Extracranial internal carotid artery-dissecting aneurysm having a re-entry tear and causing lower cranial nerve palsies treated with flow-diverting stent: A case report

Background

Extracranial internal carotid artery (ICA)-dissecting aneurysms (DAs) rarely cause re-entry tears and lower cranial nerve palsies. The therapeutic strategies for these pathologies are not well established. This report presents a case of an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy.

Case Description

A 60-year-old man presented with left neck pain, hoarseness, and dysphagia. Physical examination and laryngoscopy determined palsies of the left cranial nerves IX, X, and XII. Digital subtraction angiography (DSA) revealed a DA in the left extracranial ICA, and three-dimensional DSA showed entry and re-entry tears in the intimal flap. Flow-diverting stents (FDSs) were placed on the lesion that covered the entry and re-entry tears because the symptoms did not improve after five weeks of conservative treatment. A post-procedural angiogram indicated flow stagnation in the DA. Symptoms improved remarkably immediately after the procedure, and the aneurysm was almost completely occluded six months later.

Conclusion

Herein, an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy did not improve after five weeks of conservative treatment. FDS placement promptly resolved the aneurysm and symptoms. Thus, FDS placement may be an effective treatment option for extracranial ICA-DAs with re-entry tears or lower cranial nerve palsies.

Bilateral carotid dissection due to Eagle syndrome

Eagle syndrome is defined as a collection of symptoms affecting the cervical and cranial regions, resulting from an elongated styloid process or ossified stylohyoid ligament encroaching on surrounding structures and causing a variety of symptoms. Classically, Eagle syndrome presents as neck, throat, or ear pain. Carotid artery dissection is a rare complication of Eagle syndrome. We report the case of a 40-year-old man who presented with bilateral internal carotid artery dissection secondary to pathological elongation of the styloid processes.

Internal carotid artery dissection caused by elongated styloid process

A 69-year-old man with impaired consciousness, right hemiplegia, and aphasia was admitted to our emergency room for thorough examination. Magnetic resonance imaging (MRI) and 3-dimensional computed tomography (3D CT) scan of the head revealed a cerebral infarction due to dissection of the left internal carotid artery. Contrast-enhanced CT prior to internal carotid artery stenting showed that the left elongated styloid process ran in close proximity to the left internal carotid artery, with a minimum distance of 2 mm. The patient underwent stenting at the internal carotid artery 16 days after disease onset. The patient was referred to our department for left elongated styloid process resection to reduce the risk of further internal carotid artery injury. Resection of the left styloid process through a cervical incision was performed. Six months after surgery, there was no recurrence of the internal carotid artery dissection.

Eagle syndrome: An updated review

Background

This work aims to review the current literature and our experience on vascular Eagle syndrome (ES) that can present misleading clinical presentations and better understand the possible therapeutic strategies.

Methods

We reviewed the existing literature on PubMed from January 1, 2017, to December 31, 2022, including the sequential keywords "vascular AND Eagle syndrome," "vascular AND styloid syndrome," "vascular AND elongated styloid process," "vascular AND stylocarotid syndrome," and "Eagle syndrome AND carotid artery dissection."

Results

38 vascular ES cases, including our experience, were analyzed. The most frequent clinical onset was hemiparesis (n 21, 57%), but other regular clinical presentations were aphasia, loss of consciousness, amaurosis, headache, or a combination of the latter. Massive oral bleeding was reported only once in the literature before our case. Twelve patients were treated with only antiplatelet therapy, either single or double. Nine patients were treated with anticoagulation therapy only. In 14 patients, a carotid artery stent was used, associated with anticoagulation or antiplatelet therapy. In 17 cases, a styloid process (SP) resection was performed.

Conclusion

ES has many clinical presentations, and carotid artery dissection resulting in oral bleeding seems rare. Literature results and our experience make us believe that when dealing with vascular ES, the best treatment strategy is endovascular internal carotid artery stenting with antiplatelet therapy, followed by surgical removal of the elongated SP to prevent stent fracture.

The prevalence of elongated styloid process in the population of Barcelona: a cross-sectional study & review of literature

BACKGROUND

Styloid process (SP) is a cylindrical bony projection that originates from the inferior part of the petrous temporal bone just anteriorly to the stylomastoid foramen. Several nerves, muscles, and ligaments are related closely to the (SP). It is considered elongated when the measurement exceeds 30 mm. The overall prevalence of the styloid process is between 3.3% to 84.4%. The elongation of the styloid process (ESP) is associated with the manifestation of Eagle's Syndrome (ES) which is characterized by various types of pain in the head and neck region such as headache, tinnitus, otalgia, and trigeminal neuralgia. Eagle's syndrome occurs in 4-10.3% of individuals with an elongated styloid process (ESP). The objective of the study is to determine the prevalence of (ESP) in the patients who were treated in the Dental Hospital University of Barcelona (HOUB), to review the literature to spot the light on the different demographic data worldwide.

METHODS

The archived panoramic image in the University of Barcelona dental Hospital were consecutively retrieved to investigate the prevalence of (ESP). Of all digital panoramic radiographs (OPG), 400 met the inclusion criteria and were furtherly analyzed. The results are correlated with the participant's gender, age, and occurrence. Age is subcategorized into three groups. A chi-square test is used to measure the significant differences and the P-value is set at < 0.05 for the level of significance.

RESULTS

Among the included 400, we found 291 demonstrating (ESP). The prevalence of (ESP) which exceeds 30 mm is 72.75%. It is found that the most common morphological type is type 1 which is regarded as the uninterrupted (ESP) regardless of gender and age group. Concerning the calcification pattern, the most prevalent is the partial calcified (ESP) despite genders and age groups.

CONCLUSION

(OPG) is a sufficient tool for the screening of the elongated styloid process. Regarding the prevalence, our results are considered higher than previously reported prevalence in different populations using (OPG) radiography tool. A study on a wider spectrum of the Spanish population is recommended to further investigate the correlation between the elongated styloid process and the occurrence of Eagle's syndrome.

Cerebral infarction caused by coexisting elongated styloid process and carotid web

OBJECTIVE

Elongated styloid process (ESP) and carotid web are rare etiologies of ischemic stroke. We report a rare case of ESP concomitant with carotid web as the cause of recurrent stroke.

CASE PRESENTATION

A 59-year-old man was admitted to our hospital with recurrent numbness and weakness in the right upper extremity. The patient had a long-standing history of lightheadedness and left-side amaurosis with neck flexion. Magnetic resonance imaging (MRI) confirmed scattered infarctions in the left frontal and parietal lobes. After multi-modal imaging we determined that embolic cerebral infarction was most likely to be secondary to the carotid web. Moreover, ESP causes dynamic hypoperfusion during neck flexion. We believe that this is a good reason for dealing with both pathologies during the same surgery. Thus, carotid endarterectomy and styloid process resection were performed at the same time. The previous symptoms during the head position change did not recur, and the right hand weakness was resolved.

CONCLUSION

ESP and carotid web are unusual mechanisms of ischemic stroke. Early diagnosis and timely treatment are essential to prevent subsequent severe strokes.

Carotid artery type of Eagle syndrome: an uncommon cause of ischemic stroke

Acute ischemic stroke in patients younger than the age of 50 years is a rare occurrence that results in high mortality and substantial loss of functional years of life. Internal carotid artery dissection (CAD) presents a rare, but serious condition that needs to be fully evaluated and carefully treated, as it may lead to an acute ischemic stroke in all, but mostly in younger patients. A possible cause for CAD, the carotid artery type of Eagle syndrome (ESy), is atypical and underrecognized. In this case report we present a case of a young patient with carotid artery type of ESy, resulting in a severe acute ischemic stroke. Only recognition of such a syndrome in its early symptomatic phase could allow appropriate management to prevent this kind of a deleterious outcome.

Of Eagle's Syndrome and Finding Some Clarity on Its Management

Eagle's Syndrome is a much discussed yet controversial and debatable diagnosis of exclusion which is treated by many specialities with often unsatisfactory results. Due to entrapment/impingement on surrounding neurovascular structures by elongated styloid process patient may present with multitude of symptoms. Treatment is controversial and opinions are divided on choice of conservative and surgical management. Aim was to study outcomes of conservative and surgical modalities of treatment of Eagle's Syndrome and bring some clarity on management, what to offer, to whom and when. This prospective observational descriptive study included 15 patients of Eagle's Syndrome, 7 were treated with conservative method and 8 underwent resection of styloid process with intraoral approach. With objectives in mind to study efficacy of both management modalities, pain visual analogue scale (VAS) scores were recorded pre-intervention, post-intervention and during follow up on 1, 3 and 6 months and compared. Conservative management resulted in up to 70% reduction in pain VAS scores till 3 months of therapy (mean pre-intervention score being 3.71, 3 months-1, 6 months-1.29), while surgical modality resulted in nearly 99% reduction in mean pain VAS scores up to 3 months and even improved after 6 months (mean pre-intervention score being 6.75, 3 months-0.5, 6 months-0.13). With this we can conclude that conservative management provide satisfactory short-term (up to 3 months) results but recurrences are known, while surgical resection of elongated styloid process gives better long-term results (6 months and beyond).

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.

Carotid micromesh stent for the cervical carotid artery dissecting aneurysm in a patient with vascular Eagle syndrome

OBJECTIVES

An elongated styloid process may cause vascular Eagle syndrome that includes cervical carotid artery (CCA) dissection with stenosis and aneurysm formation. There are only four reported cases with vascular Eagle syndrome-related CCA dissecting aneurysm treated with carotid artery stenting (CAS). This is the first report of applying a dual-layer nitinol micromesh stent (CASPER) for vascular Eagle syndrome-related CCA dissecting aneurysm.

CASE PRESENTATION

A 38-year-old man presented with a sudden onset of aphasia and right hemiplegia. Cerebral angiography demonstrated the left CCA dissecting aneurysm. The superior trunk of the left middle cerebral artery (MCA) was also occluded, and emergent thrombectomy was performed. Computed tomography with angiography (CTA) revealed that a 33 mm-long styloid process compressed the CCA at the aneurysm formation. Three weeks later, a CASPER stent was applied for the CCA aneurysm under the flow reversal system. Immediately after stent placement, blood flow in the aneurysm became stagnant, and postoperative CTA demonstrated regression of the aneurysm. The aneurysm did not recur for 6 months with no styloid process resection.

CONCLUSIONS

The dual-layer nitinol micromesh stent (CASPER) was useful to treat vascular Eagle syndrome-related CCA dissecting aneurysm.

Retrospective study of the styloid process in a Taiwanese population using cone beam computed tomography

Background/purpose

Review of literature, evaluation of the styloid process (SP) using cone beam computed tomography (CBCT) has not been performed in a Taiwanese population. Our study aimed to evaluate the different characteristics of SP using CBCT in a Taiwanese population.

Materials and methods

CBCT scans of 121 patients (55 males, 66 females; mean age, 27 ± 9.09 years) were evaluated to assess the length, morphological type, calcification pattern, and angulation of the SP. A SP length greater than or equal to 30.00 mm is considered to indicate an elongated SP (ESP). ESP was classified in terms of morphology as Type I: uninterrupted; Type II: pseudo-articulated; or Type III: segmented. The calcification pattern of SP was categorized as Type A: calcified outline; Type B: partially calcified; Type C: nodular; or Type D: completely calcified. The transverse and sagittal angles between the bilateral SP were also measured.

Results

One-hundred and nine patients had a bilateral SP and 12 patients had a unilateral SP. The mean SP length was 26.34 ± 7.44 mm. Forty-two (34.71%) patients had an ESP. The most common ESP morphology was Type 1, followed by Type II, then Type III, while the calcification pattern prevalence was of the descending order Type B, Type A, Type C, and Type D. The mean transverse and sagittal angles were 66.90 ± 5.41° and 26.67° ± 6.50°, respectively.

Conclusion

The present study was the first to evaluate the characteristics of SP in a Taiwanese population using CBCT. The data contribute a useful basis for clinical investigation of the SP in future.

Prevalence and features of elongated styloid process on imaging studies: a systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of the elongated styloid process (ESP) and its characteristics, such as sex and age of the patient, unilateral and bilateral incidence, besides variations between different populations and panoramic and CBCT examinations.

MATERIALS AND METHODS

A search was performed in six databases (PubMed, Web of Science, Scopus, Cochrane, Lilacs, and Embase) to identify observational studies that used imaging exams and assessed ESP prevalence among panoramic radiograph CBCT examinations, whose transversal prevalence studies were included. Furthermore, studies with a specific group of patients or symptomatic patients were excluded. Additionally, Joanna Briggs Institute checklist was used to evaluate the quality of the studies. A meta-analysis was conducted, then subgroup analyses were performed by grouping studies according to the secondary outcomes, with a significance level set at 5%. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the certainty in the evidence.

RESULTS

The initial search resulted in 1635 studies, from which 39 articles met the inclusion criteria, encompassing 50,655 participants. The sample size varied between 82 and 5,000 participants. The prevalence of the ESP ranged from 1.3 to 94.8%, with an overall prevalence of 30.2%. The bilateral occurrence was higher than the unilateral one, but no significant predilection was observed according to sex, age, or population. The type of imaging examination also showed no difference in its detection.

CONCLUSION

The overall prevalence of ESP was 30.2%, with a propensity for bilaterality, but not for any sex, age, or population geographic location. The imaging examination modality did not influence the diagnosis of ESP. However, the quality level of the studies evaluated was very low, demonstrating the need for more homogeneous primary studies on the prevalence of the ESP with a more standardized methodology.

CLINICAL RELEVANCE

There is no consensus in the literature regarding the prevalence of the ESP and the characteristics of the affected patients that can cause chronic and debilitating discomfort in the head and neck region. Therefore, knowledge about the prevalence and characteristics of this condition would help dental clinicians reach the correct diagnosis.

Recurrence of internal carotid artery dissection associated with elongated styloid process: A case report

Background

An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process has good outcomes when treated conservatively; however, long-term follow-up has not been attempted and recurrence in the later period has not been reported so far. We report a case of recurrence of symptoms over a decade after the initial onset.

Case Description

A 59-year-old man experienced a transient ischemic attack (TIA) 10 years ago. Six years ago, he experienced hemispheric TIA, and magnetic resonance angiography revealed a diminished signal of the left ICA; however, no further examination was performed. Four years ago, he experienced another transient amaurosis attack and was treated with antiplatelet therapy because no embolic source was detected using ultrasonography examination, and he was diagnosed with idiopathic ICA dissection. Recently, he experienced a third amaurosis fugax attack. Digital subtraction angiography and cone-beam computed tomography demonstrated left cervical ICA dissection due to elongated styloid process. He underwent surgical resection of the left styloid process and cervical stent placement. He had no ischemic attacks postoperatively.

Conclusion

The elongated styloid process may cause recurrent ischemic attacks over a decade due to ICA dissection.

Bilateral carotid dissection due to Eagle syndrome in a young female

Eagle syndrome (ES) is a rare clinical syndrome characterized by the elongation of the temporal bone's styloid process, or calcification of stylohyoid ligament, compressing surrounding structures causing pharyngalgia. One of its variants, the styloid-carotid artery syndrome, produces symptoms by compression of the external or internal carotid arteries (ICA). Here, we present a case of a 43-year-old woman with ES and bilateral ICA dissections. The patient underwent staged bilateral angioplasty and covered stent placement, followed by styloidectomy. A computerized tomography angiogram revealed patency of both stents at a two-year follow-up.

•

Bilateral carotid artery dissection due to Eagle Syndrome is extremely rare.

•

Limited evidence exists on the management of styloid-carotid artery syndrome.

•

There is a strong male predominance and high rates of infarcts on this entity.

•

Endovascular treatment in the acute phase may help reduce new/recurrent strokes.

Eagle Syndrome: 3D endoscope-assisted anterior tonsillar fossa approach to styloid process

BACKGROUND

The aim of this study was to describe the potential advantages of the 3D endoscope-assisted anterior tonsillar fossa approach to elongated styloid process.

METHODS

A 58 years-old woman was reported to our Department with one-year history of odynophagia, latero-cervical pain on the left side, and ipsilateral foreign body sensation. Pain was dull and intermittent in nature. The patient had visited different clinics, she had a physiatric and maxillo-facial evaluation with two dental extraction without any relief of the symptoms. On physical examination a hard-bony consistency area was palpated over left-sided tonsillar fossa, evocating severe pain. Three-dimensional computed tomography (CT) confirmed an anomalous length of the left styloid process and a diagnosis of Eagle's syndrome (ES) was made. After careful surgical and anesthesiology evaluation, we decided to proceed with the partial excision of the styloid process with a 3d endoscope-assisted transoral anterior tonsillar fossa approach (Reddy et al., 2020).

RESULTS

The patient was relieved of her symptoms after the surgery and was discharged after 1 day. Postsurgical healing was uneventful, pharyngodynia was observed for the first 48 h and treated with anti-inflammatory medication. No early or late postoperative complications, including massive bleeding, neurovascular injury or infection, were encountered. At 1 year follow up visit the patient was still asymptomatic and the CT scan did not show any abnormalities. The 3D endoscope provided a high-quality magnification of the tonsillar fossa, which allow us to correctly identify the site of incision. Styloid process was identified through digital palpation. After sufficient dissection of the tip, the distal part of the elongated styloid process was osteotomised and retrieved with a curved instrument. Local hemostasis was achieved and wound was closed in layers.

CONCLUSION

Some authors suggested novel surgical approach for ES like transoral robotic surgery (Rizzo-Riera et al., 2020 [2]). We present the 3D endoscope-assisted anterior tonsillar fossa approach as a feasible alternative for the surgical management of ES. Our experience with this approach has been outstanding, guaranteeing an optimal vision and depth of the surgical field with safe manipulation of the instruments which avoided injuries to healthy tissue. Furthermore, 3d endoscope was a great didactic tool. In our opinion is not necessary to remove all the styloid process, as other authors suggest (Lisan et al., 2019 [3]), but is sufficient a partial styloidectomy after cutting the stylohyoid ligament.

Dural Arteriovenous Fistula Formation as Eagle Jugular Syndrome: A Case Report and Literature Review

BACKGROUND

An elongated styloid process can less frequently lead to symptomatic compression of the internal jugular vein (IJV). We present the first case of dural arteriovenous fistula (DAVF) in association with compressed IJV by an elongated styloid process.

CASE DESCRIPTION

A 77-year-old woman presented with pulsating tinnitus. DAVF at the right hypoglossal canal was diagnosed, and she underwent transvenous embolization. The shunt flow was reduced, and the symptom disappeared after transvenous embolization. However, 2 years and 8 months later, retrograde sinus drainage from the residual shunt was asymptomatically found on magnetic resonance imaging, and angiography revealed progression of IJV stenosis caused by an elongated styloid process. Subsequently, she underwent a second transvenous embolization, and the arteriovenous shunt was almost completely obliterated.

CONCLUSIONS

The present case suggests that venous hypertension by compressed IJV can induce the development of DAVF. It is helpful for the diagnosis and treatment of DAVF to keep in mind the possibility of IJV stenosis owing to an elongated styloid process.

Cervico-facial pain associated with Eagle's syndrome misdiagnosed as cranio-mandibular disorders. A retrospective study

AIM OF STUDY

a retrospective study was done to assess symptoms correlated with and responsible for the misdiagnosis of Eagle's syndrome with Cranio-Mandibular Disorders.

MATERIALS AND METHODS

Our study comprised patients suffering from vague craniofacial pain resulting from elongated styloid processes, presented to the outpatient clinic of the oral and maxillofacial surgery department, October 6 University Hospital. The length of styloid processes was measured on 3D-CT X-rays. All our patients were operated by surgical treatment in the form of shortening of the styloid process (styloidectomy) under general anaesthesia and followed up clinically as well as radiographically for 12 months.

RESULTS

Patients were assessed preoperatively as well as postoperatively throughout the following scheduled regular follow up intervals at 1 week and at 1,3,6 and 12 months postoperatively for the following parameters. VAS pain score gradually decreased from a median of 9, with a minimum of 7 and a maximum of 10 pre-operatively to a median of 1.5, with a minimum of 0 and a maximum of 3 at twelve months. Freidman test revealed a statistically significant difference by time. Maximum unassisted mouth opening was assessed. Mouth opening significantly decreased from 30.23 ± 3.28 pre-operatively to 26.08 ± 2.83 after one week, then gradually increased to reach its highest level (43.56 ± 0.72) at twelve months.

CONCLUSION

When dealing with cases of vague craniofacial pain, possibility of Eagle syndrome should be considered.

Evaluation of styloid chain calcification related to temporomandibular joint disc displacement: a retrospective cohort study

OBJECTIVES

The present study aimed to evaluate any relationship between elongated styloid process (ESP) and temporomandibular joint disc displacement (TMJD).

STUDY DESIGN

A retrospective cohort study.

SETTING

Dentomaxillofacial Radiology division of Erciyes University Dental Hospital.

PARTICIPANTS

Ninety-four temporomandibular joints (TMJs) of 47 patients were allocated in this study. Intervention-disease: Two experienced dentomaxillofacial radiologists have interpreted all CBCT and MR images. Patients who referred with TMJ disorders were classified according to temporomandibular joint's disc status as normal disc position (ND), displacement with reduction (DWR) and displacement without reduction (DWoR).

METHODS

Main outcome measures: Interpretation of styloid chain calcification pattern and styloid processes length measured linearly on reconstructed sagittal slices of CBCT. Randomization: Cone beam computed tomography (CBCT) and magnetic resonance (MR) images of 154 patients who were admitted between September 1, 2012 and September 1, 2019. Only 47 of them fulfilled the study requirements. Blinding: Single blind of the outcome measurements and interpretations of MR images.

RESULTS

Total 94 TMJs of 47 patients disc status groups were analyzed and defined as DWoR (n = 25), DWR (n = 32), and ND (n = 37). On multivariate analysis, no statistical significant differences were found between groups in terms of styloid process lengths. Mean SP length and standard deviation of disc status groups (DWoR, DWR, and ND) are 35.5 (± 9.8) mm, 34.6 (± 9.2) mm, and 38.3 (± 8.9) mm, respectively. When patients were grouped individually according to their post-MRI diagnosis, the mean styloid process length in the non-temporomandibular joint disc displacement (non-TMJD) patients (47.9 ± 10.8) was significantly higher than the TMJD patients (36.1 ± 9.3). In this study, there is no intervention to cause any harm or side effects.

CONCLUSION

Our results indicate that styloid-stylohyoid syndrome may be misdiagnosed with temporomandibular joint disorder (TMD).

TRIAL REGISTRATION

Clinical Trials NCT04280107.

The eagle jugular syndrome

BACKGROUND

The elongation of the styloid process is historically associated with two variants of the Eagle syndrome. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein.

METHODS

We reviewed all the cases of Eagle syndrome, including the jugular variant, admitted in our Hospital in the last six years. We compared symptomatology, associated comorbidities and imaging. Data were statistically analyzed.

RESULTS

Overall 23 patients were admitted to the Hospital for symptomatic elongation of the styloid process, 11 male and 12 females. The jugular variant of the Eagle syndrome is clinically delineated by significant differences, as compared to the classic variant and carotid variants. Headache was the more prominent symptom (p < .009) as well as a documented peri-mesencephalic hemorrhage was the more significant comorbidity (p < .0003). The group classic-carotid variant was characterized by ipsilateral pain respect to the jugular variant (p < .0003). CT angiography with venous phase extended to the neck veins and imaging reconstruction is highly recommended as imaging technique, complemented by color-Doppler ultrasound.

CONCLUSIONS

The elongation of the styloid process may have different paths which creates compression on the surrounding anatomical structures. There may be a possible association of jugular impingement by an elongated styloid process with symptoms.

TRIAL REGISTRATION

Protocol n°45-2013.

Internal jugular vein stenosis associated with elongated styloid process: five case reports and literature review

Background

Internal jugular vein stenosis (IJVS), characterized by a series of clinical manifestations, such as head and neck symptoms, visual and ear symptoms, as well as sleep disorder, has been receiving attention in recent years. However, its’ etiologies are not fully understood.

Case presentation

We report a cases series of IJVS induced by styloid oppression. We define it as the stylo-jugular type of Eagle syndrome (ES).

Conclusions

Our study reveals that external oppression, especially by styloid process, is an important etiology of IJVS. The stylo-jugular ES diagnosis can be identified by Computed tomography venography. Whether stylo-jugular ES can be corrected by styloidectomy requires further investigation.

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.

Bilateral hypoglossal nerve paralysis following elongated styloid process resection: case report

We report a case of anesthetic management of a 43-year-old patient with Eagle's syndrome (ES) in whom post-extubation acute airway obstruction occurred due to bilateral hypoglossal nerve paralysis. After an accurate examination, elongated bilateral stylohyoid ligament was observed and surgical resection was planned. After completion of the surgery following extubation, significant dysfunction in swallowing, speech function, and tongue motion was observed. The clinical situation was evaluated as bilateral hypoglossal nerve paralysis related to the procedure. The patient was closely observed over 48 h in the intensive care unit. After 2 days, the patient was discharged to a surgical ward. Following clinical assessment, the patient was discharged from hospital for monthly return. At the 6-month follow-up, there were no further episodes of paresthesia and other symptoms. In conclusion, patients with ES represent a real challenge for physicians from diagnosis to treatment, especially regarding perioperative complications, and close collaboration between surgeons and anesthesiologists is of crucial importance.

A Case of a Very Elongated Styloid Process 8 cm in Length with Frequent Throat Pain for 10 Years

We experienced a case of an elongated styloid process that was 8 cm in length. The patient was a 68-year-old Japanese man with frequent episodes of left-sided throat pain for 10 years. The elongated styloid process could be diagnosed by 3D-computed tomography (left and right length: 7.8 cm and 8.0 cm, respectively) and successfully treated with surgery, since the anatomic relationships could be fully visualized. Surgical methods for shortening an elongated styloid process involve an intraoral or external approach. The external approach to the styloid process involves a trans-cervical approach to the parapharyngeal space, which enables wider visualization in the operative field than an intraoral approach. In the present case, the styloid process reached the parapharyngal space. Therefore, we selected the external approach and shortened only the left-sided styloid process (the same side as the throat pain). The chief complaint disappeared immediately after the operation.

Does the state of dentition effect the type of stylohyoid chain calcification pattern?

INTRODUCTION

The human stylohyoid chain calcification patterns (SCP) present considerable anatomic variability. This study was performed to investigate the calcification on SCP in the dentate and total edentulous population and its relation to mandibular protrusive movement.

MATERIALS AND METHODS

The study analyzed 1.234 SCP in digital panoramic radiographs of 617 subjects. The SCP were classified according to Mac Donald-Jankowski. The amount of mandibular protrusion movement limitation was evaluated for each subject. The data were analyzed using one-way Anova, Kruskall Wallis, Mann-Whitney U, and Chi-squared tests with significance set at p = 0.05.

RESULTS

Among the 617 subjects evaluated there was symmetry of the SCP between the left and right sides in 87.3 % of the cases. In the study population 501 subjects were dentate (Class I, Class II, Class III molar relationship) and 116 subjects were total edentulous. There were significant differences among dentate and total edentulous patients for the distribution of SCP (p < 0.05). Elongated group was more prevalent in total edentulous subjects while in subjects with Class I occlusion normal SCP was observed. Although mandibular protrusive movement range was within normal limits for all the groups, calcified and elongated groups have numerically less protrusive movement compared to normal groups (p < 0.05).

CONCLUSION

Among dentate and total edentulous subjects, similarity in SCP for right and left side was observed. The elongation of SCP was more common in the total edentulous group. Further studies conducted on larger populations are necessary to establish the effect of the state of dentition on the SCP.

Eagle's syndrome: a case report

Eagle's syndrome is a disease caused by an elongated styloid process or calcified stylohyoid ligament. Eagle defined the disorder in 1937 by describing clinical findings related to an elongated styloid process, which is one of the numerous causes of pain in the craniofacial and cervical region. The prevalence of individuals with this anatomic abnormality in the adult population is estimated to be 4% with 0.16% of these individuals reported to be symptomatic. Eagle's syndrome is usually characterized by neck, throat, or ear pain; pharyngeal foreign body sensation; dysphagia; pain upon head movement; and headache. The diagnosis of Eagle's syndrome must be made in association with data from the clinical history, physical examination, and imaging studies. Patients with increased symptom severity require surgical excision of the styloid process, which can be performed through an intraoral or an extraoral approach. Here, we report a rare case of stylohyoid ligament bilaterally elongated to more than 60 mm in a 51-year-old female. We did a surgery by extraoral approach and patient's symptom was improved.

Eagle's syndrome

Eagle's syndrome is a rare entity, which is not commonly suspected in clinical practice. The occurrence of similar signs in diseases other than Eagle's syndrome may make a precise diagnosis difficult and time-consuming for many clinicians. Radiological examinations are useful to make the accurate diagnosis. Three-dimensional volume-rendering CT scan is the most valuable diagnostic tool.

A case of bilaterally elongated styloid process differing in osseo-morphology

In a cranium of a male cadaver styloid processes have been found to be unusually long with different lengths. Elongation of styloid process involvethe entire 'Stylohyoid complex/chain', though not rare as reported in earlier literatures, but the osseomorphological and radiological analysis of present case brings out a unique variety as its described in the article.

Evaluation of Elongated Styloid Process in Patients with Oral Submucous Fibrosis Using Panoramic Radiographs

INTRODUCTION

Oral submucous fibrosis (OSF) is an insidious disease affecting the oral cavity, pharynx, and upper digestive tract. It is characterized by a juxtaepithelial inflammatory reaction followed by fibroelastic change in the lamina propria and associated epithelial atrophy. Higher levels of TGF-β present in patients with OSF could be responsible for impetus to remnants of Reichert's cartilage present in styloid complex leading to partial or complete ossification of associated ligaments. So, a study was conducted to evaluate the elongation of the styloid process in patients with OSF by using panoramic radiographs.

MATERIALS AND METHODS

Panoramic radiographs of patients with OSF were studied from 2007-2011. The apparent lengths of styloid process were measured with the help of divider and steel metric ruler. The length of the styloid process and/or ossification of stylomandibular ligaments which were longer than 30 mm were considered.

RESULTS

Out of 47 patients, 35 patients (34 males & 1 female) met the inclusion criteria. Eleven patients (31.4%) were found to have elongated styloid processes which included 10 male patients and 1 female patient.

CONCLUSION

It had been estimated that between 2 % and 4% of the general population presents radiographic evidence of an ossified portion of the styloid complex. The high incidence of elongation of styloid process (31.4 %) in patients with oral submucous fibrosis highlights that progressive OSF might have some influence on elongation of styloid process.

Tonsillo-Styloidectomy for Eagle's Syndrome: A Review of 15 Cases in KVG Medical College Sullia

Elongated styloid process causing Eagle's Syndrome is a rare clinical entity and the diagnosis is often difficult as a result of its vague symptomatology. However, palpation of tonsillar fossa with radiological demonstration of the elongated styloid process confirms the diagnosis. This is a report of a retrospective study conducted at the KVG Medical College, Hospital, Sullia, Karnataka, India where 15 patients who were surgically treated for Eagle's syndrome in the ENT department were retrospectively studied. Fourteen patients became symptom free after surgery within three months of follow up. Tonsillo-styloidectomy is the treatment of choice for Eagle's syndrome with a high success rate.

Eagle's syndrome - A case report and review of the literature

Eagle's syndrome (ES) occurs when an elongated styloid process or calcified stylohyoid ligament causes 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. The symptoms related to this condition can be confused with those attributed to a wide variety of facial neuralgias. ES can be diagnosed radiologically and by physical examination. The treatment of ES is primarily surgical. The styloid process can be shortened through an intraoral or external approach. In this paper a case of ES exhibiting unilateral symptoms with bilateral elongation of styloid process is reported and the literature is reviewed.

Significance of styloidectomy in Eagle's syndrome: an analysis

OBJECTIVES/HYPOTHESIS

Reported here is a randomized retrospective analysis of 28 cases of elongated styloid process causing nagging cervicofacial pain, both unilateral and bilateral, and the effect of styloidectomy in these cases in relieving the symptom complex of the patient, in situations where conservative management failed in alleviating the symptoms.

STUDY DESIGN

Randomized retrospective analysis over a period of 25 months.

CONCLUSION

Elongated styloid process causing glossopharyn-geal neuralgia is beginning to be a frequently encountered clinical entity nowadays. Of the 28 cases of elongated styloid process who underwent unilateral/bilateral styloidectomy, 27 patients had total relief of symptoms. Hence, we advocate styloidectomy, following careful diagnosis of the entity with clinical and radiological correlation, if the patient does not respond to medical therapy. The psychological status of the patient would provide clue to the authenticity of the symptoms in unrelieved cases.

Surgical treatment of elongated styloid process: experience of 61 cases

AIM

To describe the management of patients with elongated styloid process syndrome (Eagle's syndrome).

MATERIALS AND METHODS

Sixty-one patients with elongated styloid process were treated between 2000 and 2005. Computed tomography examination defines those whose symptoms suggest the diagnosis. Patients with styloid processes longer than 25 mm were treated by surgical resection.

RESULTS

Fifty-seven (93.4%) of 61 patients treated for Eagle's syndrome became asymptomatic after resection. There were no serious complications.

CONCLUSION

Patients with clinically and radiologically established elongated styloid process can be managed successfully by surgical resection using an external approach.