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
2.
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
1


Stylohyoid complex from Reichert’s cartilage of 2 nd
brachial arch

Tympanohyal → base of styloid process
 stylohyal → shaft of styloid process
 ceratohyal → stylohyoid ligament
 hypohyal → lesser cornu of hyoid bone
3.
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?
4.
Symptoms:

Classical stylohyoid syndrome:

Following tonsillectomy, especially with snare

Contracture of scar tissue stimulate 5 th
, 7 th
, 9 th
, and 10 th
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:

Facial pain from brow to chin

Constant neck pain

Tinnitus when turning head

Compression of internal carotid artery:

Headache from ophthalmic region to occipital region
5.
Pathogenesis:

Why elongation?

Congenital elongation due to persistence of cartilaginous element
2

3

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
6.
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)

4
7.
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

5
8.
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%
9.
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.