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Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
17
PAN Arab Journal of Rhinology, Vol. 2, No. 1, March, 2012
The role of oral myofunctional therapy in managing patients with mild to
moderate obstructive sleep apnea
Hemmat Baz,1 Mohsen Elshafey,2 Shawky Elmorsy,3Mohamed Abu-Samra3
1Phoniatrics Unit, 2Thoracic Medicine Department 3ENT Department. Faculty of Medicine, Mansoura University, Egypt
Correspondence to: Shawky Elmorsy, Email: shawky_morsy2003@yahoo.com
Introduction: Oral Myofunctional therapy could be considered as a new therapy for snoring and obstructive sleep apnea
syndrome (OSAS), because of its direct action on oral motility.
Aim of this work: to evaluate the effect of Oral Myofunctional therapy as a simple method for treatment of patients with
mild to moderate Obstructive Sleep Apnea Syndrome (OSAS).
Materials and methods: 30 patients with mild to moderate OSAS were subjected to the following: 1-Thorough history
taking with stress on symptoms of OSAS (snoring, fragmented sleep, witnessed apneas, morning headache and daytime
sleepiness) and calculation of Epworth sleepiness scale. 2-Physical examination with stress on neck circumference, body
mass Index (BMI), and vocal tract examination to exclude space occupying lesions in the nose, mouth and larynx. 3-Full
night polysomonography for objective diagnosis of OSAS 4- All patients were treated by Oral myofunctional therapy. 5-
Full night polysomonography repeated 3 month after the myofunctional therapy.
Results: There was significant decrease of apnea hypopnea index (AHI), arousal index after myofunctional therapy as
compared to before myofunctional therapy (p < 0.001 for all). Also there were significant decrease in desaturation
parameters (desaturation index, average duration SaO2 < 90%, % total sleep time SaO2 < 90%) after myofunctional
therapy (p < 0.001).
Conclusion: myofunctional therapy can achieve subjective improvement in OSAS symptoms, as well as
polysomonographic abnormalities in patients with mild to moderate OSAS and so can be considered as an alternative
method of treatment.
Keywords: Myofunctional therapy, Obstructive Sleep Apnea Syndrome, Snoring.
INTRODUCTION
Obstructive sleep apnea Syndrome (OSAS) is
characterized by recurrent episodes of upper airway
collapse and obstruction during sleep. These episodes of
obstruction are associated with recurrent oxyhemoglobin
desaturations and arousals from sleep.(1) The upper
airway is a compliant tube and, therefore, is subjected to
collapse.(2)
Most patients with obstructive sleep apnea (OSAS)
demonstrate upper air way obstruction at either the level
of the soft palate, or the level of the tongue. Research
indicates that both anatomic factors (e.g., enlarged tonsils;
volume of the tongue, soft tissue, or lateral pharyngeal
walls; length of the soft palate; abnormal positioning of
the maxilla and mandible) and/ or associated
neuromuscular insults are the main etiological factors
predisposing to OSAS.(3,4)
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
18 PAN Arab Journal of Rhinology
Many treatment modalities had been implicated in
managing OSAS including; Continuous positive airway
pressure which is considered the most effective line of
treatment in cases of OSAS patients, mainly those who
present expressive drop of the oxygen saturation (SaO2),
moderate OSAS and severe OSAS.(5)
Intra-oral devices, lingual retainers, and jaw (mandible)
positioners are indicated in OSAS patients from mild to
moderate, and retrognathic OSAS patients who are not
above the ideal weight, and have not severe oxemoglobin
desaturations.(6)
Surgical techniques that vary from otorhinolaryngologic
surgeries (as Laser-assisted uvulopalatoplasty (LAUP), or
Radiofrequency-assisted uvulopalatoplasty (RAUP)), to
maxillary functional orthopedic surgeries present variable
results.(7) The most common procedures reach between
40% and 50% of efficiency and many times more than one
technique must be combined, as one- stage or two- stage
procedure.
Another form of the treatment modalities is the loss of
corporal weight through diet regimen or surgery,
ponderal reductions of 10% of corporal weight may lead
to the reduction of up to 50% of AHI, and with 20% of
corporal weight loss, the patient may become
asymptomatic. However, the long term success rates are
discouraging with the regaining of weight and
reappearance or aggravation of the OSAS.(8)
The treatment modalities aforementioned may act in a
palliative way, since they may not effectively treat the
factor that precipitates the installation of the OSAS, or
they are of difficult acceptance by the patients (high cost,
long term difficult maintenance, etc.). Thus, in the pursuit
of searching for other therapeutic methods, the hypothesis
of the phoniatrics intervention in managing OSAS through
the myofunctional therapy was raised, to bring benefits
for these patients. As in patients with OSAS there was a
significant reduction of the muscular tonus and increase of
the resistance of the upper airway during sleep.(5) It is also
believed that the dilating force of the upper airway
muscles is the only force responsible for counterbalance
the forces which promotes the collapse, represented by the
negative pharyngeal transmural pressure and for the
weight of the structures which form the upper airway,
these facts justify the rehabilitation of the orofacial and
pharyngeal musculature of these individuals.(5)
Aim of the work: The aim of this work was to evaluate the
effect of oral myofunctional therapy as a simple method
for treatment of patients with mild to moderate
obstructive sleep apnea syndrome.
PATIENTS AND METHODS
This prospective study was conducted upon 40 patients
diagnosed as having mild to moderate OSAS. Ten
patients were excluded from the study because they were
reluctant in performing the oral myofunctional therapy
(2008-2011). Approval of ethic committee and informed
consent were obtained. The study excluded patients with
Body mass index > 40, craniofacial malformation, using
hypnotics, hypothyroidism, previous stroke,
neuromuscular disease, heart failure, coronary artery
disease, severe OSAS, physical obstruction in nose or
throat, abnormally large tonsils, uncorrected deviated
septum, drug/alcohol abuse, depression, and previous
treatment for snoring (surgical or non-surgical). All
participants were underwent the following:
1. Thorough history taking with stress on symptoms of
OSAS (snoring, fragmented sleep, witnessed apneas,
morning headache and daytime sleepiness) and
calculation of Epworth sleepiness scale.
2. Physical examination with stress on neck
circumference, body mass index (BMI), vocal tract
examination to exclude space occupying lesions in the
nose and mouth, and dental examination (teeth and
gum).
3. Full night polysomonography (Jaeger sleep screen)
for objective diagnosis of OSAS, performed in a sleep
center in the presence of specially trained technicians.
During polysomnography, multiple body functions
are monitored. Sleep stages are recorded via an
electroencephalogram, electrooculogram, and chin
electromyogram.
Breathing is monitored, including airflow at the nose
and mouth (using both a thermal sensors and a nasal
pressure transducer), effort (using inductance
plethysmography), and oxygen saturation.
The breathing pattern is analyzed for the presence of
apneas and hypopneas,(definitions have been
standardized by the American Academy of Sleep
Medicine (AASM)),this breathing pattern analysis is
repeated later on 3 months after the oral
myofunctional therapy.
4. Oral myofunctional therapy including variety of
training strategies according to Galye Burditt 9 and
Cuimaraes et al. 10 from these strategies we focused
on certain training strategies to the tongue, soft palate,
and the pharynx, aiming at increasing the tone and
endurance of the targeted muscles. The therapy were
given to patients on three months period, twice
sessions weekly in a hierarchal manner, providing to
teach the patients to practice the therapy regularly at
home by a rate of three to five times per day with
minimum 10 minutes for each time.
Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
19
Oral myofunctional therapy can be divided into:
A) Non articualtory oral myofunctional therapy:
1. Tongue stabilization:
- Push tongue tip forward just in front of lips
without touching teeth or lips for about 30 seconds.
- Spread centre of the tongue, so the sides of the
tongue touch bottom of upper teeth for about 30
seconds.
2. Tongue protrusion outside the mouth (tip forward,
tip lift and tip down).
3. Tongue lateralization: push tongue to right/left
corner of the mouth keep it pointed
4. Tongue elevation:
- Place tongue tip as far as possible on the roof of the
mouth.
- Place tongue on the roof of the mouth with tip
against upper front teeth while sucking it against
roof of the mouth.
5. Holding the tongue tip between teeth anteriorly while
trying to swallow
6. Resistive therapy in which tongue press against palate
and against hand resistance applied to the check on
both sides.
7. Palatal elevation with and without yawn (to feel the
soft palatal lift).
B) Articulatory therapy:
1. Production of Lingovelar sounds (produced by
contacting the dorsum of the tongue and the velum)
G, K, separately several times each.
2. Production of Uvular sounds Y, X, and Q (produced
by contraction of the uvula) separately several times
each.
Statistics: Data were analyzed using SPSS (Statistical
Package for Social Sciences) version 10. Qualitative data
was presented as number and percent. Comparison
between groups was done by Chi-square test. Normally
distributed data was presented as mean ± SD. Pearson’s
correlation coefficient was used to test correlation between
variables. P<0.05 was considered to be statistically
significant.
RESULTS
The mean age of the studied cases was 44.07± 7.54 years,
73.3%were males and 26.7% were females, mean BMI was
33.59± 1.98 mean neck circumference was 42.77 ± 1.67 cm
(Table 1). There was significant improvement of OSAS
symptoms (snoring, excessive daytime sleepiness,
morning headache) after oral myofunctional therapy as
compared to before the therapy (p=0.008, 0.003, 0.014
respectively) while there were lower percentages of
nocturnal choking and witnessed apnea after oral
myofunctional therapy as compared to before
myofunctional therapy but without statistical significance
(p=0.083 and 0.083 respectively) (Table 2). There were
significant decrease in neck circumference and ESS after
oral myofunctional therapy as compared to before the
therapy (p < 0.001 for both) while there were no
significant change in BMI (p=0.232)
(Table 3). There were significant decrease of AHI, arousal
index and % total sleep time in snoring after
myofunctional therapy as compared to before
myofunctional therapy
(p<0.001 for all). Also there were significant
decrease in desaturation parameters (desaturation index,
average duration SaO2 < 90%, % total sleep time
SaO2 < 90%,) after myofunctional therapy as compared to
before myofunctional therapy (p< 0.001 for all), while
there was significant increase in minimum SaO2 %
(p=0.006) after myofunctional therapy as compared to
before myofunctional therapy (Table 4). There were
significant positive correlation between changes
of AHI and changes of neck circumference (r=0.561
p<0.001) while no significant correlation between
changes of AHI and changes of BMI (r = 0.418 p=0.121)
during the period of the oral myofunctional therapy
(Table 5).
Table 1. Demographic data of the studied cases.
Mean ± SD
Age ( years)
BMI (kg/m2)
Neck circumference(cm)
Sex [No (%)]
Male
Female
44.07 ± 7.54
33.59 ± 1.98
42.77 ± 1.67
22 (73.3%
8 (26.7%)
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
20 PAN Arab Journal of Rhinology
Table 2. Symptoms of studied cases with OSA before and after upper airway exercises.
Symptoms Before upper airway exercises After upper airway exercises P value
No % No %
Snoring 30 100 16 53.3 0.008
Excessive day time sleepiness 30 100 12 40 0.003
Morning headache 18 60 6 20 0.014
Nocturnal choking 12 40 6 20 0.083
Witnessed apnea 10 33.3 4 13.3 0.083
Table 3. Anthropometric variables and ESS before and after upper airway exercises.
Before upper airway
exercises Mean ± SD After upper airway
exercises Mean ± SD P value
Neck circumference(cm) 42.77 ± 1.67 42.01 ± 1.96 < 0.001
BMI(kg/m2) 33.59 ± 1.98 33.50 ± 2.04 0.232
ESS 16.40 ± 1.96 9.27 ± 2.89 < 0.001
Table 4. Polysomnographic variables before and after upper airway exercises.
Before upper airway
exercises Mean ± SD After upper airway
exercises Mean ± SD P value
AHI 22.27 ± 4.51 11.53 ± 5.38 < 0.001
Desaturation index 14.53 ± 5.04 9.27 ± 4.27 < 0.001
Average duration SaO2 < 90% 18.27 ± 6.79 9.40 ± 3.29 < 0.001
% total sleep time SaO2 < 90% 2.01 ± 1.22 1.09 ± 0.72 < 0.001
Minimum Sao2% 84 ± 4 87 ± 5 = 0.006
Arousal index 28.87 ± 8.41 15.33 ± 6.11 < 0.001
% total sleep time snoring 14.05 ± 4.89 3.87 ± 4.12 < 0.001
Table 5. Correlation of changes of AHI with changes of neck circumference and BMI.
Changes in AHI
R P
Changes in neck circumference (cm) 0.561 < 0.001
Changes in BMI(kg/m2) 0.418 =0.121
Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
21
DISCUSSION
Maintenance of pharyngeal patency during breathing
requires the coordinated activity of pharyngeal and
thoracic respiratory muscles. During inspiration,
subatmospheric pressures are produced in the upper
airway as a result of inspiratory muscle contraction. The
tendency for the pharyngeal lumen to collapse is opposed
by the activation and contraction of the upper airway
muscles including dilators, such as the sternohyoid and
the omohyoid, and pharyngeal lumen regulators, such as
the geniglossus and digastric muscles.(11) Genesis of OSAS
is multifactorial and includes anatomical and
physiological factors. Upper airway dilator muscles are
crucial to the maintenance of pharyngeal patency and may
contribute to the genesis of OSAS.(12) the aim of this work
was to evaluate the effect of myofunctional therapy as a
simple method for treatment of patients with mild to
moderate obstructive sleep apnea syndrome. Out of 40
cases, 30 cases with mild to moderate OSAS were eligible
for the study and completed the course of oral
myofunctional therapy
(3 months). The symptoms of OSAS (snoring excessive
daytime sleepiness and morning headache) showed
significant decrease after myofunctional therapy as
compared to before myofunctional therapy (p=0.008,
0.003, and 0.014 respectively) also the significant decrease
in % total sleep time of snoring (p<0.001) and in Epworth
sleepiness scale (p<0.001) confirmed the subjective
significant improvement in snoring and excessive daytime
sleepiness. These were in accordance to Cuimaraes et al.(10)
who reported significant improvement in snoring
frequency and intensity (by using visual analogue scale)
and in excessive daytime sleepiness (by Epworth
sleepiness scale) p=0.001, 0.001 and 0.006 respectively after
use of myofunctional therapy for 3 months. Also this was
in accordance to Puhan et al.(13) who reported
improvement in snoring and daytime sleepiness after 4
months training of upper airway muscles by didgeridoo
playing (a wooden wind instrument that is may be from
3-10 feet in length which is common among the
indigenous people of northern Australia). Ojay and
Ernest(14) by using singing therapy reported some
improvement in the mean value of recorded snoring per
hour slept (pretreatment 6.1 ± 1.8 minutes versus post
treatment 5.1± 2.6 minutes, mean reduction 17.6%) post
therapy (p=0.04). This can be explained by the existence of
elongated and floppy soft palate and uvula, enlarged
tongue and inferior displacement of hyoid bone in
OSAS.(15) Specific therapy were developed targeting
tongue repositioning. The facial muscles are also recruited
during chewing and were also trained with intention of
training muscles that promote mandibular elevation,
avoid mouth opening and so may affect the propensity to
myofunctional edema and collapsibility.(16) There was
significant decrease in neck circumference after oral
myofunctional therapy in comparison to before
myofunctional therapy (p<0.001) and this decrease
correlate positively with the decrease in AHI (p=0.029)
while BMI does not change significantly after
myofunctional therapy (p=0.232) and did not correlate
significantly with changes in AHI (p=0.121). This was in
accordance to Cuimaraes et al. 10 who reported significant
decrease in neck circumference (p = 0.01) but no
significant change in BMI (p=0.65) after myofunctional
therapy. This illustrate that the changes in neck
circumference cannot be attributed to changes in BMI
during this period of therapy as there were no significant
changes in BMI and so these changes in neck
circumference can be attributed to myofunctional
remodeling. Carrera et al.(17) reported that snoring and
OSAS patients have a prevalence of type 11 muscle fiber,
probably because of inflammatory trauma promoted by
vibration, affecting and decreasing the myofunction of
upper airway. Blottner et al.(18) reported that
improvement of muscle tone by physical training was
associated with increase in the proportion of type I muscle
fibers and in the size of type 11 muscle fibers as
demonstrated by muscle biopsy (type 1 having endurance
and type 11 having speed capability). Methods to increase
muscle tone of the upper airway are based on gain of
endurance and strength properties. So increase in type 1
muscle fibers by therapy resulting in improvement in
OSAS manifestation. There was significant decrease in
AHI and arousal index after myofunctional therapy
(p<0.001 for both). This was in accordance to Cuimaraes et
al.(10) who reported significant decrease in apnea index
and hypopnea index (p=0.004, 0.007 respectively). The
decrease in AHI in our study was from 22.27 to 12.93
events/ hour which represent 41.9% decrease while in
study of Cuimaraes et al.(10) it was from 22.4 to 13.7
events/ hour which represent 39.3% decrease.this
decrease in AHI approach what reported by review about
mandibular advancement by Hoffstein19 which was 42%.
Pitta et al.(5) reported improvement in two patients with
severe OSAS by application of oral myofunctional therapy
for a period of 16 week (a decrease in AHI, ESS, snoring
and an improvement in oxygen desaturation). So this
gives the potential use of this treatment in patients with
severe OSAS especially if CPAP cannot be tolerated by the
patients. Puhan et al.(13) reported marginal improvement
in AHI (p=0.05) by using didgeridoo playing for 4
months. This marginal improvement can be explained by
the non-specific myofunctional therapy applied by
didgeridoo playing in comparison to specified oral
myofunctional therapy applied in our study and study of
Cuimaraes et al.(10) (myofunctional therapy, tongue
therapy and pronounced voice for soft palate). Four cases
showed normalization of AHI (AHI <5 events/hour) after
oral myofunctional therapy and 14 cases showed >50%
decrease in AHI but without normalization of AHI while
12 cases showed less than 50 % decrease in AHI. The BMI
of cases that showed response (>50% decrease in AHI)
ranged from 30-32 while of those that showed no response
(<50% decrease in AHI) ranged from 35-36.7. This
illustrate that patients selection is critical for potential
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
22 PAN Arab Journal of Rhinology
benefits from therapy (those with low BMI) because
obstruction is caused not only by weak and collapsing
muscles but also by bulk formed by deposits around the
tongue and throat in obese patients The desaturation
index, average duration SaO2 <90%, % total sleep time
SaO2 <90% were significantly decreased after
myofunctional therapy (p<0.001 for all) while the
minimum SaO2 < 90% was significantly increased (from
84 ± 4 to 87± 5, p=0.006). This was in accordance to
Cuimaraes et al.(10) who reported significant increase in
minimum SaO2 from 83 ± 6 to 85 ± 7% (p<0.001). This
illustrates that only slight improvement occurred in SaO2
(about 3%) and so this method can be applied to cases of
OSAS with slight decrease in SaO2. The limitation of this
study is the application on small number of cases together
with the dependence of the results on the compliance of
the patients on regular application of the therapy. Another
limitation was absence of standardization of the
maneuvers and duration of the therapy that can achieve
maximum effect. It is not clear how long the therapeutic
effects in the responders persist and whether a longer
duration of training beyond 3 months or repetition of
training after an interval might be beneficial.
CONCLUSION
- Oral myofunctional therapy can achieve subjective
and objective improvement in OSAS symptoms and
their polysomonographic abnormalities in patients
with mild to moderate OSAS.
- Oral myofunctional therapy can be considered as
alternative method of treatment of mild to moderate
OSAS.
- Future studies will be needed to determine optimal
treatment elements (i.e., load/intensity, frequency,
and duration) and to confirm the hypothesized need
for ongoing practice to maintain beneficial treatment
effects.
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