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To supplement the understanding of the airway it is also important to understand the nerves that supply the muscles of the upper airway (Table 3.5).

To best facilitate this, the specific nerve that supplies the muscle is listed. It should be recognized that the muscles that are involved with respiration either are supplied by either cranial nerves or are nerves that originate from the cervical spine. For that reason, it is equally important that the evaluation of patients with the SRBD also has an evaluation of their posture, the cervical spine, and when indicated a cranial nerve screening evaluation.

An area of interest and concern is that there is also a neurologic basis related to SRBD. Neurologic considerations related to SRBD involve what is termed the upper airway reflex along with various neurologic conditions and neurogenic remodeling of the upper airway associated with repetitive mechanical trauma (snoring and apneas). The upper airway reflex impacts the tone of the airway musculature to limit or prevent collapse [12]. If this reflex does not adequately maintain the airway, then the possibility for airway collapse and for apnea to occur is more likely. This reflex may be both motor and sensory. In addition, neurogenic remodeling or changes associated with apnea may also occur [13]. These changes have been attributed to inflammation that occurs as well as vibrations associated mainly with snoring and hypoxia. These changes have been found to involve the hypoglossal nerve and the genioglossus muscle.

Previously a condition termed progressive snorers disease also contributed to neurogenic changes in the upper airway [14]. These changes were found to be present based on biopsies of the musculature in the palatopharyngeal area and were attributed to mechanical trauma associated with snoring, hence the recommendation to manage snoring as a preventive action. It has been found that there is an increased amount of inflammation associated with vibration in the airway associated with snoring [15], and this may result in carotid artery atherosclerosis [16].

Table 3.5 Nerve supply to the muscles of the upper airway.

Source: Adapted from Norton [7].

Nerve	Supplies and innervates
Trigeminal CN V	Tensor veli palatini
Mylohyoid
Anterior belly of digastric
Masseter
Medial/lateral pterygoids
Temporalis
Facial CN VII	Stylohyoid
Posterior belly of digastric
Glossopharyngeal CN IX	Stylopharyngeus
Pharyngeal plexus from vagus CN X	Musculus uvulae
Palatoglossus
Palatopharyngeus
Cranial part of accessory CN XI	Palatopharyngeus (possibly)
Levator veli palatini
Salpingopharyngeus
Superior constrictor
Middle constrictor
Spinal accessory CN XI	Sternocleidomastoid (SCM)
Trapezius (along with C‐3 and C‐4 branches)
Pharyngeal plexus – external laryngeal of vagus and recurrent	Inferior constrictor laryngeal of vagus
Hypoglossal CN XII	Genioglossus
Hyoglossus
Styloglossus
Superior longitudinal
Inferior longitudinal
Transverse
Vertical
C‐1 follows CN XII	Thyrohyoid
Geniohyoid
Ansa cervicalis	Omohyoid
Motor component of cervical	Sternohyoid
Plexus (C‐1 to C‐4)	Sternothyroid
Ventral rami
C‐4 to C‐6	Anterior scalenes
C‐5 to C‐8	Middle scalenes
C‐6 to C‐8	Posterior scalenes
Phrenic nerve from C‐3 to C‐5	Diaphragm