Introduction: 1937, Watt w eagle defined symptomatic elongated styloid process and later call Eagle’s syndrome

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Laryngology Seminar

Eagle’s syndrome (Elongated Styloid Process)

R3黃俊棋 2005/10/26

  1. Introduction:

    • 1937, Watt W Eagle defined symptomatic elongated styloid process and later call Eagle’s syndrome

    • Symptoms associated with pathological condition of stylohyoid complex

  1. Anatomy and Embryology:

    • 3 muscles: stylopharyngeal, stylohyoid and styloglossal muscle

    • 2 ligaments: stylohyoid and stylomandibular ligament

    • Stylohyoid chain or complex: styloid process, stylohyoid ligament and lesser cornu of hyoid bone

    • Stylohyoid complex from Reichert’s cartilage of 2nd brachial arch

      • Tympanohyal → base of styloid process

      • stylohyal → shaft of styloid process

      • ceratohyal → stylohyoid ligament

      • hypohyal → lesser cornu of hyoid bone

  1. Incidance:

    • > 3 cm → elongated styloid process

    • Eagle: 4% of population and 4% were symptomatic

    • Incidence from 1.4 to 30% and 7.8-10.3% were symptomatic

    • Male : female: 1:1 to 1:3

    • More than 30-40 y/o

    • Most bilateral elongation but usually symptomatic, why?

  1. Symptoms:

    • Classical stylohyoid syndrome:

  • Following tonsillectomy, especially with snare

  • Contracture of scar tissue stimulate 5th, 7th, 9th, and 10th cranial nerves

  • Sensation of raw throat

  • Refer otalgia, especially when swallowing

  • Odynophagia or dysphagia

  • Persistent dull-aching sorethroat

  • Pain when extending tongue or changing voice

  • Sensation of hypersalivation

  • Stylocarotid syndrome:

  • Impinge carotid artery with or without tonsillectomy

  • Stimulate perivascular sympathetic fibers

  • Compression of external carotid artery:

    • Compression of internal carotid artery:

      • Headache from ophthalmic region to occipital region

  1. Pathogenesis:

  • Why elongation?

    • Congenital elongation due to persistence of cartilaginous element

    • Part or complete ossification of stylohyoid ligament

    • Growth of osseous tissue at insertion of stylohyoid ligament

    • Post-traumatic reactive hyperplasia

    • Association of early onset of menopause

    • Degenerative processes of ligament or osteocartilaginous element with secondary calcification

  • Why symptomatic?

    • Traumatic fracture of ossified stylohyoid ligament cause proliferation of granulation tissue

    • Direct nerve compression

    • Degenerative and inflammatory changes over insertion of tendon

    • Post-tonsillectomy fibrosis

    • Impinge carotid artery

    • Rheumatic styloiditis result from pharyngeal infection

  1. Diagnosis:

  • Symptoms

  • Palpation of elongated styloid process in tonsillar bed and aggravate symptom

    • Ravinder Verma grade I: tip of styloid process in upper pole of tonsillar fossa

    • Grade II: in middle of tonsillar fossa

    • Grade III: lower pole of tonsillar fossa

  • Immediate relief of symptom with infiltration of 1 ml of 2% lidocaine

  • Radiographic findings (orthopantomography or lateral view)

  1. Differential diagnosis:

  • Unerupted or impacted molar: in teenagers or early twenties

  • Sphenopalatine ganglion neuralgia: usually with nasal symptom; cocaine infiltration

  • Temporomandibular joint syndrome: PE

  • Glossopharyngeal or trigeminal neuralgia: momentary piercing or lancinating pain

  • Carotidynia: hyperpulsation and vessel dilation

  • Irritation from dental prosthesis

  • Oropharyngeal or hypopharyngeal tumor

  • Chronic pharyngitis and tonsillitis

  1. Treatment:

  • Styloidectomy or NSAID

  • Intraoral approach:

    • Advantage: safe, simple, less time consumption, no scar

    • Disadvantage: deep neck infection, injury of major vessel, poor visualization

  • External approach:

    • Advantage: reduce deep neck infection, good visualization

    • Disadvantage: scar, long duration, injury of facial nerve

  • Success rate: 50-80%

  1. References:

  • Buono U, Mangone GM, Michelotti A, Longo F, Califano L. Surgical approach to the stylohyoid process in Eagle's syndrome. J Oral Maxillofac Surg. 2005 May;63(5):714-6.

  • Mupparapu M, Robinson MD. The mineralized and elongated styloid process: a review of current diagnostic criteria and evaluation strategies. Gen Dent. 2005 Jan-Feb;53(1):54-9.

  • Ilguy M, Ilguy D, Guler N, Bayirli G. Incidence of the type and calcification patterns in patients with elongated styloid process. J Int Med Res. 2005 Jan-Feb;33(1):96-102.

  • Salamone FN, Falciglia M, Steward DL. Eagle's syndrome reconsidered as a cervical manifestation of heterotopic ossification: woman presenting with a neck mass. Otolaryngol Head Neck Surg. 2004 Apr;130(4):501-3.

  • Ferreira de Albuquerque R Jr, Muller K, Hotta TH, Goncalves M. Temporomandibular disorder or Eagle's syndrome? A clinical report. J Prosthet Dent. 2003 Oct;90(4):317-20.

  • Mortellaro C, Biancucci P, Picciolo G, Vercellino V. Eagle's syndrome: importance of a corrected diagnosis and adequate surgical treatment. J Craniofac Surg. 2002 Nov;13(6):755-8.

  • Prasad KC, Kamath MP, Reddy KJ, Raju K, Agarwal S. Elongated styloid process (Eagle's syndrome): a clinical study. J Oral Maxillofac Surg. 2002 Feb;60(2):171-5.

  • Fini G, Gasparini G, Filippini F, Becelli R, Marcotullio D. The long styloid process syndrome or Eagle's syndrome. J Craniomaxillofac Surg. 2000 Apr;28(2):123-7.

  • Rechtweg JS, Wax MK. Eagle's syndrome: a review. Am J Otolaryngol. 1998 Sep-Oct;19(5):316-21.

  • Strauss M, Zohar Y, Laurian N. Elongated styloid process syndrome: intraoral versus external approach for styloid surgery. Laryngoscope. 1985 Aug;95(8):976-9.

  • Russell TE. Eagle's syndrome: diagnostic considerations and report of case. J Am Dent Assoc. 1977 Mar;94(3):548-50.

  • EAGLE WW. The symptoms, diagnosis and treatment of the elongated styloid process. Am Surg. 1962 Jan;28:1-5.

  • EAGLE WW. Elongated styloid process; symptoms and treatment. AMA Arch Otolaryngol. 1958 Feb;67(2):172-6.

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