Open Access Review

Article DOI: 10.7759/cureus.3695

The Anatomical Relationships of the Tongue with

the Body System
Bruno Bordoni 1 , Bruno Morabito 2 , Roberto Mitrano 3 , Marta Simonelli 4 , Anastasia Toccafondi 3

1. Cardiology, Foundation Don Carlo Gnocchi / Institute of Hospitalization and Care, Milan, ITA 2. Osteopathy, School
of Osteopathic Centre for Research and Studies, Milan, ITA 3. Cardiology, Foundation Don Carlo Gnocchi/institute of
Hospitalization and Care, Milan, ITA 4. Osteopathy, School of French-Italian Osteopathy, Pisa, ITA

Corresponding author: Bruno Bordoni, [email protected]

Abstract
The tongue plays a fundamental role in several body functions such as swallowing, breathing, speaking, and
chewing. Its action is not confined to the oral cavity, but it affects lower limb muscle strength and posture.
The tongue is an organ that has an autocrine/paracrine mechanism of action to synthesize different
substances to interact with the whole body; according to a line of thought, it is also an extension of the
enteric system. The aim of this study was to review the functions of the tongue and its anatomical
association with the body system. According to the authors' knowledge, this is the first scientific article
focusing on the tongue in a systemic context. In a clinical evaluation, connections with the tongue should
be considered to optimize the clinical examination of the tongue and therefore enhance rehabilitation
programs and therapeutic results.

Categories: Medical Education, Miscellaneous, Anatomy

Keywords: tongue, diaphragm, speech therapy, osteopathic, physiotherapy, fascia

Introduction And Background

The tongue is an area of interest for different professional profiles. Alterations in the tongue muscle
properties are associated with different pathological conditions. Systemic disorders may involve secondarily
the tongue, or local tongue alterations can cause systemic diseases: scleroderma, local tongue
dysfunction, tumors, old age, obstructive sleep apnea syndrome (OSAS), and emotional disorders.

Scleroderma
Scleroderma is a chronic connective tissue disease generally classified as one of the autoimmune rheumatic
diseases, presenting with vascular anomalies and antibody production; scleroderma most frequently affects
women compared to men (4:1); its pathogenesis remains not entirely understood [1]. Scleroderma is
classified as two separate but related entities, a localized form and a systemic form: systemic sclerosis and
morphea (localized scleroderma) [2]. The tongue is involved in scleroderma, with changes in its form and
Received 11/27/2018
Review began 12/02/2018
function, i.e., the tongue becomes rigid with less ability to perform its functions, which can cause problems
Review ended 12/03/2018 that may affect the temporomandibular joint (TMJ), dysphagia, dysgeusia, and logopedic problems [1].
Published 12/05/2018

© Copyright 2018 Local tongue dysfunction

Bordoni et al. This is an open access
article distributed under the terms of the In the absence of pathological conditions, altered tongue function leads to TMJ disorders and pain [3]. The
Creative Commons Attribution License most likely explanation for this phenomenon could be a dysfunction of the genioglossus muscle activity
CC-BY 3.0., which permits unrestricted
during the jaw-closing phases, suggesting a peripheral mechanism (jaw-tongue reflexes or afferent fibers
use, distribution, and reproduction in any
medium, provided the original author and
from the extrinsic muscles of the tongue), or a central organization (a central cortical generator that
source are credited. controls the mastication process), or both neural mechanisms [4].

Tumors
The tongue is a common site for tumors involving the oral cavity and the cervical tract. One of the most
frequent intraoral areas affected by carcinomas is the tongue, occurring after the age of 40 on average, with
men affected more than women (10%); however, the causes of tongue cancer still remain unclear [5].
Chemotherapy treatments will lead to dysphagia, loss of tongue strength and tone, and dysgeusia [6].

Old age
In patients requiring long-term management, from the hospital to home setting (Parkinson's disease, stroke,
and dementia), especially in the elderly population, there is a direct association between the lean mass loss
(muscles) and the lingual discoordination; the decline in tongue motor skills has the same characteristics of
the voluntary skeletal muscle degeneration [7-8]. Usually, an age-related loss of the tongue muscle mass and
strength exists in healthy subjects, with an increased adiposity in the posterior area; after the age of 55, an
age-dependent motor unit remodeling occurs, with a tongue functional impairment [9-10].

How to cite this article

Bordoni B, Morabito B, Mitrano R, et al. (December 05, 2018) The Anatomical Relationships of the Tongue with the Body System. Cureus 10(12):
e3695. DOI 10.7759/cureus.3695
 Obstructive sleep apnea syndrome
OSAS is a systemic disease that involves the tongue; 2% of women and 4% of men present this disorder,
especially in the middle-aged population. OSAS is the most common type of sleep apnea or hypopnea and is
caused by complete or partial obstructions of the upper airway. It is characterized by repetitive episodes of
shallow or paused breathing during sleep and is usually associated with a reduction in blood oxygen
saturation and hypercapnia [11-12]. The most important cause of this syndrome is the dysfunction of the
lingual muscles, with changes in shape and altered electrical activation [12].

Emotional disorders
The tongue position changes with emotions and state of mind, thus becoming an instrument for
psychological observation; usually, an anterior tongue placement occurs with a feeling of fear [13]. The
multidisciplinary collaboration between the different professional profiles is fundamental to obtaining an
appropriate therapeutic effect.

Review
Anatomic connections of the tongue
The cell origin of the tongue is hybrid. The connective tissues and the vascular system are derived from the
cranial neural crest cell-derived mesenchyme; the tongue muscle cells originate from the somite mesoderm,
while the muscles of mastication are derived from the unsegmented somitomeres. Lingual musculature
stems from muscle cells that immigrate from the occipital somites into the tongue [7]. A close embryological
and functional association exists among the tongue, the occipital area, and the hyoid bone that originates
from the second branchial arch [7]. Anatomically, the tongue maintains several relations with the hyoid
bone, and therefore, with the hyoid musculature (the suprahyoid and the infrahyoid muscles) [7]. The
hyoglossus membrane and the lingual septum bind the tongue to the hyoid muscles [8]. The suprahyoid
muscular action helped in maintaining the posture and the equilibrium of the head. Electromyography
showed electrical activity in the omohyoid muscle and in the anterior belly of the digastric muscle during
different movements of the tongue; these muscles intervene to allow a proper association between the
tongue and the head (neck), during flexion, extension, and rotation of the neck and the cervical tract [8]. The
suprahyoid and the infrahyoid muscles act together in the jaw and tongue movements, during the first phase
of swallowing and phonation [8]. These two muscles and the tongue act simultaneously in all the tongue
movements (except retraction); the lingual musculature and the suprahyoid and the infrahyoid muscles
influence each other [8]. Chewing involves an anterior-posterior movement of the tongue and of the hyoid
bone on the horizontal plane, whereas the hyoid bone has almost no role in speaking [7]. During respiration,
the hyoid bone moves in a craniocaudal direction, due to the action of the extrinsic muscles of the tongue,
causing the pharyngeal space to dilate [7]. Generally, the anterior part of the tongue is considered important
for non-respiratory activities, while the posterior part is important for respiration [9]. It should be
emphasized that all the tongue muscles, extrinsic and intrinsic muscle groups, always work synergistically
and not separately [9]. The tonus of these muscles must be well-balanced; otherwise, dysfunctions can
occur, resulting in an alteration in the position of the hyoid bone and the functionality of the tongue [3,9-
10]. The suprahyoid region extends from the base of the skull to the hyoid bone and includes the pharyngeal,
parapharyngeal, parotid, carotid, masticator, retropharyngeal, and perivertebral spaces, as well as the oral
cavity [11]. The tongue is a part of the anatomical structures that cover the occipitocervical area, the
anterior area of the neck, and the muscles of mastication, including the temporomandibular joint, as well as
the three layers of the cervical fascia (superficial, middle, and deep) [11]. The suprahyoid region and the
tongue have some muscles in common: the masseter, the buccinator, the temporalis, the pterygoid, and the
mylohyoid [11]. The floor of the oral cavity is formed by the mylohyoid muscle, a quadrilateral sheet
consisting of two bellies, whose lower fasciae are in contact with the anterior fascia of the digastric
muscle and superiorly with the geniohyoid and hyoglossus muscles; with a connective raphe and a sagittal
fibrous lamina, the mylohyoid muscle contacts the hyoid bone. The infrahyoid region is located below the
hyoid bone and continues into the suprahyoid region. The deep cervical fascia extends from the hyoid bone
to the upper mediastinum, continuing along its path toward the visceral, anterior cervical, posterior cervical,
carotid, retropharyngeal, and perivertebral spaces [12]. For fascial continuity, the tongue is connected to the
strap muscles and the sternocleidomastoid muscle and to the musculature acting on the thoracic outlet [12-
13]. The tongue can change its shape and produce different actions working as a hydrostat; all the muscular
components, in direct or indirect contact with the tongue, respond with proper contractile tonus to allow the
tongue to work properly, thanks to the complex organization of the central and peripheral nervous system
[14-15].

Neurological relationships
Studies demonstrated the highly organized and extensive representation of the tongue at multiple levels in
the brain (cortex, mesencephalon, medulla oblongata, and limbic system), with the highest specificity and
integration reached at the cortical level, with a clear somatotopic organization [16]. Neuroplastic changes in
the cortex demonstrate how the brain control of the tongue activity can be modified by environmental
stimuli: an improvement in functions occurs in case of physiological stimuli; instead, functional disorders
occur with pathological stimuli [17] These stimuli are given by the position of the tongue inside the mouth,
as described later. Afferent nerve fibers of the peripheral nervous system send information to the central

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 nervous system, and the information is able to oscillate between one hemisphere and another, to ensure the
optimal tongue movement efficiency [18]. The tongue position influences the whole body. If the tongue is
positioned against the palate, the parasympathetic system will reduce its systemic activity (for example,
heartbeats and respiratory rhythm increase), but if it is positioned against the soft palate, the sympathetic
system will reduce its activity [17]. The tongue position and its voluntary (or non-voluntary) strength might
vary with the lung volume. Changes in the tracheal traction at different lung volumes may alter the
mechanics of the tongue muscles and their ability to produce protrusion force, and these changes in the
lung volume alter tension transferred through the trachea to the hyoid arch. Pulmonary stretch activates the
pleural receptors that work by inhibiting the hypoglossal/phrenic motoneurons [18-19]. It is assumed that
when a chronic pathology takes over, restricting lungs expansion and decreasing lungs volume, the
hypoglossal/phrenic motoneurons are less inhibited, resulting in a reduced tongue control [20]. Tongue
movements, generally postero-lateral, activate the anterior cingulate cortex (ACC), which plays an important
role in the sensory, motor, cognitive, and emotional information and pain processing; some studies using
magnetoencephalography showed the ACC to often be concerned with visceral sensation [21]. Lingual
behavior has a link with the amygdala, especially for taste learning, forming motor patterns during
mastication [22]. The amygdala has multiple functions regulating mood and emotions [23]. According to
some authors, the tongue represents the gateway to the enteric system, due to the presence of specialized
ganglia on the anterior and posterior area of the tongue; it would act as a chemical "spy", alerting the enteric
system through the chemical analysis of food during mastication [24]. In this way, the digestive system
would already be prepared, before the food arrives in the stomach and the intestine; the tongue would
modulate the digestive functions [24].

Systemic relationships
The tongue has autocrine and paracrine functions, modulating the function of the tongue muscles and the
surrounding environment. Type II receptor taste bud cells secrete adenosine triphosphate (ATP) during taste
stimulation. In turn, ATP activates the type III cells to release serotonin, norepinephrine, and gamma-
aminobutyric acid (GABA) [25]. They also synthesize acetylcholine that also stimulates ATP secretion by
releasing calcium into the Type II receptors; through these autocrine strategies, the tongue modulates
gustatory signals that are transmitted to the central nervous system [25]. Perhaps, ATP is secreted via the
paracrine mechanism to stimulate the systemic pathways for adenosine production; the tongue needs
adenosine to recreate ATP [26]. In the animal model, the tongue has a sympathetic innervation from the
superior cervical ganglion, whose fibers provide sympathetic innervation to the whole tongue [27]. Most
likely, the human tongue also has sympathetic innervations, but less is known in this regard [28]. The tongue
influences the neuromotor control of the lower limb. A pilot study showed a significant improvement in the
isokinetic knee performance with the tongue positioned up to the palatine spot, increasing the performance
of thigh muscles (through the use of an isokinetic machine), for about +30% with respect to the resting
position (during both endurance and high-force muscular exercise) [29]. The palatine spot has a high density
of trigeminal nerve endings and exteroceptors [29]. Electrical tongue stimulation improves balance, gait,
and posture in subjects with postural impairments [30]. A hypothesis to explain these behavioral changes is
based on the neuroanatomy of the trigeminal system (V) and facial nerve (VII). The brainstem projections of
these nerves are the trigeminal and solitary nuclei, located immediately adjacent to the vestibular nuclei
near the dorsal aspect of the pontomedullary junction and extending superiorly through the pons; electrical
stimulation of these cranial nerves may induce modulating activity in the vestibular system [30]. The body
position induces changes in the tongue's myoelectric activity; tonic tongue muscle activity and movements
related to spontaneous respiration increase significantly in the supine position with respect to the upright
position, thus maintaining an adequate upper airway patency [31]. A study shows that the mean center of
gravity (COG) velocity decreased significantly while the tongue was positioned against the upper incisors,
suggesting that this tongue position can enhance the postural stability during upright standing on an
unstable surface and in the absence of vision in healthy young adults [32]. Another study investigated the
improvement of head postural control in the absence of visual sensory cues, through an electrical
stimulation of the tongue with a biofeedback [33]. The tongue has control on the posture, thanks to its
greater tactile sensitivity than the finger; besides, compared with other body parts, the tongue is represented
by the large primary motor and sensory cortical areas [34]. The tongue position would interact with the body
posture in the context of postural dysfunction. We know that the tongue affects the occlusal class and that
there exists a relationship between the occlusal class and the pathological postures; during child growth or
fetal development, the tongue could cause postural modifications, altering systemic tensions by fascial or
trigeminal connections [35-37]. Tongue representation in the primary somatosensory cortex is activated,
during observation of video sequences of bimanual hand movements associated with nouns; the lingual
complex interacts with what we observe, influencing the same speech, through a neurological relationship
not yet elucidated, suggesting a greater complexity of the tongue functions [38]. The human tongue
innervation involves the lingual nerve that is a branch of the mandibular division of the trigeminal
nerve and the hypoglossal nerve (CN XII) [39]. The hypoglossal nerve through the ansa cervicalis is in
contact with the first three or four cervical nerves and receives presynaptic impulses from the phrenic nerve;
it is linked to the trigeminal system by afferent fibers [40]. The tongue becomes a crossroad of efferent and
afferent information, and its dysfunction will negatively affect all the systems. For example, a chronic
decline in the heart function (chronic heart failure: CHF) alters the morphology and function of the
diaphragm with a concomitant functional alteration in the tongue, causing OSAS [41]. An altered function of
the tongue negatively affects the TMJ; consequently, a dysfunctional TMJ will negatively affect the
trigeminocardiac reflexes, altering values such as heart rate (bradycardia) and blood pressure (hypotension)

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 [42]. The morphology and the non-physiological position of the tongue negatively affect renal function,
smell and hearing, and the cognitive area [43-45]. The causes are probably related to an incorrect breathing
at night connected to tissue deoxygenation.

Conclusions
The tongue influences and interacts with the body system. Its dysfunction leads to different local and
systemic pathologies. During the assessment of the tongue, other associations that may influence its
physiological behavior, such as the lower limb, the TMJ, the neck, the respiratory, and the pelvic diaphragm,
and the muscles of the thoracic outlet, should not be neglected. Considering its anatomical and physiological
connections, during manual evaluation, will help the operators increase the importance of the tongue
assessment, the rehabilitation organization, and consequently, the therapeutic results.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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