Eagle’s syndrome after fracture of the elongated styloid process

Stylalgia: Our Experience of 101 Cases Treated by Intraoral Styloidectomy

Evidence from research and literature suggest that Eagle's syndrome may present with a variety of symptoms creating diagnostic predicament amongst clinicians. We describe a detailed clinical review of symptomatology, diagnosis and management of hundred and one cases of stylalgia. The aim of our study was to asses effectiveness of intraoral styloidectomy as a definitive modality of treatment in stylalgia. A prospective clinical study was conducted in a tertiary referral centre and included 101 patients presenting with symptoms suggestive of stylalgia. The diagnosis of stylalgia was confirmed by history and clinical examination supplemented by orthopentomogram. All patients underwent intra oral styloidectomy following adequate trial of medical treatment. The success rate of intraoral styloidectomy was found to be 80. 19% i.e. 81 out of 101 patients were considered as cured based on pain assessment using visual analogue scale pre and post operatively. Though medical treatment can provide short term relief of symptoms, styloidectomy is the proven definitive modality of treatment for stylalgia.

Traumatic Events and Eagle Syndrome: Is There Any Correlation? A Systematic Review

Background: Eagle syndrome occurs when elongated styloid process or ossification of the stylohyoid ligament interfere with the surrounding anatomical structures giving rise to various symptoms. Watt W. Eagle identified two types: stylo-hyoid classic syndrome and stylo-carotid artery syndrome. The aim of this systematic review of the literature is to evaluate correlations between Eagle syndrome and traumatic events or teeth extractions. Methods: out of 294 articles, the final study allowed the identification of 13 studies focusing on traumatic events. Out of 342 articles, the final study allowed the analysis of two studies regarding extractive dental events. Results: 13 articles showed correlations between the onset of symptoms in Eagle syndrome and traumatic events and highlighted two possibilities: traumatic event could fracture the already elongated styloid process or calcified stylohyoid ligament; trauma itself triggers the pathophysiological mechanisms that lead to lengthening of styloid process or calcification of stylohyoid ligament and therefore the typical symptoms. The only two case reports concerning Eagle syndrome symptoms after extractive dental events describe the onset of classic type. Conclusions: The analyzed articles confirm correlation between traumatic event and onset of typical symptoms of Eagle syndrome. There is not enough literature linking extractive dental events to Eagle syndrome. Trial registration: CRD42020185176.

Prevalence of morphological and structural changes in the stylohyoid chain

Background

Total or partial calcification of the stylohyoid chain, elongation of the stylohyoid process of the temporal bone and/or calcification of the stylohyoid ligament are usually incidental radiographic findings. The purpose of this study was to evaluate the prevalence of morphological and structural changes within the stylohyoid chain in 4413 digital panoramic radiographs.

Material and Methods

The images were evaluated for the presence or absence of changes in the stylohyoid chain by a specialist in dentofacial radiology and the information collected comprised gender, age, side, right and left measurements and classification of the chain side elongated or calcified stylohyoid process, as well as type and pattern of right or left calcification.

Results

275 (6.2%) subjects presented alterations, mostly bilateral, in the stylohyoid chain, being 186 females (67.6%) and 89 males (32.4%), with a higher proportion elongation. Partial calcification was more prevalent than total calcification. The right side was most affected and the frequency of events increased with age.

Conclusions

The findings of the present study demonstrate that the commonest alterations in the stylohyoid chain are bilateral, mainly elongation, with a clear trend to increased prevalence with increasing age, presenting a low incidence. Noneless, the clinicians must be aware of these alterations in the routinely radiographic examination.

Key words:Stylohyoid process, Stylohyoid ligament calcification, Stylohyoid chain, Eagle’s syndrome.

Cervico-stylo-mandibular complex fracture: a critical review of literature along with a protocol to recognize and proposal of a new classification

Fractures of the styloid process of the temporal bone may occur with or without an obvious relation to trauma. The incidence of either isolated styloid process fracture or in combination with mandibular fractures is rare, and such occurrences are often misdiagnosed or neglected. A fractured styloid when displaced may impinge on adjacent vital structures, leading to neurological or vascular symptoms that vary according to the anatomical structure compressed. Styloid process fractures associated with atlas/C1 fractures have also been rarely reported in the literature. In this review of literature, the majority of patients was treated conservatively, as few demonstrated the necessity of surgical intervention. There is a definitive need for a protocol to recognize and classify styloid fractures to plan for further treatment. The aim of this review was to achieve a comprehensive understanding of all types of styloid fractures, determine the clinical severity of symptoms, and to consider management and prognosis. In addition, a new classification of cervico-stylo-mandibular fractures is proposed based on important evidence in the literature regarding clinical and radiographic factors that might influence the treatment and prognosis of such fractures.

Provoked Eagle syndrome after dental procedure: A review of the literature

Eagle syndrome is an uncommon condition caused by an elongated ossified styloid process. The majority of individuals with an elongated ossified styloid process are asymptomatic. Therefore, this condition is diagnosed based on clinical presentation, with radiologic imaging serving to confirm the diagnosis. The styloid process is considered elongated if measuring greater than 3 cm, but there is little correlation between length of the styloid process and severity of symptoms. This syndrome was originally described in post-tonsillectomy patients, but has since been seen in other clinical settings. We present a case of Eagle syndrome that became symptomatic after a dental procedure (wisdom teeth removal). A literature review performed with focus on various etiologies of Eagle syndrome diagnosis found a previously published case of Eagle syndrome presenting as pain of dental origin;1 however, no case reports of symptoms arising in a patient post-dental procedure were found in our search.

Fractures of the Stylomandibular Complex: A Prospective Study Proposing a Classification and Clinical Protocol

PURPOSE

Mandibular trauma can result in stylomandibular complex (SMC) fractures with clinical symptoms including glossopharyngeal neuralgia, globus pharyngeus, otalgia, and dysphonia. Fracture of the styloid process is noteworthy because of its proximity to numerous vital structures. The study objectives were 1) to determine the incidence of SMC fractures and develop a clinical grading system and 2) to institute and assess a treatment protocol.

MATERIALS AND METHODS

This prospective clinical trial involved 206 patients with mandibular trauma based on a set of inclusion and exclusion criteria. On the basis of the clinical presentation of symptoms, patients were categorized as mild, moderate, or severe, and the radiographic features were characterized as type 1, 2, or 3. Patients were treated by an institutional protocol, and outcome was evaluated. A grading system was developed by correlating clinical features with imaging. Data were analyzed using SPSS software (version 22; IBM, Armonk, NY). Descriptive and analytic statistics were computed.

RESULTS

The incidence of styloid fracture was 11.17%. The most common concomitant mandibular fractures were condyle (13 patients) and angle (7 patients) fractures. Dysphagia and restricted mouth opening were the most common symptoms. The distribution of radiographic types 1, 2, and 3 was 26.1%, 69.6%, and 4.3%, respectively. A significant correlation (P < .001) was found between clinical symptoms and radiographic types using the Fisher exact test.

CONCLUSIONS

This study proposes a clinical grading system for SMC fractures and a symptom-based management algorithm.

Fractured styloid process masquerading as neck pain: Cone-beam computed tomography investigation and review of the literature

Historically, Eagle syndrome is a term that has been used to describe radiating pain in the orofacial region, foreign body sensation, and/or dysphagia due to a unilateral or bilateral elongated styloid process impinging upon the tonsillar region. Because elongated styloid processes-with or without associated Eagle syndrome-can present with various symptoms and radiographic findings, it can be challenging for healthcare practitioners to formulate an accurate diagnosis. Abnormal styloid anatomy can lead to a multitude of symptoms, including chronic orofacial/neck pain, thus masquerading as more commonly diagnosed conditions. In this report, we describe a patient who presented to our department with styloid process elongation and fracture. A careful history, physical examination, and a conebeam computed tomography (CBCT) investigation led to the diagnosis. The patient was then referred for appropriate care. This case report demonstrates the utilization of CBCT in differentiating a fracture site from a pseudo-joint that might mimic a fracture.

A truncated temporal styloid process from the Jordanian Ottoman Period: Developmental variant or fracture?

Styloid process (SP) development and its role in an individual's lived experience plays a negligible role in paleopathological research, although a handful of possible Eagle's syndrome cases have been reported. Here, the development of the stylohyoid chain and the medical research of SP variants are reviewed to inform the differential diagnosis of a probable SP fracture in a young adult male associated with the Ottoman Period (13-19thC) in Jordan. The fracture surface of the right SP is smooth rather than irregular, the coloration is uniform with the surrounding cortical bone staining, and no new bone formation is visible. All features are consistent with a perimortem injury. An unossified stylohyal is a differential diagnosis, while the left elongated SP suggests a predisposition to intrinsic injury. The implications of SP fractures are considered.

Concomitant "Ear Bleed and Styloid Fracture": An Unusual Complication of Impacted Mandibular Third Molar Removal

The removal of impacted mandibular third molar is associated with potential complications such as dry socket, paresthesia, uncontrolled socket bleeding, angle fracture, etc., which are commonly encountered in dental practice. This article presents a peculiar case of "ear bleed" concomitant with "isolated styloid" fracture following removal of impacted mandibular third molar, not reported in the literature till date. Ear bleed is a bothersome clinical sign that requires thorough investigation and prompt treatment because it is frequently related to fractures of the skull base. Isolated fracture of the styloid process is rare; its diagnosis, impact on adjacent vital structures, and treatment protocol are less discussed in maxillofacial literature. The case report elucidates the etiopathogenesis of ear bleed and styloid fracture which have great clinical implications. The clinical correlation between the two entities and dental extraction is discussed in this report to guide a dental practitioner in its management.

Styloid Process Fracture Associated With Maxillofacial Trauma: Incidence, Distribution, and Management

PURPOSE

Fracture of the styloid process of the temporal bone has been infrequently reported. The present study evaluated the incidence, causes, distribution, and management of styloid process fracture in association with other maxillofacial fractures.

MATERIALS AND METHODS

A prospective evaluation of patients with maxillofacial trauma over a period of 1 year was carried out and patients' characteristics, mode and distribution of injury, and length of styloid process were recorded. Patients were divided into 5 groups based on the site of maxillofacial fracture and into 2 groups based on styloid process length to evaluate their association with styloid process fracture. The authors' unit protocol was carried out for management of styloid process fracture.

RESULTS

Of 84 patients with maxillofacial trauma, 27 patients (14 men, 13 women; mean age, 25.7 ± 8.92 yr) had styloid process fracture. The most common cause of injury was road traffic accidents. Mandibular and multiple facial fractures accounted for most concomitant styloid process fractures. The mean length of the styloid process in patients with fracture was 2.46 ± 0.89 cm and no relevant association was present between the length and fracture of the styloid process. All patients responded well to initial conservative management.

CONCLUSION

Styloid process fractures are relatively common injuries in developing countries and a meticulous examination is essential for prompt diagnosis and adequate care.

An Asymptomatic and Overelongated Styloid Process

Elongation of the styloid process is a rare condition. Only 4% of patients have clinical symptoms where elongated styloid process (ESP) occasionally irritates or disrupts adjacent anatomical structures, which is called Eagle syndrome. This present report was aimed at reporting an asymptomatic ESP with unusual width and length.

An unusual etiology of posttraumatic Collet-Sicard Syndrome: a case report

Posttraumatic Unilateral paralysis of the last four cranial nerves (IX-XI), known as collet-Sicard syndrome, is rare following closed head injury. A 21-year-old man presented with slurred speech, hoarseness voice and difficulty swallowing his saliva following closed head trauma. The cranial nerve examination revealed left sided severe dysfunction of cranial nerves VII, IX, X, XI, and XII. A CT-Scan of the neck was performed demonstrating a fracture of the left styloid process at the base of the skull. The Magnetic Resonance Imaging showed unusually well seen lower cranial nerves due to nerve edema. The patient was managed conservatively with steroids and regular sessions of neuromuscular and orthophonic rehabilitation. The nutrition had to be administered by gastrostomy since he was unable to swallow. Six months after the injury a total neurological recovery was noted. We present the exceptional case of Collet-Sicard Syndrome caused by styloid process fracture.

Nonsyndromic Isolated Temporal Bone Styloid Process Fracture

Introduction:

Fracture of the styloid process (SP) of the temporal bone is a rare traumatic injury in normal individuals who are not suffering from Eagle’s syndrome. Diagnosis and management of this problem requires comprehensive knowledge about its signs and symptoms. This study aimed to present an isolated styloid process fracture in a nonsyndromic patient.

Case Presentation:

A 50-year-old male patient was referred to our department with a complaint of sore throat. However, presentation of the problem resembled the symptoms of temporomandibular joint disorder (TMD). Fracture of the SP of the temporal bone was detected on the radiographs. Conservative treatment was undertaken for the patient. The symptoms diminished after about four months.

Conclusions:

Physicians should be aware of the signs and symptoms of different pain sources to prevent misdiagnosis and maltreatment.

'Stylo-mandibular complex' fracture from a maxillofacial surgeon's perspective--review of the literature and proposal of a management algorithm

The incidence of fractures of styloid process, either in isolation or association with mandibular fractures, is rare, and frequently overlooked. When present, they pose clinical dilemma in diagnosis and management. Proper management of styloid fractures is essential, not just to alleviate the patients' symptoms, but also to prevent potential complications like post-traumatic styloid syndrome and injury to adjacent vital structures. This article features a review of literature on 'styloid fracture concomitant with mandibular fracture' along with a case report. The article explores the biomechanics resulting in styloid fracture especially when co-existing with mandibular fractures. The article also enumerates the clinical features of this unusual clinical phenomenon and aims at rationalizing the need for its medical or surgical management. A simple protocol for the management of 'stylo-mandibular complex' fracture has been proposed.

Elongated styloid processes and calcified stylohyoid ligaments in a patient with neck pain: implications for manual therapy practice

OBJECTIVE

The purpose of this paper is to present a case of a patient with neck pain, tinnitus, and headache in the setting of bilateral elongated styloid processes (ESP) and calcified stylohyoid ligaments (CSL), how knowledge of this anatomical variation and symptomatic presentation affected the rehabilitation management plan for this patient, and to discuss the potential relevance of ESPs and CSLs to carotid artery dissection.

CLINICAL FEATURES

A 29-year-old male military helicopter mechanic presented for chiropractic care for chronic pain in the right side of his neck and upper back, tinnitus, and dizziness with a past history of right side parietal headaches and tonsillitis. Conventional radiographs showed C6 and C7 spinous process fractures, degenerative disc disease at C6/7, and an elongated right styloid process with associated calcification of the left stylohyoid ligament. Volumetric computerized tomography demonstrated calcification of the stylohyoid ligaments bilaterally.

INTERVENTION AND OUTCOME

Given the proximity of the calcified stylohyoid apparatus to the carotid arteries, spinal manipulation techniques were modified to minimize rotation of the neck. Rehabilitation also included soft tissue mobilization and stretching, corrective postural exercises, and acupuncture. An otolaryngologist felt that the symptoms were not consistent with Eagle syndrome and the tinnitus was associated with symmetric high frequency hearing loss, likely due to occupational noise exposure. Initially, the patient's symptoms improved but plateaued by the fifth visit.

CONCLUSION

Neck pain in the presence of ESPs and CSLs can be associated with Eagle syndrome, which can include ipsilateral head and neck pain, odynophagia, dysphagia, and cerebrovascular symptoms. This case, initially thought to be Eagle syndrome, highlights proper diagnostic workup for this condition and presents potential contraindications to consider with regard to cervical spine manipulation in such patients. Manual therapy precautions pertaining to cervical spine manipulation may be appropriate in cases involving ESPs and calcified stylohyoid ligaments.

Calcification of the stylohyoid ligament in panoramic radiography and cone beam computed tomography among patients referred for dental implant treatment planning

BACKGROUND

Calcification of the stylohyoid ligament (SHL) is a common condition noted as an incidental finding in routine radiographic examination. Due to proximity with important neurovascular structures, elongation and calcification may sometimes lead to dysphagia and pain. The objective of this study was to evaluate the incidence of calcified SHL detected on cone beam computed tomography (CBCT) scans and panoramic radiographs (PR) in patients referred for dental implant therapy.

METHODS

Retrospective analysis of 30 patients referred for dental implants to the Department of Oral and Maxillofacial Radiology at the University of Connecticut School of Dental Medicine was done. Patients were imaged using Hitachi CB MercuRay CBCT machine, and PRs were obtained using Planmeca panoramic machine. CBCT reconstructions and panoramic images were evaluated for the incidence and pattern of SHL calcification.

RESULTS

Nineteen patients (63.3%) had calcified SHLs, 16 of whom were reported to have bilateral involvement. PR was unable to show complete calcification of the ligament in any of the cases, whereas CBCT showed evidence of complete calcification when present (14 cases).

CONCLUSION

CBCT was more accurate in determining the pattern and extent of calcification of the SHL in patients undergoing implant treatment planning.

Complete ossification of the stylohyoid chain as cause of Eagle's syndrome: a very rare case report

AIM

To report on a patient with Eagle's syndrome with a complete and very large ossification of the stylohyoid complex on the right side that to our best knowledge has never been published previously.

BACKGROUND

Eagle's syndrome is characterized by a set of symptoms that are caused by the irritation of the neurovascular and soft-tissues caused by an elongated styloid process or ossification of stylohyoid ligament.

CASE DESCRIPTION

Because of the high discomfort and pain degree as well as limitations of mandibular and head mobility and also the thickness of the ossifed stylohyoid chain, the patient was treated surgically by removing the hypertrophic segment.

CONCLUSION

These symptoms subsided completely after the surgical excision of the anomaly. The elongated styloid process on the left side was symptom free.

CLINICAL SIGNIFICANCE

Eagle's syndrome symptoms are not specific and can mimic those of other disorders, the syndrome must be included in the differential diagnosis of patients with pain in the orofacial, pharyngeal and cervical area.

Fracture of the styloid process associated with the mandible fracture

Fracture of the styloid process (SP) of temporal bone is an uncommon injuries. Fracture of the SP can be associated with the facial injuries including mandible fracture. However, injury to the SP may be concealed and missed diagnosis may lead to the improper or various unnecessary treatments. A rare case of SP fracture associated with the ipsilateral mandibular fracture and also the diagnostic and management considerations of the SP fracture are discussed.

Symptomatic Elongated Styloid Process or Eagle's Syndrome: A Case Report

Elongation of the styloid process or stylohyoid ligament calcification is a well recognized finding of dental prac-tice, and an incidence of 4 to 30 percent has been reported on radiographs. Rarely, complete mineralization of the stylohyoid ligament or elongation of styloid process has been associated with difficulties in intubation and significant clinical symptoms, which is termed Eagle’s syndrome, and it exhibits dull or sharp intermittent pain felt along the glossopharyngeal nerve that is located in the hypopharynx and at the base of the tongue and recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In the case presented, the elongated process caused a broad tenderness in left lateral and posterior cervical as well as temporal regions.