Endoscopic view of a hypermobile tongue in the nasopharynx.

A healthy 45-year-old man presented for evaluation of hoarseness and a globus sensation. Findings on head and neck examinations were normal except for signs of reflux laryngitis (posterior commissure hypertrophy, arytenoid erythema, etc.) on fiberoptic videolaryngoscopy.

More interesting, however, was the patient's report that he was able to clean his nasal secretions and moisten his nasopharynx with his tongue. He then demonstrated this remarkable lingual dexterity by easily maneuvering his anterior tongue behind his soft palate, into his nasopharynx, and then through both his posterior choanae (figure, A-D). Telescopic videonasopharyngoscopy captured the image as the hypermobile tongue came up through the velopharyngeal opening into the nasopharynx (figure, E and F). The tongue almost filled the nasopharyngeal space and reached to its roof (figure, F). The patient was able to move the tip of his tongue in any direction in the nasopharynx. The tongue easily reached the pharyngeal orifices of the eustachian tube. He was able to direct the tip of the tongue into the posterior portions of the middle meatus (figure, G) and inferior meatus (figure, H) and clear the mucus there. He was also able to bend the anterior portion of the tongue forward into the posterior nasal cavity (figure, H). With the tongue in this position, intraoral examination showed that the uvula was pushed up and into direct contact with the base of the frenulum (figure, I).

At rest, the tongue appeared to be of normal size and in a normal position behind the teeth. It did not protrude extensively in an anterior direction. The lingual frenulum was normal in length and position, although it was stretchable. The patient denied velopharyngeal insufficiency, snoring, and obstructive sleep apnea. His speech and sense of smell were normal.

[FIGURES A-I OMITTED]

The patient was not disturbed by his lingual hypermobility. He recalled that he had had this ability since childhood. In fact, the same otolaryngologist (E.Y.) had noted this unusual condition then and now.

Restricted tongue mobility, such as ankyloglossia, is well reported. Hypermobility of the tongue, on the other hand, appears to be a rather rare phenomenon. The absence of a lingual frenulum, which has been associated with EhlersDanlos syndrome, can result in a hypermobile tongue, but not to the degree seen in this patient. (1) Case reports of lingual hypermobility in patients with a normal frenulum appear only twice in the English-language literature. (2,3) Cinar et al described a healthy 45-year-old Turkish man who was able to pass the tip of his tongue past his uvula and into his nasal cavity to clear nasal secretions, just as our patient could. (2) The authors called this condition "idiopathic hypermobile tongue." Cincik et al discovered a hypermobile tongue while examining a 16-year-old boy (also Turkish) who had presented for evaluation of loud snoring. (3) His tongue was capable of reaching the posterior nasal cavity. The boy also had an elongated uvula.

References

(1.) De Felice C, Toti P, Di Maggio G, et al. Absence of the inferior labial and lingual frenula in Eblers-Danlos syndrome. Lancet 2001;357:1500-2.

(2.) Cinar F, Uzun L, Ugur MB, Agaoglu H. An unusual movement of the tongue. Plast Reconstr Surg 2004;113:773-4.

(3.) Cincik H, Cekin E, Gungor A, Poyrazoglu E. Does a hyperflexible tongue cause snoring? The Internet Journal of Otorhinolaryngology 2005;3(2). Available at: http://www.ispub.com/ostia/index. php?xmlFilePath=journals/ijorl/vol3n2/snoring.xml. Accessed Aug. 4, 2006.

Adam J. LeVay, MD; Eiji Yanagisawa, MD

From the Section of Otolaryngology, Yale University School of Medicine, and the Section of Otolaryngology, Hospital of St. Raphael (Dr. LeVay and Dr. Yanagisawa), and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group (Dr. Yanagisawa), New Haven, Conn.