Anda di halaman 1dari 8

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/265861932

Mechanics of Circular Breathing in Wind Musicians Using Cine Magnetic


Resonance Imaging Techniques

Article  in  The Laryngoscope · February 2015


DOI: 10.1002/lary.24928 · Source: PubMed

CITATIONS READS

0 63

4 authors, including:

Clifford Douglas Phillips Jonathan Dyke


Weill Cornell Medical College Weill Cornell Medical College
130 PUBLICATIONS   3,969 CITATIONS    145 PUBLICATIONS   3,384 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Measurement of Bone Perfusion View project

MRI and Spectroscopy in Essential Tremor View project

All content following this page was uploaded by Jonathan Dyke on 10 July 2018.

The user has requested enhancement of the downloaded file.


The Laryngoscope
C 2014 The American Laryngological,
V
Rhinological and Otological Society, Inc.

Mechanics of Circular Breathing in Wind Musicians Using Cine


Magnetic Resonance Imaging Techniques

Tiffany Peng, MD; C. Douglas Phillips, MD; Jonathan P. Dyke, PhD; Michael G. Stewart, MD, MPH

Objectives/Hypothesis: To investigate the mechanics of circular breathing using cine magnetic resonance imaging
(cMRI).
Study Design: Pilot study.
Methods: Eight musicians were asked to sustain a note by circular breathing while being studied inside a Siemens Trio
3T magnetic resonance imaging scanner. Subjects were imaged in the midsagittal plane using an innovative T1-weighted
cMRI. Our study population included six professionals and two experienced amateurs (two saxophonists, two trombonists,
and four trumpeters). Five predetermined oropharyngeal distances were measured frame by frame. Data were analyzed for
displacement and percentage change over time. Oral airway area was measured using automated bounding box techniques.
Results: All subjects were observed to complete the same series of steps characterized by 1) superior/posterior tongue
displacement, 2) inferior/anterior soft palate displacement, 3) anterior tongue/soft palate displacement, 4) superior/posterior
soft palate displacement, and 5) return of the tongue to baseline. Posterior oropharyngeal occlusion was demonstrated in
bounding box data. Relative occlusion time was significantly longer among experienced amateurs than professionals (P 5.01),
with a similar trend in absolute occlusion time (P 5.08). A trend toward a longer circular breathing cycle time was observed
among saxophonists and trumpeters (P 5.2), although the difference among trumpeters disappeared when amateurs were
excluded.
Conclusions: Circular breathing has been investigated as therapy for obstructive sleep apnea. This study defines the
mechanics of circular breathing for use in training—and potentially in therapy—if proven useful. We demonstrated similar
mechanics across subgroups, and increased efficiency among professionals. Our findings demonstrate the feasibility and reli-
ability of cMRI in the dynamic assessment of oropharyngeal motion.
Key Words: Circular breathing, cine magnetic resonance imaging, cine magnetic resonance, obstructive sleep apnea.
Level of Evidence: NA
Laryngoscope, 00:000–000, 2014

INTRODUCTION they are circular breathing, which allows them to play


Circular breathing is a musical performance tech- their instrument through the mouth continuously while
nique in which wind instrumentalists play a seemingly occasionally breathing in through their nose to simulta-
impossibly long note or note progression without taking neously refill the lungs. This is accomplished by expel-
a breath. This is not because they have increased lung ling air via cheek compression in the anterior
capacity and are playing from a single breath. Rather, oropharynx during nasal inhalation.1
Circular breathing is employed when playing an
obscure instrument called the didgeridoo. There is some
Additional Supporting Information may be found in the online evidence that didgeridoo practice may be therapeutic in
version of this article.
From the Department of Otolaryngology–Head and Neck Surgery
obstructive sleep apnea (OSA).2,3 Puhan et al. demon-
(T.P., M.G.S.), and the Department of Radiology (C.D.P., J.P.D.), Weill Cornell strated in a cohort of 25 adult patients with moderate
Medical College, New York, New York, U.S.A. OSA that 3 months of didgeridoo practice led to signifi-
Editor’s Note: This Manuscript was accepted for publication cant improvements in daytime sleepiness, apnea-
August 20, 2014.
Presented at the 47th Annual Meeting of the American Society of
hypopnea index scores, and partner-reported sleep dis-
Head and Neck Radiology, Milwaukee, Wisconsin, U.S.A., September 29, turbance.2 Although studies have investigated didgeri-
2013. doo practice in medical therapy, and one study
Funding for this study was provided by the Music and Medicine
Initiative of Weill Cornell Medical College and the Departments of visualized glottic activity during didgeridoo performance
Radiology and Otolaryngology of NewYork–Presbyterian Hospital/Weill using transnasal endoscopy, no evidence exists directly
Cornell Medical Center. characterizing the oropharyngeal mechanics of circular
The authors have no funding, financial relationships, or conflicts
of interest to disclose. breathing.4,5 Consequently, there are no data in the lit-
Send correspondence to Michael G. Stewart, MD, Professor and erature to demonstrate exactly how circular breathing is
Chairman, Otolaryngology Medical Director, Center for the Performing
Artist, Vice Dean, Weill Cornell Medical College Department of Otolar-
accomplished, whether different circular breathers uti-
yngology–Head and Neck Surgery, NewYork–Presbyterian Hospital/Weill lize the same techniques, the impact of different instru-
Cornell Medical Center, 1305 York Avenue, 5th Floor, New York, NY ments on the technique, and whether amateurs perform
10021. E-mail: mgs2002@med.cornell.edu
this technique similarly to trained professionals. To
DOI: 10.1002/lary.24928 assess circular breathing as therapy and begin to

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
1
TABLE I. pushing against the back pressure, or resistance, of the instru-
Demographics of Study Participants. ment, native instrument resistance may impact the oropharyn-
geal dynamics of circular breathing and overall task efficiency.
Professional Age, Years of Hours Playing Exclusion criteria included age <18 years, contraindication
Subject Status Instrument yr Experience per Week
to MRI, significant imaging artifact, and inability to sustain a
note while circular breathing in a supine position. All subjects
1 Professional Trumpet 26 14 35
were consented per IRB regulations prior to participation.
2 Professional Trumpet 48 38 30
3 Professional Trumpet 60 48 46
4 Professional Trombone 25 15 46 Imaging Technique and Study Protocol
5 Professional Saxophone 25 14 27 Subjects were studied in a 12-channel head coil in a Sie-
mens Trio 3T (Siemens Healthcare, Erlangen, Germany) MRI
6 Professional Saxophone 31 21 33
scanner, and imaged in the midsagittal plane using a fast radial
7 Amateur Trumpet 25 15 1 k-space sampled, T1-weighted gradient echo cMRI technique
8 Amateur Trombone 21 11 11 (LiveView; Siemens Healthcare).10 The sequence acquired a sin-
gle 8-mm slice with a 25.6-cm field of view and a 128 3 128
matrix, yielding an in-plane voxel size of 2.0 3 2.0 mm. A flip
understand the physiologic basis for any incurred benefit angle of 5 was used, with repetition and echo times of 2.1 ms
from its practice, further knowledge of circular breath- and 1.3 ms, respectively, producing a frame speed of 19 fps.
ing is required. Subjects were supplied with MRI-compatible instrument
Cine magnetic resonance imaging (cMRI) is a tech- equipment. Trumpet players were given a Kelly plastic trumpet
mouthpiece, size 1-1/2C, and trombonists were given a Kelly
nique that has been used for the assessment of cardiac
small-shank plastic trombone mouthpiece, size 51D. Saxophon-
and bowel motility.6–8 It has also been utilized in the study
ists were permitted to use their own plastic mouthpieces. Metal
of upper airway dynamics of the M€ uller maneuver in ligatures (part of the mouthpiece securing the reed to the plas-
healthy subjects.9 This imaging modality allows for real- tic body of the mouthpiece) were replaced with modified Velcro
time analysis and high-quality visualization of oropharyn- ligatures. Saxophonists provided their own reeds. No image dis-
geal structures. Using an innovative, fast, temporally tortion was evident as a result of this equipment. Mouthpieces
resolved T1-weighted cMRI sequence, we sought to explore were cleaned with Roche-Thomas Mi-T mouthpiece cleaner
the feasibility of cMRI for the assessment of oropharyngeal (Roche-Thomas Corp., Dubuque, IA) and alcohol swabs.
motion, and then, if feasible, to utilize this technology to Once inside the MRI scanner, subjects were instructed to
characterize the mechanics of circular breathing in profes- breathe quietly through the mouth and imaged with cMRI for 5
sional and experienced amateur wind musicians. seconds to assess baseline dimensions. Oral breathing was
selected as a baseline state, because the action of circular
breathing consists of sustained oral exhalation with superim-
MATERIALS AND METHODS posed nasal inhalation. After completion of quiet breathing, sub-
jects were asked to sustain a note by circular breathing on their
Subject Recruitment mouthpiece while modeling the usual technique utilized to per-
After obtaining institutional review (IRB) board approval, form their tuning note. Emphasis was placed on modeling their
eight volunteer subjects were recruited from the New York/New usual technique, because sustaining the actual pitch of their
Jersey area, primarily through The Juilliard School. Our study tuning note on the mouthpiece alone would not reflect their
population included six professionals and two experienced ama- true playing technique on the complete instrument. Subjects
teurs (two saxophonists, two trombonists, and four trumpeters) were observed to complete a minimum of two complete cycles of
(Table I). The mean age of participants was 32.6 years (range, circular breathing before terminating the study, a task achieved
21–60 years). All participants were male. Professionals played by all subjects on the first attempt. The first two consecutive
their instruments for an average of 25 years (range, 14–48 cycles of circular breathing were analyzed.
years) and reported playing their instrument for an average of
36 hours per week (range, 27–46 hours) over the preceding 6
months. Experienced amateurs, referred to as “amateurs” in the Measurements and Data Analysis
remainder of this article, played their instruments for an aver- Five predetermined oropharyngeal distances were meas-
age of 13 years (range, 11–15 years) and reported playing their ured frame by frame across two complete cycles of circular
instrument for an average of 6 hours per week (range, 1–11 breathing per subject: 1) lip to tongue distance (the anteroposte-
hours) over the preceding six months. rior distance from the posterior border of the lip aperture to the
Professionals were defined as full-time musicians whose anterior tip of the tongue), 2) midtongue to palatal height (the
sole source of income was instrument performance. Amateurs vertical distance from the midpoint of the superior border of
were defined as those who do not receive payment for instru- tongue to the inferior border of the hard palate), 3) uvula tip to
ment performance. Musicians receiving part-time or occasional tongue distance (the distance from the inferior tip of the soft
pay were excluded from the study. Trumpeters, trombonists, palate to the posterior border of the tongue), 4) base of tongue
and saxophonists were studied because circular breathing is to first vertebra distance (the anteroposterior distance from the
commonly employed among these musicians, and because it base of tongue to the superior border of the first vertebra),
would be feasible for subjects to play these instrument mouth- and 5) roof of nasopharynx to soft palate height (the vertical
pieces while inside the magnetic resonance imaging (MRI) scan- distance from the midpoint of the roof of the nasopharynx to
ner and head coil. The selected instruments allow for the soft palate) (Fig. 1). Measurements were recorded for two
comparison of brass versus reed instruments, and differences in consecutive cycles, yielding two complete datasets per subject.
native instrument resistance, including high resistance (trum- Because circular breathing cycle time varied between subjects,
pet), intermediate resistance (trombone), and low resistance averages were calculated by normalizing the time as a percent-
(saxophone). Because circular breathers partially rely on age of trial completed.

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
2
Fig. 1. Five predetermined oropharyngeal distances. Measurements were conducted frame by frame across two complete cycles of circular
breathing for each subject. (A) Lip to tongue distance. (B) Midtongue to palatal height. (C) Uvula tip to tongue distance. (D) Base of tongue
to first vertebra distance. (E) Roof of nasopharynx to soft palate height.

The volume of the oral airway was measured using a semi- 5) return of the tongue to baseline (Fig. 2) (see Support-
automated bounding box technique written with IDL 8.1 (Excelis ing Video 1 in the online version of this article). These
Visual, Boulder, CO). A rectangular box was defined, including steps were clearly noted on imaging and by graphical
the entire tongue and oral cavity. Airway volume was calculated representation of oropharyngeal measurements over
using a region-growing algorithm to include all neighboring vox-
time (Fig. 3). Occlusion of the posterior oropharynx from
els within a specific intensity range. This threshold was defined
the anterior oral cavity was achieved during step 2,
for each subject as the mean 6 three standard deviations of a 5
3 5-voxel kernel placed just posterior to the lips. Neighboring when the soft palate swings inferiorly and anteriorly to
voxels were smoothed, dilated, and eroded to produce a contigu- meet the posterior tongue, creating a seal.
ous mask of the airway at each point in the cine loop. The total Relative occlusion time was significantly longer
number of voxels per frame was multiplied by 4.0E-3 cc/voxel to among amateurs than professionals (P 5.01). A similar
produce a measurement of the volume. trend was noted in absolute occlusion time (P 5.08), sug-
Data were analyzed for displacement and percentage gesting that experienced amateurs required more time to
change from baseline with ImageJ (National Institutes of Health, complete adequate nasal inhalation (Table II). A trend
Bethesda, MD), and assessed for changes in spatial relationships toward longer cycle time was observed among saxophonists
over time. Circular breathing cycle time (time required to com- and trumpeters (P 5.2), although the difference among
plete one five-step cycle of circular breathing, or “cycle time”)
trumpeters disappeared when amateurs were excluded.
and posterior oropharyngeal occlusion time (duration in which
There was no difference in occlusion time among instru-
the posterior oropharynx was fully occluded from the anterior
oropharynx, or “occlusion time”) were recorded for each subject. ment subgroups (Table III). Mean, range, and standard
Cycle time was measured to gauge each subject’s overall task deviations for each oropharyngeal distance are reported
efficiency. Posterior oropharyngeal occlusion was regarded as (Table IV).
critical to circular breathing technique for nasal inhalation and Bounding box data could not be acquired in one ama-
for generation of intraoral pressures high enough to sustain a teur subject due to signal dropout, but we have nonethe-
continuous tone. Occlusion time was measured to gauge each less reported our data in professionals to demonstrate the
subject’s efficiency in nasal inhalation. Because occlusion time measurement technique (Fig. 4). Measurements of airway
may be confounded by total cycle time for each subject, compari-
sons were made with both absolute values (“absolute occlusion
time”) and relative values (“relative occlusion time”). Relative
occlusion time reports the absolute occlusion time as a percent-
age of the subject’s total cycle time, thus accounting for differen-
ces in total time required to complete the task.
Comparisons were made between amateurs and professio-
nals, and between instrument types. In light of the small sam-
ple size of this study, analysis of statistical significance was
conducted using the nonparametric Mann-Whitney U test. Sta-
tistical significance was set at a P value < .05.

RESULTS
All subjects successfully accomplished circular
breathing using their mouthpiece while in the MRI scan-
ner. We were able to obtain clear, interpretable images—
both dynamic and static—of the oral cavity mechanics
during circular breathing. Fig. 2. Graphical representation of a single professional trumpet
All subjects were observed to complete the same player during one complete cycle of circular breathing. Five oro-
series of steps characterized by 1) superior/posterior pharyngeal distances shown here as a percentage of baseline val-
ues over time. Similar findings were elicited from all subjects. (A)
tongue displacement, 2) inferior/anterior soft palate dis- Lip to tongue distance. (B) Midtongue to palatal height. (C) Uvula
placement, 3) anterior tongue and soft palate displace- tip to tongue distance. (D) Base of tongue to first vertebra dis-
ment, 4) superior/posterior soft palate displacement, and tance. (E) Roof of nasopharynx to soft palate height.

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
3
Fig. 3. Still-frame radiographs (A) and graphical representation (B) of a single professional trumpet player during circular breathing. Each of
the five steps are shown: step 1, superior/posterior tongue displacement; step 2, inferior/anterior soft palate displacement; step 3, anterior
tongue and soft palate displacement; step 4, superior/posterior soft palate displacement; step 5, return of the tongue to baseline. A 5 lip to
tongue distance; B 5 midtongue to palatal height; C 5 uvula tip to tongue distance; D 5 base of tongue to first vertebra distance; E 5 roof
of nasopharynx to soft palate height.

volume showed a reduction in the airway of 55.4% 6 10.9% Numerous breathing exercises have been explored in the
for professional musicians (n 5 6). literature, including yoga breathing techniques, wind
instrument performance, and circular breathing via
didgeridoo performance.2–4,11–15
DISCUSSION Our findings delineate a uniform mechanism for cir-
Breathing exercises have been investigated for clini- cular breathing among participants playing different
cal utility in disease, including OSA and asthma. instruments and with different degrees of playing

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
4
TABLE II.
Results Comparison of Circular Breathing Cycle Time and Posterior Oropharynx Occlusion
Time (Absolute and Relative) by Professional Status.
Professionals, Mean (SD), Range, s Amateurs, Mean (SD), Range, s P

Circular breathing cycle time 1.18 (0.421), 0.630–1.83 2.18 (1.6), 1.2–3.6 .5
Absolute occlusion time 0.480 (0.232), 0.210–0.780 1.5 (1.3), 0.470–2.7 .08
Relative occlusion time 42% (15%), 20%–75% 67% (9%), 56%–75% .01

Relative posterior oropharyngeal occlusion time (relative occlusion time) compares posterior oropharyngeal occlusion time for each subject as a percent-
age of his respective circular breathing cycle time for the same trial.
SD 5 standard deviation.

experience. This anatomical information may aid future oral cavity (from external cheek compression) may also
investigations in identifying specific populations of exert force posteriorly. Thus, the action of the palatoglos-
patients who may benefit from the intervention, and sus muscle likely plays an important role in opposing
assist in generating theories for other potential applica- these forces, causing both the downward and forward
tions of the therapy, if proven useful. In this study, expe- motion of the velum and the elevation of the posterior
rienced amateurs and professionals performed the task tongue. Further studies are required to determine
similarly. Our results suggest that experienced ama- whether the palatoglossus is a “trainable” muscle.
teurs, and potentially nonmusicians, have the ability to
acquire this skill in a manner that is mechanistically
comparable to professionals. Professionals performed the Learnability of Circular Breathing
task in less time than experienced amateurs, suggesting The learnability of circular breathing in
that their movements were more efficient. instrument-na€ıve users remains unknown; a learnability
assessment in this population is needed to delineate the
clinical feasibility and cost-effectiveness of teaching this
Anatomy and Physiology of Circular Breathing skill as therapy. Furthermore, the instrument utilized
Our results demonstrate that circular breathing pri- may impact learnability and efficacy. Ward et al. demon-
marily involves the posterior tongue and the velophar- strated in a nationwide survey study that rates of OSA
ynx. Because circular breathing consists of nasal were lower in double reed instrumentalists, but not in
inhalation superimposed on sustained oral exhalation, wind instrumentalists, compared to the general popula-
the most critical movements appear to involve the com- tion.17 Although our findings suggest that native instru-
ponent of nasal inhalation. Previous research on the ment resistance does not alter the oropharyngeal
velopharyngeal system states that the movement of dynamics of the technique, there may be differences in
these muscles in humans relies largely on changes in therapeutic efficacy depending upon the instrument
airflow and air pressure,16 raising questions about which used. Evaluation with different instruments would be
muscles, if any, are specifically strengthened by circular valuable in the study of circular breathing as therapy.
breathing. Current literature also suggests that humans
have limited voluntary control of velopharyngeal move-
ments, and that kinesthesia and proprioception in the Circular Breathing and OSA
velar anatomy is minimal.16 Puhan et al. postulated that the perceived benefit of
The pharyngeal constrictors may play a role in modi- circular breathing during didgeridoo performance in OSA
fying airway diameter (and thus airflow and air pressure) was related to strengthening of upper airway muscula-
through the oropharynx. However, these changes may be ture.2 Decreased pharyngeal tone has been reported as a
insufficient to explain circular breathing. In contrast with potential contributor to the pathophysiology of OSA.18,19
the observed anterior/inferior movement of the velum, Although the role of circular breathing in the treatment
increased airflow in the posterior oropharynx during of OSA must be further elucidated, our findings demon-
nasal inhalation would draw the velum posteriorly via strate utilization of velopharyngeal structures in a way
Bernoulli’s principle. Increased pressure in the anterior that may strengthen the involved muscles.

TABLE III.
Results Comparison of Circular Breathing Cycle Time and Posterior Oropharynx Occlusion
Time (Absolute and Relative) by Instrument Type.
Trumpets, Mean (SD), Range, s Trombones, Mean (SD), Range, s Saxophones, Mean (SD), Range, s

Circular breathing cycle time 1.65 (1.3), 0.630–3.6 0.880 (0.137), 0.680–1.05 1.52 (0.237), 1.3–1.8
Absolute occlusion time 0.980 (1.1), 0.210–2.7 0.520 (0.184), 0.370–0.780 0.510 (0.258), 0.260–0.730
Relative occlusion time 50% (16%), 31%–75% 56% (15%), 39%–75% 34% (17%), 20%–54%

Relative posterior oropharyngeal occlusion time (relative occlusion time) compares posterior oropharyngeal occlusion time for each subject as a percent-
age of his respective circular breathing cycle time for the same trial.
SD 5 standard deviation.

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
5
TABLE IV.
Mean, Standard Deviation, and Range of All Measured Oropharyngeal Distances in All Subjects.
Lip to Tongue Midtongue-Palatal Uvula Tip to Tongue Base of Tongue Roof of Nasopharynx to
Performer Distance, Height, Mean (SD), Distance, to First Vertebra Distance, Soft Palate Height,
Subject Type Mean (SD), Range Range Mean (SD), Range Mean (SD), Range Mean (SD), Range

1 Professional, 1.0 (0.21), 0.50–1.5 0.80 (0.28), 0.03–1 1.1 (0.75), 0–3.7 1.3 (0.33), 0.82–3.3 1.0 (0.61), 0.95–2.8
trumpet
2 Professional, 0.77 (0.22), 0.41–1.4 1.0 (0.27), 0.25–1.3 0.89 (0.32), 0–1.1 1.2 (0.33), 1.0–1.8 1.0 (0.24), 0.96–1.8
trumpet
3 Professional, 0.70 (0.33), 0.38–1 0.53 (0.33), 0.03–1 0.81 (0.23), 0–1 1.1 (0.26), 0.78–2.0 0.96 (0.27), 0.95–1.6
trumpet
4 Professional, 0.91 (0.21), 0.36–1.1 0.91 (0.29), 0.02–1 1.3 (0.48), 0–1.8 1.1 (0.53), 0.8–2.8 1.0 (0.44),0.85–2.5
trombone
5 Professional, 0.97 (0.40), 0.76–2.3 0.93 (0.50), 0.03–1.2 1.0 (0.43), 0–1.2 0.92 (0.28), 0.12–1.1 0.96 (0.80), 0.92–3.5
saxophone
6 Professional, 1.08 (0.33), 0.86–2.2 0.81 (0.30), 0.11–1 0.91 (0.34), 0–1.0 1.0 (0.13), 0.66–1.2 0.99 (0.62), 0.88–2.6
saxophone
7 Amateur, 0.99 (0.24), 0.61–1.4 0.98 (0.39), 0.12–1.2 1.0 (0.43), 0–1.5 1.1 (0.81), 0.50–2.7 0.99 (0.97), 0.94–3.3
trumpet
8 Amateur, 1.0 (0.21), 0.53–1.4 0.99 (0.39), 0.02–1.1 1.6 (0.92), 0–3.3 1.5 (2.1), 0.75–7.8 0.99 (0.54), 0.93–2.7
trombone

All values are reported as ratios of baseline. Because the circular breathing cycle time varied significantly between subjects, average values were calcu-
lated by normalizing the time as a percentage of trial completed. Subject numbers correlate with the demographics listed in Table I.

Exercises derived from speech therapy by Guimaraes Further investigation is required to compare circular
et al. were effective in reducing symptoms, such as snor- breathing to other techniques, such as the Guimaraes
ing and daytime sleepiness, among adult patients with exercises and typical wind instrument performance.22
moderate OSA.20 These exercises were designed for soft The possibility that circular breathing may specifically
palate elevation and tongue repositioning, with specific and reliably strengthen the upper pharyngeal muscula-
targeting of upper airway musculature, including the ten- ture is supported by our observations in this study,
sor and levator veli palatini, palatopharyngeus, and the including the observed soft palate movement against pre-
palatoglossus. Previous studies have demonstrated that 8 sumably higher pressures in the oral cavity anteriorly
weeks of twice-daily 20-minute tongue muscle training during performance, the ability of experienced amateurs
did not reduce apnea-hypopnea index scores despite a and professionals to apply similar mechanics during the
reduction in snoring.21 Our results suggest that strength- exercise, and the repetitive nature of the exercise.
ening in circular breathing may be related to velophar-
yngeal movement against resistance. Because circular
breathing utilizes both the velopharynx and tongue, how- Clinical Applications for cMRI
ever, it is not clear if one or both of these elements would cMRI has numerous applications for the dynamic
be responsible for therapeutic benefit. oral cavity, including evaluation of speech pathology,

Fig. 4. Graphical representation of


airway volume during three cycles of
circular breathing in a single profes-
sional saxophonist. This clearly dem-
onstrates three episodes of greatly
decreased airway volume coinciding
with occlusion of the posterior oro-
pharynx. [Color figure can be viewed
in the online issue, which is available
at www.laryngoscope.com.]

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
6
dysphagia, and obstructive sleep apnea.23,24 We demon- Hospital/Weill Cornell Medical Center for their generous
strated one method by which real-time analysis of oro- contributions in funding this investigation. In addition,
pharyngeal motion could be objectively and reproducibly the authors would like to acknowledge the Departments of
conducted to ascertain a greater anatomical understand- Otolaryngology and Radiology of NewYork-Presbyterian
ing of a potential therapeutic intervention. The appropri- Hospital/Weill Cornell Medical Center, the Citigroup Bio-
ate measurements and analysis will likely vary medical Imaging Center, The Juilliard School, Dr. David
considerably based upon the reason for investigation. Shapiro, and Dr. Gary S. Dorfman for their professional
Nonetheless, cMRI may prove to be an invaluable imag- advisement and support for this study.
ing modality in the assessment of oropharyngeal move-
ment, and further applications must be investigated to BIBLIOGRAPHY
explore the full potential of this technology.
1. Kynaston T, Kynaston TP. Circular Breathing: For the Wind Performer.
Los Angeles, CA: Alfred Music; 1978.
2. Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo
playing as alternative treatment for obstructive sleep apnoea syndrome:
Limitations randomised controlled trial. BMJ 2006;332:266–270.
This investigation is limited by a small sample size 3. Eley R, Gorman D. Didgeridoo playing and singing to support asthma
and few instruments studied. This was unavoidable, management in Aboriginal Australians. J Rural Health 2010;26:100–
104.
because time on the cMRI machine is expensive, and 4. Eley R, Gorman D. Music therapy to manage asthma. Aboriginal Islander
this was designed as a pilot study. Although we are Health Worker J 2008;32:9–10.
5. Izdebski K, Hyde L, Ward RR, Ross JC. Visual observations of glottic activ-
aware of the resultant limitations of our analysis and ity during didgeridoo performance. Proc. SPIE 8207. Photonic Therapeu-
affirm that larger groups are needed to make statisti- tics and Diagnostics VIII, 82072U (February 3, 2012).Available at:
http://dx.doi.org/10.1117/12.925215. Accessed on July 17, 2013.
cally significant comparisons, we feel it is important to 6. Heitner J, Bhumireddy GP, Crowley AL, et al. Clinical application of cine-
report our data to provide a foundation for future inves- MRI in the visual assessment of mitral regurgitation compared to echo-
cardiography and cardiac catheterization. PloS One 2012;7:e40491.
tigations into the mechanics and therapeutic potential of 7. Kirchhoff S, Nicolaus M, Schirra J, Reiser MF, G€oke B, Lienemann A.
circular breathing. Assessment of colon motility using simultaneous manometric and func-
tional cine-MRI analysis: preliminary results. Abdom Imaging 2011;36:
The exact impact of the modified instrument equip- 24–30.
ment and supine position on circular breathing tech- 8. Wakamiya M, Furukawa A, Kanasaki S, Murata K. Assessment of small
bowel motility function with cine MRI using balanced steady-state free
nique is not known, but is not felt to be significant. The precession sequence. J Magn Reson Imaging 2011;33:1235–1240.
plastic trumpet and trombone mouthpieces used in this 9. Fukushi I, Okada Y. Dynamics of upper airways during the M€ uller maneu-
ver in healthy subjects: A cine MRI study. Adv Exp Med Biol 2013;788:
study are commercial models used by musicians for play- 189–195.
ing in cold weather conditions. Saxophone-playing sub- 10. Niebergall A, Zhang S, Kunay E, et al. Real-time MRI of speaking at a
jects utilized normal saxophone mouthpieces, and the resolution of 33 ms: undersampled radial FLASH with nonlinear inverse
reconstruction. Magn Reson Med 2013;69:477–485.
modification applied (Velcro ligatures) served only to 11. Singh V, Wisniewski A, Britton J, Tattersfield A. Effect of yoga breathing
secure the reed to the mouthpieces. Supine position exercises (pranayama) on airway reactivity in subjects with asthma.
Lancet 1990;335:1381–1383.
likely caused the task of circular breathing to be more 12. Cooper S, Oborne J, Newton S, et al. Effect of two breathing exercises
challenging, but study subjects were able to accomplish (Buteyko and pranayama) in asthma: a randomised controlled trial.
Thorax 2003;58:674–679.
the task in this position. Nonetheless, the potential 13. Holloway E, Ram FSF. Breathing exercises for asthma. Cochrane Database
impact on ease of task performance and on task effi- Syst Rev 2004;(1):CD001277.
14. Lucia, R. Effects of playing a musical wind instrument in asthmatic teen-
ciency is worth noting. agers. J Asthma 1994;31:375–385.
15. Deniz O, Savci S, Tozkoparan E, Ince DI, Ucar M, Ciftci F. Reduced pul-
monary function in wind instrument players. Arch Med Res 2006;37:
CONCLUSION 506–510.
16. Hixon TJ, Weismer J, Hoit JD. Velopharyngeal-nasal function and speech
Circular breathing has been studied as potential production. In: Preclinical Speech Science: Anatomy Physiology Acous-
therapy in obstructive sleep apnea. This study tics Perception. 2nd ed. San Diego, CA: Plural Publishing; 2014:171–231.
17. Ward CP, York KM, McCoy JG. Risk of obstructive sleep apnea lower in
delineated the velopharyngeal mechanics of circular double reed wind musicians. J Clin Sleep Med 2012;8:251–255.
breathing, and demonstrated similar mechanics across 18. Horner, RL. Pathophysiology of obstructive sleep apnea. J Cardiopulm
Rehabil Prev 2008;28:289–298.
subgroups, with increased efficiency among professionals 19. Ayappa I, Rapoport DM. The upper airway in sleep: physiology of the
compared to experienced amateurs. Our data represent pharynx. Sleep Med Rev 2003;7:9–33.
20. Guimaraes KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G.
a real-time anatomical study of circular breathing and Effects of oropharyngeal exercises on patients with moderate obstructive
provide a foundation for future studies. cMRI is a reli- sleep apnea syndrome. Am J Respir Crit Care Med 2009;179:962–966.
21. Randerath WJ, Galetke W, Domanski U, Weitkunat R, Ruhle KH. Tongue-
able technique for imaging dynamic motion in the oral muscle training by intraoral electrical neurostimulation in patients with
airway, and has many potential applications for the eval- obstructive sleep apnea. Sleep 2004;27:254–258.
22. Brown DL, Zahuranec DB, Majersik JJ, et al. Risk of sleep apnea in
uation of oropharyngeal pathology and therapy. orchestra members. Sleep Med 2009;10:657–660.
23. Kitano H, Asada Y, Hayashi K, Inoue H, Kitajima K. The evaluation of
dysphagia following radical surgery for oral and pharyngeal carcinomas
Acknowledgments by cine-magnetic resonance imaging (cine-MRI). Dysphagia 2002;17:
The authors would like to acknowledge the Music and 187–191.
24. Takemoto H, Honda K, Masaki S, Shimada Y, Fujimoto I. Measurement of
Medicine Initiative of Weill Cornell Medical College and temporal changes in vocal tract area function from 3D cine-MRI data.
the Department of Radiology of NewYork-Presbyterian J Acoust Soc Am 2006;119:1037.

Laryngoscope 00: Month 2014 Peng et al.: Circular Breathing Mechanics With Cine MRI
7

View publication stats