Nasal Muscle Research Articles

Jacques-Louis David and his post-traumatic facial pathology

Jacques-Louis David is regarded as one of France's most recognized painters, who's most famous work—the Death of Marat (1793)—has been subject to medical review, as it was well-known that Marat suffered from an exasperating chronic skin condition.1 It is interesting to note, however, that David's life-story and self-portrait also reveal an underlying pathology, that to date has not received attention in the medical literature. In his youth, David suffered from a deep left peri-oral sword wound after a fencing incident, whereupon he subsequently lost his left nasolabial groove while his left cheek gradually swelled.2 As a result, he found it difficult to make left-sided facial movements, particularly those around his left mouth, which led to a noticeable asymmetry during facial expression. Furthermore, eating or speaking in public became strenuous, which, when added to a longstanding speech impediment whereby he could not pronounce some consonants (such as ‘r’), made him highly and understandably self-conscious. Biographers and art historians over the centuries have defined this post-traumatic pathology as a ‘benign tumour’ or ‘exostosis’.2 Looking at David's self-portrait (Figure 1A), it becomes clear that a discernible scar representing the rapier wound is visible at the left labiomarginal sulcus (painted on the right side in the image as it was based on a mirror's reflection), extending for a short distance laterally into the midface. Anatomically, this corresponds to a path taken by some of the buccal branches of the facial nerve, which have an inconstant origin and variable course from the parotid gland, passing horizontally to a distribution below the orbit, to the nose and mouth. Those branches ending close to the labiomarginal sulcus include the deep lower branches that supply buccinator, orbicularis oris and joint filaments of the buccal branch of the mandibular nerve.3 Furthermore, in view of some of the complex routes taken by the buccal branches of the facial nerve, a number of the divisions that supply the lip elevators and small nasal muscles may also correspond to this area of trauma. This therefore could explain David's facial affliction as a result of a likely injury to the buccal branch of the facial nerve, resulting in the difficulties with left facial movement and the associated loss of the left nasolabial groove. Other differentials include facial asymmetry as a result of a lesion centrally or more proximally in the course of the facial nerve. Figure 1 A: Self-portrait by Jacques-Louis David (painted from a mirror reflection), 1794 (81 × 64 cm). B: Sculpture of Jacques-Louis David by Francois Rude, 1831 (26 × 39 × 21 cm); Musee du Louvre, Paris The subsequent description of a facial ‘growth’ following traumatic injury may therefore be ascribable to recognized complications of midface soft tissue injury, which could include either a post-traumatic rapier wound, a foreign body granuloma,4 or even a post-traumatic neuroma.5 These could have caused the artist significant anxiety regarding self-image, and thus (being a shrewd propagandist), he is reputed to have diminished the extent of his disfigurement from his own self-portrait. This only becomes conspicuously evident when one studies sculptures of Jacques-Louis David produced during his lifetime by other artists, who would have probably presented his facial characteristics with more objectivity (Figure 1B).

Soft tissue functional anatomy of the nose

The author discusses the role of soft tissues in aesthetic and functional rhinoplasty outcomes, stressing the dynamic function of the nasal muscles. These muscles are thin and difficult to visualize, but their preservation is vital to nasal function and appearance.

Treatment of Nasal Wrinkles with Botulinum Toxin

Nasal wrinkles on the dorsum of the nose can frequently be treated with botulinum toxin type A by injecting a few units into the nasalis muscle. Between 2 and 5 U of botulinum toxin have commonly been used. However, clinicians have observed that some nasal wrinkles persist following nasalis treatment. To detail remaining nasal and perinasal rhytids and further injection sites, which can lead to improvement. Two hundred fifty patients with nasal rhytids were treated between 1997 and 2004. Three units of botulinum toxin type A were injected bilaterally into the nasalis muscle. Patients were seen at 1 month for follow-up, and the remaining rhytids were documented. Forty percent of patients had satisfactory treatment of nasal wrinkles with the initial bilateral 3 U injections. Sixty percent of subjects had remaining nasal rhytids following the nasalis muscle injections. Thirty percent o f subjects hadpersistent wrinkles at the root of the nose (nasal orbicular wrinkles), and 30% had wrinkles at the nasal root and between the eyes (nasociliary wrinkles). The injection of botulinum toxin into additional locations according to the anatomic differences of each person showed excellent resolution of the rhytids without complications. Understanding nasal wrinkle patterns allows for complete wrinkle treatment of the nose beyond simple bilateral treatment of the nasalis. New points of botulinum toxin application improve not only wrinkles at the root of the nose but also wrinkles in the nasoalar area.

Sensitivity of repetitive facial‐nerve stimulation in patients with myasthenia gravis

Repetitive stimulation of the facial nerve is commonly performed in cases of suspected myasthenia gravis (MG) because bulbar weakness is often present, but the most sensitive facial muscle is unknown. We compared the sensitivity of repetitive nerve stimulation (RNS) to the frontalis and nasalis muscles in 244 patients with suspected MG. We found no difference in sensitivity of RNS when recording from these muscles in both ocular and generalized MG. In addition, we confirmed the low sensitivity of RNS for ocular (18%) or generalized (47%) MG. The specificity of facial RNS for both muscles was 100% and, in certain circumstances, may obviate the need for further diagnostic testing.

Biofeedback training of nasal muscles using internal and external surface electromyography of the nose

Background The purpose of this paper is to describe the outcome of biofeedback training of nasal muscles in cases of nasal valve stenosis and collapse. The present study was performed to investigate the best way of using surface electromyography (sEMG) in biofeedback training of muscles involved in nasal valve function. In the present study, we present the way of biofeedback training of these muscles introducing the intranasal placement of sEMG electrodes and a home exercise program. Methods A nonrandomized pilot study of patients presenting with symptoms of obstructed nasal breathing was conducted. All selected patients (n = 15) demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Follow-up ranged from 9 to 12 months. Treatment included surface and intranasal EMG biofeedback-assisted specific strategies for nasal muscle education and a home exercise program of specific nasal movements. Results All patients exhibited variable subjective improvement. In 86.66% (n = 13), the improvement was proved objectively and there was no need for operation. In 13.33% (n = 2), an endonasal operation was recommended. Conclusion Relieve of obstructed nasal breathing after nasal valve stenosis and/or collapse can be achieved with biofeedback training of nasal muscles and a home exercise program as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention.

Effects of the Nasal Muscles on the Nasal Airway

The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway. Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared. The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis. All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation

We conducted a prospective, randomized, double-blind pilot study of patients presenting with symptoms of obstructed nasal breathing to determine whether electrotherapy could provide nonsurgical symptom relief. Forty patients were divided into an electrotherapy group (n = 20) and a placebo group (n = 20). All selected patients demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Treatment consisted of high-frequency transcutaneous and intranasal electric stimulation of nasal muscles for 15 minutes, 3 times a week for 10 weeks. Treated patients were followed for 10 to 12 months. Twelve patients in the electrotherapy group (60%) exhibited subjective improvement; in 8 cases (40%), the improvement was proved objectively. In the placebo group, 7 patients (35%) indicated subjective improvement; and in one case (50%), the improvement was proved objectively. Follow-up visits showed a rapid decline of positive results when treatment was discontinued. Therefore, we concluded that sure relief of nasal valve stenosis and collapse cannot be achieved with treatment by electric stimulation alone, and this method appears to have limited application. However, further studies are needed to determine whether electrotherapy used in combination with other treatments (e.g., biofeedback training or nasal springs) may provide more lasting relief for patients who want to avoid endonasal surgical intervention.

Repetitive nerve stimulation in myasthenia gravis—relative sensitivity of different muscles

Objective: To correlate repetitive nerve stimulation (RNS) decrement in different muscles with the predominant clinical presentation in myasthenia gravis (MG), and to study single fibre EMG (SFEMG) sensitivity in ocular MG. Methods: Sixty-nine, untreated, consecutive patients suspected for MG were observed prospectively for a minimum of 6 months. Those who improved on medical treatment were diagnosed as MG. The others, in whom the neurophysiological studies were normal and that did not improve on medical treatment served as a control group, from which normative data for RNS and SFEMG was obtained. The MG patients were further classified in 3 subgroups according to the predominant clinical presentation: group I (ocular); group b (bulbar); and group a (axial). We performed RNS in nasalis, trapezius, anconeus, and abductor digiti minimi. All patients with ocular MG underwent jitter determination of the orbicularis oculi muscle. Results: Thirty-seven patients were diagnosed as MG (group I, 15; group b, 13; group a, 9). In group I, RNS was abnormal in 33% of the patients. RNS studies disclosed at least one abnormal muscle response in every patient in groups a and b. Trapezius was significantly more sensitive in group a, and anconeus and nasalis in group b ( P<0.01). Jitter was abnormal in all patients in group I, and the most sensitive parameter was an increased number of unstable pairs, 100%. Conclusions: Based on these observations, we recommend that a shoulder muscle, as the trapezius, should be studied first in the limb-axial presentation of MG, and the anconeus–nasalis muscles in predominant bulbar MG. In ocular MG, RNS is not sensitive and jitter should be performed in facial muscles. Significance: This paper shows the unequal sensitivity of several muscles to RNS in different forms of MG.

Isolated Local Hypoexcitability to Canalicular Magnetic Stimulation within Three Days after Onset of Facial Nerve Paresis can be due to Borreliosis

Nerve conduction studies of the facial nerve with electric and magnetic stimulation within three days after onset of Bell's palsy provide information about the differential diagnosis of the etiology, particularly with regard to borreliosis as a specifically treatable cause. Canalicular hypoexcitability is considered as a very specific finding for (idiopathic) Bell's palsy in the literature. A 38-year-old man presented with a moderate facial palsy of the left side one month after a tick bite on the thigh with erythema which had been treated with roxithromycine for 10 days. No other neurological abnormalities could be found at admission to our hospital. Cranial CT and MRI revealed normal results. Serum antibodies of Borrelia IgM were positive, CSF showed initially the following pathological results: cell count 4275/3 (normal 0–9/3), protein 248.5mg/dl (15.0–45.0), albumin 2070.0mg/l (0.0–350.0), elevated IgM and IgA with dominant IgM synthesis. Antibodies of Borrelia (IgM and IgG) were positive with an elevated antibody index that proved intrathecal local antibody synthesis. CSF cytology showed predominant lymphocytes with plasma cells. On the third day after onset of the facial palsy (28/8/2003) electroneurography and magnetic stimulation of both facial nerves were performed for the first time. They were stimulated electrically at the stylomastoid fossa and magnetically within its canalicular portion with 30 and 70% of the maximum output of our device (Magstim 200). The contralateral face-associated motor cortex was also stimulated magnetically. The responses were recorded from the nasalis muscle. The right side showed normal results, but at the left side a canalicular hypoexcitability was found. Similar results were obtained at controls on 1/9 and 9/9/2004. After therapy with ceftriaxone the palsy disappeared within 8 weeks. Our observation shows that isolated canalicular hypoexcitabilty of the facial nerve within three days after onset of Bell's palsy does not exclude borreliosis reliably. Serum antibody tests and lumbar puncture can provide more specific information in particular cases.

Significance of coil orientation for motor evoked potentials from nasalis muscle elicited by transcranial magnetic stimulation.

In transcranial magnetic stimulation (TMS) of the motor cortex, the optimal orientation of the coil on the scalp is dependent on the muscle under investigation, but not yet known for facial muscles. Using a figure-of-eight coil, we compared TMS induced motor evoked potentials (MEPs) from eight different coil orientations when recording from ipsi- and contralateral nasalis muscle. The MEPs from nasalis muscle revealed three components: The major ipsi- and contra-lateral middle latency responses of approximately 10 ms onset latency proved entirely dependent on voluntary pre-innervation. They were most easily obtained from a coil orientation with posterior inducing current direction, and in this respect resembled the intrinsic hand rather than the masseter muscles. Early short duration responses of around 6 ms onset latency were best elicited with an antero-lateral current direction and not pre-innervation dependent, and therefore most probably due to stimulation of the nerve roots. Late responses (>18 ms) could inconsistently be elicited with posterior coil orientations in pre-innervated condition. By using the appropriate coil orientation and both conditions relaxed and pre-innervated, cortically evoked MEP responses from nasalis muscle can reliably be separated from peripheral and reflex components and also from cross talk of masseter muscle activation.

Cleft lip and palate surgery.

The surgical procedures addressing the problems with the unilateral cleft lip and palate do all include a technique for lengthening the skin of the lip in the cleft area. This procedure can vary according to the preference of the surgeon. The best known are those according to Millard, Tennison and Skoog. The important part of lip repair is, however, reconstruction the muscles entering the lip. This repair should include a reconstruction of the zygomatic and nasal muscles separated from the lower part of the orbicular muscle of the lip (9) (Fig. 2). In Goteborg we have developed a technique using half of Cupid’s bow as a yardstick. The skin inci-

Relationship between tip nasal muscles and the short upper lip.

Since 1993 the authors have been using a new approach to the treatment of the muscles intimately related with the nasal tip and the upper lip, today known as dynamic rhinoplasty. With the idea of improving the dorsum-tip-labial relationship, the dynamic rhinoplasty technique is based on performing an intraoral zetaplasty at the labial frenum, allowing the access to the local musculature, represented by the depressor septi nasi muscle and its three fascicles. Next, we perform a subperiosteal undermining of the medial bundles, releasing them from the lower nasal spine, followed by the treatment of the intermedial bundles (which substitute the former by the special kind of plication at the median line, according to the primary characteristics of the upper lip). Initially, we used the new method only for the treatment of negroid nose or for cases of exuberant droopy nasal tip. Today, with improvements in the surgical technique, it is possible to operate on almost any kind of nasolabial combination, including mouth-breather patients and even cases with long upper lip and upright nose tip. Thus, the authors have established a semiotic classification, discussing both surgical indication and technique, and also showing the importance of combining several surgical stages (septoplasty, dynamic rhinoplasty, rhinosculpture, and turbinectomy) involved in each group.

The soft triangle revisited.

Five cadaveric adult human noses were examined to further elucidate the region of the soft triangle of the nose. Three distinct zones were found. Zone 1, just caudad to the lower lateral cartilages, consists of the fibers of the dilator nares anterior as it inserts into the dermis. Zone 2 is the dermal layer. Zone 3 is at the nostril rim and consists of muscle fibers interdigitating within the dermis; laterally, these fibers are continuations of the nasalis muscle, whereas medially they are extensions of the depressor septii muscle. Perpendicular incisions through any of these zones may cause notching and tip deformity. Incisions in zone 1 may, in addition, alter external nasal valve function by interrupting the fibers of the dilator naris anterior.

A more effective alar cinch technique

Secondary changes of the nasolabial region after the Le Fort I osteotomy procedure are well known and include widening of the alar base of the nose, upturning of the nasal tip, flattening and thinning of the upper lip, and downturning of the commissures of the mouth. Of these postsurgical changes, widening of the alar base of the nose probably is the most common. Surgical techniques can modify undesirable secondary changes.1,2 To reorient the displaced perinasal musculature and to control alar base width after maxillary osteotomies, many have advocated that an alar-base cinch suture be used in addition to other adjunctive procedures (eg, anterior nasal spine reduction, nasal floor reduction, and V-Y suturing) before incision closure.1-5 The cinch procedure that is commonly recommended involves the use of a slowly absorbed or nonabsorbable suture such as polyglycolic acid to engage the periosteum and nasalis muscles lateral and inferior to each ala of the nose. The suture is then tied down firmly beneath the nasal aperture in the midline approximating the alars and reorienting these structures.3-5 Tension placed on this suture is judged by comparison with presurgical measurements made after nasal intubation. Performing the cinch as described, however, is often difficult and has several pitfalls. First, to perform a proper and symmetric cinch, the surgeon must not only first find the fibroareolar tissue, grasp it with an Adson forceps, and engage it with the suture but must also perform the procedure in exactly the same way for the opposite alar. Otherwise, after placing tension on the suture, the alars will not be pulled symmetrically. In our experience, we have noted that failure to engage either the proper site or equal bulks of tissue on both sides results in unequal traction on the alars, leading to horizontal discrepancies. This will yield asymmetric nostrils. In addition, if the suture needle engages the fibroareolar tissue at higher or lower levels in comparison to each other, tightening the suture will result in one alar base being pulled down lower than the other, leading to vertical discrepancies of the alar bases. We present a modified and more reliable symmetric cinch technique to prevent alar flaring after maxillary surgery.

Repetitive hypoglossal nerve stimulation in myasthenia gravis.

To assess the diagnostic efficacy of repetitive nerve stimulation (RNS) of the hypoglossal nerve in patients with myasthenia gravis (MG) and bulbar symptoms (dysphagia, dysarthria). Twenty patients with MG and 25 normal controls had RNS of the hypoglossal nerve. All patients also had single fibre electromyography (SFEMG) of the orbicularis oculi and RNS with recordings of the nasalis, trapezius and abductor pollicis brevis muscles. All patients had positive SFEMG studies. Nine patients with bulbar symptoms had positive hypoglossal RNS, including 3 with negative RNS recordings in other muscles. Eleven patients with no bulbar symptoms showed negative hypoglossal RNS, including two with positive RNS recordings from other muscles. Abnormal RNS of the hypoglossal nerve correlates well with bulbar dysfunction and further characterises the extent of neuromuscular transmission defect in MG patients.

Nasal Muscle F Waves and EMG of the Facial Muscles

Nasal Muscle F Waves and EMG of the Facial Muscles

Intrinsic nasal muscles and their electromyographic evaluation after external septorhinoplasty

Objectives: Rhinoplastic surgery is performed for the improvement in the appearance of the nose, but it should not cause any detrimental effect on the intrinsic muscles. This study was conducted to evaluate the influence of the external rhinoplasty on intrinsic nasal muscles. Methods: Twenty-one patients were operated on by external septorhinoplasty. Functions of the nasal muscles were assessed by electromyography in response to voluntary nasal movements in patients before and after surgery. Results: Postoperative electromyographic activities of the muscles were significantly less than preoperative measurements for all movements. Conclusion: Influence of the surgical incisions, alterations of the sites of origin and/or insertion of the muscles, and the postoperative healing process can be incriminated for the decreased muscular activity. Nasal muscle function requires a better appreciation and respect for the achievement of the best aesthetic and functional results. The nasal valve reconstructive procedures should be applied routinely to compensate for this inevitable muscular involvement. (Otolaryngol Head Neck Surg 2001;125:332-8.)

Nose muscular dynamics: the tip trigonum.

In 1995, the senior author (E.E.F.) published an article in which he described the musculus digastricus septi nasi labialis. In the article presented here, work carried out by anatomists and other researchers who, over the last two centuries, studied nose muscular dynamics is described. The present study is based on Gray's Anatomy, which, in 1858, first described the nasal tip muscles, along with the other nasal muscles. Later works not only used different terminology for these muscles but also ignored some, creating tremendous confusion. The study presented here provides an update of the exact terms, location, insertions, and muscle functions of the muscles of the nose. Each nose muscle is described with regard to the two portions able to produce separate contractions. In this study, the term "dual function" is used and characterizes the nasal mimetic muscles that do not have well-defined fascia. Therefore, there is doubt about the existence of a real nasal superficial muscle aponeurotic system. The musculus myrtiformis seems to have a dual function, inserting in the canine fosse and in the periosteum of the central incisors, forming two portions-one to the septum and the other to the nostril-each of which has specific functions. This study has been based on research in physiognomy, the science of expression. With regard to the basis for nose expressions, common anatomical research is excluded because it provides a different view of the dynamics studied to date. The term trigonum musculare apicis nasi defines the interaction of the musculi compressor narium minor and dilator naris anterior, connecting with the columellar bundle of the musculus digastricus and levering the nasal spine. This muscular trigone creates circular concentric and eccentric movements of the nasal tip.

A normative study on human facial F waves

F waves from the nasalis muscle were obtained bilaterally after transcutaneous constant-current stimulation of the facial nerve in 37 of 42 (88%) healthy volunteers examined. F waves were of varying shape and latency. Standard parameters (latencies, amplitudes, ratios, chronodispersion) of F-wave analysis were assessed. Of these, minimum and mean F-wave latencies, the F ratio, and F-wave and peripheral conduction times (PCT) were approximately normally distributed, with a low standard deviation. Latencies and conduction times exhibited a significantly positive correlation with body height, as has been demonstrated for the F-wave latencies in limb muscles. Side and sex differences were present but without statistical significance. Chronodispersion and chronodispersion range, F-wave amplitudes, and F-wave frequencies were broadly scattered. It is concluded that F-wave latencies and conduction times are best suited to define a range of reference values. Moreover, facial F waves bear characteristics similar to those described for F waves recorded from limb muscles. © 2001 John Wiley & Sons, Inc. Muscle Nerve 24: 900–904, 2001

A normative study on human facial F waves.

F waves from the nasalis muscle were obtained bilaterally after transcutaneous constant-current stimulation of the facial nerve in 37 of 42 (88%) healthy volunteers examined. F waves were of varying shape and latency. Standard parameters (latencies, amplitudes, ratios, chronodispersion) of F-wave analysis were assessed. Of these, minimum and mean F-wave latencies, the F ratio, and F-wave and peripheral conduction times (PCT) were approximately normally distributed, with a low standard deviation. Latencies and conduction times exhibited a significantly positive correlation with body height, as has been demonstrated for the F-wave latencies in limb muscles. Side and sex differences were present but without statistical significance. Chronodispersion and chronodispersion range, F-wave amplitudes, and F-wave frequencies were broadly scattered. It is concluded that F-wave latencies and conduction times are best suited to define a range of reference values. Moreover, facial F waves bear characteristics similar to those described for F waves recorded from limb muscles.