Bursitis of the hamular process. Part II: Diagnosis, treatment and report of three case studies

Pterygoid hamulus syndrome: a case report

Introduction: Pterygoid hamulus syndrome (PHS) is a little-known differential diagnosis of orofacial pain. It is characterized by oropharyngeal pain, secondary to inflammatory bursitis of the tensor veli muscle of post-traumatic origin, frequently fostered by an associated hypertrophy of the hamular process. Observation: A 64-year-old female patient, type 2 diabetic, consulted for constant posterior palatal pain located near to 17, lasting for 10 years. The inspection did not reveal any mucosal lesions. Right hamulus palpation increased the pain and revealed hamulus hypertrophy. A diagnosis of PHS was evoked. Comment: A review of the literature is proposed. The treatment of PHS is initially conservative, but a surgical treatment can be proposed in case of morphological anomalies. Conclusion: PHS is a little-known syndrome whose diagnosis must be mentioned by the oral surgeon faced with chronic oropharyngeal pain. The diagnosis is clinical and radiological, the treatment is medical and/or surgical.

The Pterygoid Hamulus Syndrome - An Important Differential in Orofacial Pain

The purpose of this review was to document cases of pterygoid hamulus (PH) syndrome and to describe the various etiology, differential diagnosis, and management strategies so far reported in literature. Here, we also present two case reports of PH syndrome. A comprehensive search in PubMed/Medline database was done using MeSH terms such as "Pterygoid Hamulus," "Pterygoid Hamulus Syndrome," and "Hamular Bursitis" using various Boolean operators such as "AND" and "OR". Till date, 31 cases of this entity including the present cases have been found. Conservative management was followed in the earlier reported cases; however, most cases were treated by surgical resection.

Pterygoid Hamular Bursitis: A Possible Link to Craniofacial Pain

A striking feature of the skull base is the pterygoid hamulus known for its bizarre morphology and biomechanical location. Pterygoid hamular bursitis is an inflammation of bursae located between the tendon, muscle, and bony prominences. The minimal objective finding in an apparently normal orofacial apparatus and dependence on the subjective symptoms experienced by the patient with widespread referral pattern often perplexes the clinician. Bursitis should be considered in the differential diagnosis of craniofacial neuralgia, temporomandibular joint dysfunction, and chronic craniofacial pain. Clinical signs and symptoms of this intriguing entity are diverse and multifaceted that can sometimes demand services of clinicians across various specialties considering the anatomic density of the region. Care must be taken to avoid delay, misdiagnosis, and overtreatment.

Pterygoid hamulus bursitis as a cause of craniofacial pain: a case report

Pain on the soft palate and pharynx can originate in several associated structures. Therefore, diagnosis of patients who complain of discomfort in these areas may be difficult and complicated. Pterygoid hamulus bursitis is a rare disease showing various symptoms in the palatal and pharyngeal regions. As such, it can be one of the reported causes of pain in these areas. Treatment of hamular bursitis is either conservative or surgical. If the etiologic factor of bursitis is osteophytic formation on the hamulus or hypertrophy of the bursa, resection of the hamulus is usually the preferred surgical treatment. We report on a case of bursitis that was managed successfully by surgical treatment and a review of the literature.

Evaluation of the pterygoid hamulus morphology using cone beam computed tomography

OBJECTIVE

This study consists of anatomic research of the pterygoid hamulus (PH) using 3D cone beam computed tomography (CBCT) images reconstructed from a volumetric rendering program.

STUDY DESIGN

Three hundred ninety-six sides in the CBCT scans of 198 (115 men and 83 women) patients were retrospectively analyzed. DICOM data of the patients were transferred to a surface-rendering software so as to generate 3D hard tissue surface representations of PHs. The width, length, angle, and the distance between posterior nasal spine and tip of the PH were measured. In addition, the inclinations of PHs were also evaluated in sagittal and coronal planes of the 3D images. Pearson χ(2) and Student t test were performed for statistical analysis among age, localization, and measurements (P < .05).

RESULTS

The mean PH measurements of left and right sides were 1.72 (SD 0.94) and 1.87 (SD 1.17)-mm width, and the lengths were 5.48 (AD 1.94), and 5.40 (SD 2.0) mm, respectively, with no significant difference (P > .05). All PHs were inclined toward the lateral side in the coronal plane, whereas PHs tended to incline toward the posterior rather than anterior in the sagittal plane (∼78%). The results showed no statistically significant differences among age, localization, and measurements of PHs (P > .05).

CONCLUSIONS

Knowledge about the morphology of these structures is helpful for the interpretation of imaging and provides valuable information in the differential diagnosis of untraceable pains in the oral cavity and pharynx. Because of potential problems owing to PH morphology and elongation, oral and maxillofacial radiologists should assess the radiographic images thoroughly.

Primary yawning headache

To describe three patients with recurrent severe paroxysmal headache precipitated by yawning. Pain elicited by yawning is a well-recognized clinical phenomenon in patients with cranial neuralgia, temporomandibular joint dysfunction syndrome and Eagle syndrome. Clinical history, neurological and oral examinations, brain magnetic resonance imaging (MRI), cranial nerve electrophysiological testing and skull X-rays are reported. In all the patients pain was induced by yawning; in the third patient pain was also triggered by eructation. None had history of migraine. Facial gestures and forceful opening of the mouth did not reproduce the pain. The first patient had retroauricular pain, simvastatin-induced myopathy and subclinical axonal peripheral neuropathy; the second patient had a post-viral benign sensory neuropathy; and the third had retroauricular and facial pain and no underlying neurological illness. Cranial nerve testing and MRI of the brain were normal except for a coincidentally found pituitary adenoma on the first patient. Headache or cranial pain with yawning may occur in patients with no apparent cause (primary yawning headache). It is a chronic, benign condition that requires no specific treatment but needs to be distinguished from secondary yawning headache, of greater clinical relevance.