether such vitamin absorption depends on the specificity of the Ph of the digestive tract. The blood level of Leptin is considered as a sign of the severity of the syndrome, without wondering what neurologically controls leptin. (4) The doctors limited themselves to describe the seriusness of the apnea without making any effort to achieve a etiopathogenesis (5,6,7) An attempt to control the disease was made through rapid palatine expansion, an orthopedic intervention for the maxillary divarication and the recovery of amplitude of the palate (8) or with tonsillectomy (9), but with not always complete results. To reduce or prevent episodes of Apnea the use of C-Pap pressure fans was implemented, which, in our view, can cause damage to the middle and inner ear through the increase of pressure and thus incoraging Tinnitus and Vertigo. In cases do not respond to C-Pap, it has been proposed to intervene surgically to get throat sphincter expansion (10) and even come to advocate the use of maxillary repositioning surgery with of Le Fort operation (11) or with Mandibular Advancement (12).
As a causative factor, the epiglottis collapse (13), pharyngeal muscle hypotones and the accumulation of perifaringeal fat and mandibular retrusion were taken in to account. Meanwhile, some researchers have emphasized the co-morbidity of certain diseases such as obesity, diabetes, hypertension, hypothyroidism (14). We will try to explain later on the relationship that links these elements that are difficult to place in the clinical picture in the absence of particular basic knowledge.
Finally the tongue was taken into consideration and especially the short frenulum, as a cause of apnea. (15) From here starts our observation that will try to explain many misunderstood aspects of the problem to make the syndrome understandable.
It is necessary to give some preliminary remarks for those not familiar with the tongue and its posture. The tongue is the first organ to function in the foetus. It is already completely formed at 51st day of pregnancy, when the rest of the body is simply sketched. Starting from the 13th week of gestation, deglutition is the force for the conformation of the palate; improvement of the swallowing act itself; the functionalization of the digestive tract and kidneys.
In the absence of causes affecting the tongue function as, for example, the presence of an umbilical cord wrapped around the foetus’ neck, multiple pregnancies, incorrect fetal intrauterine positioning, tongue posture tends to be oblique, with the tongue apex in contact with the nose-palatine nerve. This position is determined by the balance of sixteen muscles that make up the tongue, which can be divided into two antagonistic groups: those that carry the tongue up and back (essential for proper swallowing) and those that move it horizontally, both in the postero-anterior direction (almost always hyperactive in an incorrect swallowing) and latero-lateral. In the correct swallow
the tongue rests with the apex on the palate in correspondence with the palatine receptors and gradually lifts the body by pressing it against the palate. This movement is learned and consolidated during the squeezing of the nipple which occurs during breast-feeding. The muscles involved are those with vertical action.
The muscles with a horizontal function are the only ones fully active in the case of lactation with artificial methods (the baby learns to swallow with the teat that compresses the tongue downwards) or in the presence of abnormalities in the shape of the tongue such as the short frenulum and the tongue frankly ankylotic. The lack of contact of the tongue with palatine receptors is, at times so prolonged and total, that a generalized hypertonic can be established able to create a lingual dyspraxis in the newborn and fibromyalgia in an adult.
In order to better understand the essence of the phenomenon of Apneas, we must clarify some aspect of the emerging deal. Everything is born from the discovery that the nose-palatine nerve (the final part of the second branch of the trigeminal nerve, which arises on the palate through the channel of the same name) (Fig. 1), presents a huge amount of all five types of postural receptors present in the human body. The first study is due to professors Halata and Baumann (16) who, at the Institute of Comparative Anatomy of the Hamburg University, found the same receptors in all the animal species studied. On the other hand, at my Myofunctional rehabilitation office, born for orofacial muscle balance and swallowing treatment in orthodontic field, we realized that, whenever we place during rehabilitation the tongue apex in physiological position in contact with the palate, which corresponded exactly to the emergence of the nose-palatine nerve, the subject examined showed apparently unexplained immediate changes in posture and of load distribution breech. The knowledge that by placing the tongue correctly, the Trigeminus was stimulated, allowed us to undertake a research path that is giving enormous results. It is discovered, for example, the importance of stimulation of this place, that has been defined SPOT. A student of the “Master on swallowing function in the postural field” that I coordinated at the Institute of Neurology of the Sapienza University in Rome, called him with an italian acronym Sensor Primitive Oral Trigeminal. This stimulation is fundamental for improving the motor skills and physical freedom in subjects with Parkinson’s disease (17, 18, 19). In two Research Theses we have seen the modification of the electro-encephalographic waves in patients with dysfunctional swallowing, positioning the tongue to the palatal Spot (20) Effects on the presence of epileptic waves have been highlighted. These anomalous waves tend to disappear very frequently when the tongue is placed at the Spot. Just shortly after the Theses produced, an American research was published confirming the goodness of our results, showing how trigeminal dysfunction can underlie many forms of epilepsy. (21)
With surface electromyography it was possible to appreciate the immediate effect on muscle tone with reduction and rebalancing of the muscles of the whole body (Alberto thesis, art. Sucking). The lack of stimulation of the palatine receptors would be the basis of the various forms of muscle hypertonus which, as I said before, can affect the whole organism. Failure to stimulate the palatine receptors is also responsible for the decrease in melatonin secretion. This substance, which in its metabolism is transformed into serotonin, easily dosed through the excretion of 5 hydroxy-indole-acetic acid, check, among others, the rate of production of cortisol which must be secreted during the day, at 8.00 and 15.00. In the absence of melatonin, it is produced at night by coming into conflict with insulin, growth hormone, leptin and ghrelin (the hunger and satiety hormones).
The explanation of all the observations made derives from the study of neurology of the nasopalatine nerve which manages to explain what has been observed. Stimulation of the nasopalatine nerve determines the activation of the brain stem with the production of Serotonin.
The trigeminal trunk, before reaching the mesencephalic Motor nucleus, emits a branch for the Locus Coeruleus which in turn is directly or indirectly responsible for the production of the various neuromediators including, Acetylcholine, Nor-adrenaline, Melatonin and Serotonin from the pineal gland. the lack of which is involved in the alterations of muscle tone, motor skills, sleep, memory. (22).
Theses conducted in the Master in Posturology at the “Sapienza” University of Rome, have shown how the stimulation of the Palatine Spot is able to bring the production of Serotonin back to normal values in subjects suffering from Idiopathic Juvenile Scoliosis (23.24) and a Thesis carried out in the Physiatry and Rehabilitation Clinic of the second University of Naples showed how the positioning of the tongue in the Spot determines an instantaneous reversal of the tested muscles. (25) Ferrante A. and Scoppa F. studies showed instantaneous changes of body posture evaluated with the scoliosometer and the weight bearing platform by stimulating the Palatine SPOT (26.27). This effect is certainly due to a change of cerebellar stimulation through the stimuli that travel the trigeminus, locus coeruleus, cerebellum way. Spot stimulation induces serotonin production, as demonstrated by two theses conducted in the master’s course in posturology, and melatonin production which we know to be correlated with thyroid control and glycemic function.There are over a thousand indexed articles that prove the importance of melatonin in controlling the general function of the organism.
Aim of work:
To prove that the Obstructive Sleep Apnea is a consequence of an improper posture of the tongue and of the hypertone from this determined, debunking of the false myths, that are not based on specific studies, but the fruit of suppositions consolidated by tradition.
In the past it was considered OSAS as determined by hypotonia of oro-faringeal musculature whose collapse would determine the “fall” of the tongue into the pharynx blocking it. (28)
Actually we are carrying out studies that show that the lack of nose-palatine receptors stimulation causes the hypertonus of the musculature of the whole body.
Obstructive apnea is probably a consequence of the jo-glosso muscle hypertonicity that drags the lingual base to the bone joid, associated with the pharynx constrictors hypertonus. The decrease of the pharyngeal lumen justifies the appearance of the obstruction much better than the muscular hypotone. The variation of pharyngeal caliber can be very well appreciated in two successive teleradiography, the first with the tongue in the usual position, the second with the tongue apex in contact with the palatine Spot. If we analyze a patient who has dysfunction of swallowing, the pharyngeal caliber variation can be appreciated very well in the two teleradiographs, the first with the tongue in the usual position, the second with the lingual apex in contact with the palatine Spot. (Fig. 2) The rx clearly shows how much the pharyngeal space is enlarged by positioning the tongue correctly and how the hyoid bone is positioned further down due to the decreased tone of the sub-mandibular muscles. An electro-myographic study conducted by us and in course of publication has shown how the muscular hypertonia often fades to disappear when the tongue is placed in contact with the Spot. (Fig. 3, 4)
These instrumental studies have accompanied the clinical findings that confirm strongly as expressed so far.
Methods
We followed a group of 28 patient suffering from sleep apnoea (between the 47 episodes and 234 per night). The age of the subjects was between 7 and 68 years. All related to our Center for lingual dysfunction problems.
In particular:
11 subjects needed orthodontic treatment ( 9 prepubertal subjects and 2 post pubertal )
3 adults treated for temporomandibular joint problems (TMJ)
6 adults suffered from Tinnitus
8 suffered from muscle-tensive headache or vertebral pain or postural problems (6 adults and 2 children)
Results
Of the 17 adult subjects treated
8 subjects had used CPAP (but only one of them reported improvements with the use of this instrument, as many as 4 people reported the appearance of tinnitus after the start of CPAP use),
4 subjects had use jaw advancers with poor results.
Of the 11 children, only 9 had been monitored by polysomnography, 2 had suffered tonsillo-adenoidectomy.
There was only one subject with very short frenulum, while everyone had received prolonged bottle feeding. Of this group, the little girl with the most serious pathology (continuous headache and apneas 140 per night), after the first 45 days of treatment, had zero episodes of apnea and four episodes of headache, she said of much less painful than in the past.
Within the first two months of re-education only the patient with the short frenulum, who feared to perform the frenulotomy, still presented apneas.
Treated adults have had improvements since the end of the second month of therapy and only two entities that had seen fewer hypertones, but that still had higher values of the standard, reported the presence of sporadic crises.
Conclusions
In light of what has been said, myofunctional re-education, carried out by trained personnel, is able to work on the lingual function and on the damage created by muscular hypertonus which is known as one of the most important and frequent causes of OSAS. From this derives the need to don’t neglect, beyond the evaluation of all the other known causes, also the correct swallowing function as a cause of Apnea.
Given the huge incidence of artificial feeding in the civilized countries and the consequent huge amount of lingual dysfunction (78% of the population), the altered swallowing and its consequences (remember that the low lingual posture and the consequent oral breathing are very often the cause of the problems of adenoids and tonsils, considered themselves causes of Apnee) (Fig. 5,6) a review and eventual treatment of swallowing pathologies is an indispensable complement of every treatment of OSAS.
REFERENCES
1 Perez C.; Obstructive sleep apnea syndrome in children; Gen Dent. 2018 Nov Dec;66(6):46-50. 2 Kirac D, Yagcioglu Yassa O, Gezmis H, Mayda Domac SF, Altunok EC, Genc E; Different VDR, VDBP genotypes and vitamin D levels may effect obstructive sleep apnea syndrome; Cell Mol Biol (Noisy-le-grand). 2019 Jan 31;65(1):46-51.
3 Yassa OY, Domac SF, Kenangil G.; Serum Vitamin D Status does not Correlate with the Severity of Obstructive Sleep Apnea in Male Adults: A Controlled Study Design with Minimized Factors Influencing Serum Vitamin D Levels; Int J Vitam Nutr Res. 2019 Feb 20:1-7
4 Cakir I, Uluhan M; Cardiotrophin-1 and leptin as cardiovascular risk markers in male patients with obstructive sleep apnea syndrome; Arch Med Sci Atheroscler Dis. 2018 Nov 6;3:e123-e128. doi: 10.5114/amsad.2018.79407. eCollection 2018
5 Trachsel D, Datta AN; ;Sleep-Disordered Breathing in Childhood; Praxis (Bern 1994). 2019 Jan;108(2):97-102. doi: 10.1024/1661-8157/a003162.
6 Stöwhas AC, Lichtblau M, Bloch KE.; Obstructive Sleep Apnea Syndrome; Praxis (Bern 1994). 2019 Jan;108(2):111-117. doi: 10.1024/1661-8157/a003198.
7Gelardi M, Intiglietta P, Porro G, Quaranta VN, Resta O, Quaranta N, Ciprandi G; The role of the nasal valve in patients with obstructive sleep apnea syndrome. Acta Biomed. 2019 Jan 11;90(2-S). doi: 10.23750/abm.v 90i2-S.8097.
8 Villa MP1, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, Ronchetti R.;
Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007 Mar;8(2):128-34. Epub 2007 Jan 18.
9 Mure C, Blumen M, Alali A, Page L, Chabolle F:Surgical ablation of lingual tonsils in the treatment of obstructive sleep apnea. Eur Ann Otorhinolaryngol Head Neck Dis. 2019 Feb;136(1):19-23. doi: 10.1016/j.anorl.2018.11.001. Epub 2018 Nov 30.
10 Güler İ, Kuzucu İ, Baklacı D, Kum RO, Kum NY, Özcan M; Efficiency of Expansion Sphincter Pharyngoplasty in the Treatment of Obstructive Sleep Apnea Syndrome.
Turk Arch Otorhinolaryngol. 2018 Dec;56(4):206-209. doi: 10.5152/tao.2018.3665. Epub 2018 Dec 21.
11 Ishida T, Manabe A, Yang SS, Watakabe K, Abe Y, Ono T An orthodontic-orthognathic patient with obstructive sleep apnea treated with Le Fort I osteotomy advancement and alar cinch suture combined with a muco-musculo-periosteal V-Y closure to minimize nose deformity. Angle Orthod. 2019 Jan 30. doi: 10.2319/052818-406.1. [Epub ahead of print]
12 Geering S, Broome M, Heinzer R, Lambercy K.; Sleep apnea : diagnostic and therapeutic modalities in case of failure of the CPAP; Rev Med Suisse. 2018 Oct 3;14(621):1751-1754.
13Chen G, Liao WJ, Zhang XW.; Research progress of obstructive sleep apnea syndrome caused by epiglottic collapse; Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2019 Feb 5;33(2):186-189. doi: 10.13201/j.issn.1001-1781.2019.02.024.
14 Sweed RA, Hassan S, ElWahab NHA, Aref SR, Mahmoud MI.; Comorbidities associated with obstructive sleep apnea: a retrospective Egyptian study on 244 patients. Sleep Breath. 2019 Jan 26. doi: 10.1007/s11325-019-01783-w. [Epub ahead of print]
15 Guilleminault C, Huseni S, Lo L.; A frequent phenotype for paediatric sleep apnoea: short lingual frenulum; ERJ Open Res. 2016 Jul 29;2(3). pii: 00043-2016. eCollection 2016 Jul.
16 HALATA Z., BAUMANN K.I.: “Sensory nerve endings in the hard palate and papilla incisiva of the rhesus monkey”; Anatomy and Embriology, vol.199, iss.5, pp 427-437,1999
17 Ferrante A., Scoppa F., Bruzzese F., Guirreri S., Nola D.: Myofunctional therapy in Parkinson’s desease patients. A controlled randomized blind clinical study; ISPGR, p 335, June 2009
18 Ferrante A., Bertoni da Silva, J.G., Bruzzese F., Guirreri S., Nola D., Fin G., Rover C., Daslanora C.T., Nodari R,J.; Efeito da Terapia Miofunctional no tratamento teraputico do mal de Parkinson.Unoesc & Ciencia –ACBS- Ed.Especial, p.47-52, 2014
19 Fetoni V., Guirreri S, Molini G. E., Ferrante A, Sasanelli F.: La Terapia Miofunzionale nella malattia di Parkinson: Studio Pilota; comunicazione XXXIV CONGRESSO NAZIONALE LIMPE, 2007
20 Pagnini P.; Risposte corticali alla stimolazione dello Spot Linguale; Master in Posturologia cl. Univ. Pisa a 2009-2010
21 DeGiorgio C.M., Shewmon A., Murray D., Whitehurst T.; Pilot Study of Trigeminal Nerve Stimulation (TNS) for Epilepsy: A Proof-of-Concept Trial ; Epilepsia,47(7);1213-1215, 2006
22 De Cicco V.; Concetti di Neuro-anatomia e Neuro-fisiologia; cap II pp 11-70, La Nuova Ortodonzia, Marrapese ed. Roma, 2007
23 Locati F., Fedeli R., Correlazione tra Deglutizione scorretta, secrezione di Serotonina e Scoliosi in età evolutiva; Tesi Master in Posturologia Univ Sapienza Roma, 2008-2009
24 Salvatore Tamburro S., Severino A., Nastro S.; Valutazione dei valori urinari di serotonina in ragazzi scoliotici, prima e dopo tre mesi di rieducazione della deglutizione; Tesi Master in Posturologia Univ. Sapienza Roma, 2009-2010
25 Ferrante Al.; Modificazioni posturali secondarie ella variazione della funzione di alcuni muscoli del capo e del collo; Dip. Scienze Ortopediche, Traumatiche, Riabilitative, Plastico-ricostruttive, II univ. Napoli, anno 2006
26 Ferrante A., Reed-Knight E., Bello A., Comentale P.: Variazioni posturali conseguenti a cambiamento della posizione della lingua e a trattamento miofunzionale; Ortognatodonzia italiana , 3, pp 307-315, 2002,
27 Ferrante A., Scoppa F.; Tongue position and postural control. Double blind random study in 360 post puberal subjects; Gait & Posture, vol. 21, suppl. 1, p. 130, June 2005
28 Schlegel J1, Urban PP.; Electrophysiological brain-stem diagnosis in patients with a pronounced obstructive sleep apnea syndrome; Dtsch Med Wochenschr. 1999 May 21;124(20):613-7.
