Stylohyoid Ligament Research Articles

Eagle Syndrome: The Huge Socioprofessional Impact of a Minor Lengthening of the Styloid Process

agle Syndrome (ES) is a rare clinical condition presenting with anterolateral neck pain and potential serious complications. This case report details a head nurse in the emergency room (ER) with a severe throbbing headache, trismus, left-sided dysphagia, left otalgia, gum pain, and a very intense left-sided headache, associated with ipsilateral facial hypoesthesia. The patient met the International Classification of Headache Disorders (ICHD-3) criteria for headaches attributed to inflammation of the stylohyoid ligament, establishing the diagnosis of Eagle syndrome. Chronic headaches associated with ES, as observed in this case, can impact concentration, comprehension, communication, and work performance, leading to economic loss. This prompts the question: Are individuals with ES capable of working under intense physical and psychological conditions? The paper proposes a management strategy for ES patients, emphasizing the need for further research on the impact of ES on occupational fitness, as no published studies currently address this concern.

Patterns of Arterial Wall Lesions in Eagle Syndrome: Case Series and Literature Review.

Background: Impingement of an elongated styloid process (ESP) or calcified stylohyoid ligament on surrounding neck structures defines Eagle syndrome. The vascular variant, also called stylocarotid syndrome, results from impingement of vascular structures and remains poorly known among physicians. Research Design: We report our own experience and review the literature in order to clarify the diagnostic and therapeutic management. Patients with vascular events in relation to an ESP and hospitalized at our institution were extracted from our databank and retrospectively reviewed. We also performed a comprehensive review of the literature on Eagle syndrome using PubMed®and Google Scholar, analysing the presentation, management, and follow-up. Results: We report five cases of the vascular variant of Eagle syndrome: one carotid perforation, one focal arteriopathy, one with both acute and chronic dissection and two acute internal carotid dissection. Vascular compression, whether permanent or transient, is also reported in the literature. Management varies, although styloidectomy is deemed appropriate for symptomatic compression, while stenting is preferred in cases of perforation. Conclusions:A common definition of Eagle syndrome is required for better diagnosis and management. The choice of styloidectomy is understandable for compression but remains to be investigated in other cases.

Eagle syndrome: tissue characteristics and structure of the styloid process.

Eagle syndrome is a bone disease where elongation of the styloid process leads to throat and neck pain, and in severe cases neurovascular symptoms such as syncope and neuralgia. The pathophysiology of Eagle syndrome is poorly understood with various theories having been proposed how this elongation is caused. To better understand the pathophysiology, we performed a work-up in 6 patients presenting with Eagle syndrome. Patients mainly presented with pain on turning the neck (100%), foreign body sensation (67%), tension in the neck (67%), and dysphagia (50%). The typical length of the styloid process ranges from 25 to 30 mm; however, [18F]NaF (sodium fluoride) PET/CT showed elongated styloid processes with an average length of 52.1 ± 15.6mm (mean ± SD) with increased turnover at the base of one of the styloid processes. The removed styloid processes were further examined by histology, micro-CT, quantitative backscatter electron imaging (qBEI), Fourier transform infrared spectroscopy (FTIR), and circularly polarized light imaging. Histology revealed one case of a fractured styloid process healing through callus formation and one case of pseudarthrosis. Bone mineral density and mineralization was similar in the styloid processes when compared to cortical bone samples derived from the mandibular bone of different patients. Circular polarized light microscopy showed a collagen orientation in the styloid process comparable to the cortical bone samples with a distinct separation of collagen structure between the mineralized structure and the surrounding soft tissue with FTIR analysis demonstrating a typical composition of bone. This altogether suggests that the elongated styloid processes in Eagle syndrome are mature bone, capable of endochondral repair, possibly growing from the base of the process through endochondral ossification, rather than being a form of secondary calcification of the stylohyoid ligament as previously postulated.

Eagle Syndrome: Case Report, Literature Review, Proposed Classification, and Role of Ultrasound in its Diagnosis and Management

Eagle syndrome is defined by a spectrum of clinical presentations related to an elongated styloid process or calcified stylohyoid ligament, in the neck, which impinges on the adjacent nerves, arteries, or veins. It is an uncommon finding but one that should be considered in clinical and imaging practice. A variety of symptoms can result. The diagnosis is often delayed, particularly if it is not considered. Although the elongated styloid process may be seen on plain X-ray, contrast-enhanced computerized tomographic angiography (CTA) is considered the diagnostic test of choice. There is, however, a role for ultrasound in both the diagnosis and consideration of the differential diagnosis of Eagle syndrome. Vascular ultrasound specialists should be aware of this entity and be prepared to characterize the findings with ultrasound. Although medical management or endovascular approaches have been described, generally, surgical excision of the styloid process is recommended. Outcomes from such treatment tend to be excellent. Most reports describe a single patient or small series, and the role of duplex scanning has not been discussed. This patient is presented to allow a review of Eagle Syndrome, classify the types, and introduce the details of modern high-resolution color duplex scanning in its management.

Treatment of hyoid bone syndrome with surgical excision: our monocentric experience in the past five years

PurposeIn 1968, Steinmann described the hyoid bone syndrome as a degenerative and inflammatory insertion tendinosis. It causes unilateral pain in the neck, increased by swallowing and palpation. The treatment is conservative, but when this fails, surgery is an option. Our aim is to assess the post-operative outcome of patients for whom a surgical hyoid bone resection procedure was performed in the University Hospital of Antwerp (UZA). MethodsA retrospective study was performed. Patients were seen at the laryngology clinic in the UZA from 2018 until 2023. They were diagnosed with the hyoid bone syndrome based on anamnesis and clinical examination. Pre-operative imaging was performed to evaluate for anatomical changes and fiberoptic laryngoscopy performed to exclude other causes. Pre- and postoperative VAS pain scores were questioned. ResultsSeventeen patients were operated, two of them bilaterally. All patients had pain located to the affected side, and almost half of patients (n = 7) had dysphagia. On imaging, 10 patients had an elongated styloid process and 7 had calcification of the stylohyoid ligament. All patients underwent resection of the greater horn of the hyoid bone, 13 patients underwent resection of the stylohyoid ligament and in 9 patients the superior horn of the thyroid cartilage was removed. Mean pre-operative VAS pain score was 9 (/10) and mean postoperative score was 1.3 (/10). ConclusionOur preliminary results show a good clinical effect of the surgical excision procedure and offer insight in the hyoid bone syndrome. Follow-up is necessary to assess the long-term results and potential recurrence of symptoms.

Eagle syndrome presentation and outcomes in a large surgical case series.

The purpose of this study is to describe both the common and uncommon symptoms associated with Eagle syndrome and share our experience treating a large group of patients with surgical intervention, primarily intraoral excision of the calcified stylohyoid ligament. This retrospective case series included 56 patients at least 18 years of age or older with a diagnosis of Eagle syndrome. All operations were conducted by a single surgeon at a tertiary medical center from 2015 to 2022. Charts were reviewed for demographics, prior medical/surgical history, symptoms, imaging results, operative details, and follow-up history. A phone survey inquired about presenting symptoms and symptom resolution following surgery. The most common areas of pain were the ear (64.3%), underneath the angle of the mandible (50%), throat (46.4%), and neck (30.4%). Over 70% of patients reported tinnitus, dysphagia, and pain that were exacerbated by head rotation. Fifty-one of the 56 patients underwent surgical treatment, 92.2% via intraoral and 7.8% via cervical approaches. All patients (100%) reached in a phone survey stated that their symptoms resolved or improved after surgery. Eagle syndrome typically presents with common symptoms. However, healthcare providers must also be vigilant for less common manifestations, such as seizures or episodes of dizziness/fainting. These may be caused by calcification of the stylohyoid ligament. Intraoral surgical resection of the calcified ligament is a safe and effective treatment for most patients. Level 4.

Calcification of stylohyoid ligaments and its association with obesity: A cross‐sectional retrospective study

AbstractIntroductionObesity is associated with an increase in pro‐inflammatory cytokines, which eventually lead to soft tissue dystrophic calcifications. Calcifications of the stylohyoid ligament (SHL) are incidental findings occasionally seen in head and neck radiographs, the cause of which is not yet established. In this study, we investigated the possible association between obesity and SHL calcification.MethodsArchived cone beam computed tomography (CBCT) scans of 136 patients were retrieved and assessed for the presence and length of calcifications of the SHLs. Patients' height and weight were retrieved from their medical records, from which body mass index (BMI) values were calculated. Later, patients were telephone‐interviewed and asked about histories of tonsillectomy and trauma to the head and neck. Chi‐square and Mann–Whitney U tests were used to assess associations between SHL calcifications and BMI values in their nominal and continuous formats, respectively.ResultsCalcification of SHLs was detected in 63 (46.3%) of the retrieved CBCT scans. BMI values ranged from 17 to 40 (mean 27.4 (SD = 4.9)), with 30% being in the healthy category. Histories of tonsillectomy and head and neck trauma were reported in 13.5% and 7.4%, respectively. SHL calcifications were associated with the female sex (p = 0.02) and normal weight (p = 0.04). No associations were seen between SHL calcifications and age, tonsillectomy or trauma.ConclusionsDespite being associated with dystrophic calcifications of ligaments, obesity—in our study—was not associated with SHL calcifications.

Three-dimensional computed tomography reconstruction of a calcified stylohyoid ligament.

Three-dimensional computed tomography reconstruction of a calcified stylohyoid ligament.

Carotid Artery Dissection Caused by an Elongated Styloid Process: A Case Report

Eagle’s syndrome is caused by an elongated styloid process or calcified stylohyoid ligament that interferes with adjacent structures. Herein, we present the case of a 26-year-old man who presented to the emergency department due to sudden onset pain in the right occipital area, dysarthria, left hemiparesis, and left arm paresthesia. Computed tomography (CT) angiography revealed an intimal flap and thrombus in the proximal right internal carotid artery (ICA), indicative of carotid artery dissection, as well as direct contact between the styloid process and ICA on both sides. The patient underwent anticoagulation with intravenous heparin for 7 days, followed by 75 mg of clopidogrel per day. Following treatment, the patient gradually improved and was discharged with slight paresthesia in the left arm two weeks after symptom onset. Carotid artery dissection is a rare manifestation of Eagle’s syndrome caused by an elongated styloid process.

Retrospective evaluation of ponticulus posticus prevalence, sella turcica types, and stylohyoid complex calcifications in a group of Turkish population.

The aim of this retrospective analysis was to assess the incidence of ponticulus posticus and stylohyoid ligament calcification and to evaluate the morphological variations of the sella turcica within the Turkish demographic using CBCT scans. Involving a retrospective review of 460 CBCT scans and utilizing the NewTom 3G system, the study analyzed high-quality CBCT images to investigate ponticulus posticus, stylohyoid ligament calcifications, and sella turcica morphology. The ponticulus posticus was examined for complete or partial formations, while the stylohyoid ligament was classified according to its elongation and calcification patterns. The sella turcica was categorized into six distinct morphological types, enhancing the understanding of structural variations in the context of the Turkish population. The calcification patterns of the styloid processes were examined on both sides of 380 individuals, revealing the highest prevalence in the 'd' and 'e' categories on the right, and similar findings on the left among 373 individuals. Symmetric calcification patterns were more common, with 68.4% symmetry observed. For the sella turcica, category 'a' was the most frequent among 363 individuals. Analysis of ponticulus posticus absence and presence showed a majority lacking this feature on both sides, with complete and partial forms less common. The study highlights the anatomical variability and bilateral symmetry of the styloid processes, sella turcica, and ponticulus posticus, illustrating that these structures do not significantly vary with gender or age. These results hold clinical significance for the diagnosis and treatment of related conditions, prompting further investigation into their impact on patient care.

Adaptive treatment strategy for a vestibular schwannoma in a patient with vascular Eagle syndrome: illustrative case.

Eagle syndrome, an uncommon condition, causes symptoms due to neural and/or vascular compression from an elongated styloid process or calcified stylohyoid ligament and can also complicate other planned surgical procedures. A 42-year-old female with loss of balance, dizziness, and ataxic gait underwent cranial magnetic resonance imaging (MRI), revealing a right-sided Koos grade IV vestibular schwannoma. Initially, a retrosigmoid craniotomy for tumor resection was planned. However, preoperative MRI and computed tomography (CT) showed a dilated right-sided mastoid emissary vein, tortuous scalp and paraspinal veins, and bilateral elongated styloid processes. CT angiography and digital subtraction angiography indicated Eagle syndrome-related compression of both internal jugular veins and concurrent occlusion of the left internal jugular vein at the jugular foramen. Consequently, given the risk of damaging venous structures, Gamma Knife radiosurgery was chosen over resection. This case highlights the importance of adapting treatment plans based on patient-specific anatomical and pathological factors. In situations in which traditional surgery poses risks to sensitive structures such as the venous system, alternative approaches like radiosurgery offer safer yet effective options. Comprehensive risk-benefit evaluations are crucial for such decisions.

Eagle Syndrome (Calcification of the Stylohyoid Ligament) Excision

Eagle Syndrome (Calcification of the Stylohyoid Ligament) Excision

Diagnosis and treatment of Eagle's syndrome and possible complications.

Eagle's syndrome (ES) is a term describing a group of symptoms associated with the elongation of the styloid process (SP) of the temporal bone or with ossification of the stylohyoid ligament. Clinically, it manifests through pain in the orofacial and pharyngeal regions, similar to that experienced by patients with temporomandibular joint disease. The presented paper aims to assess the evaluation of the success of surgical treatment and the complications associated with such treatment. Our retrospective study includes nine patients with ES treated in our Department Oral and Maxillofacial Surgery in years 2019-2023 (median age of 47 years) - all patients affected with this disease out of 2,716 patients examined at our department due to a temporomandibular joint disease. Eight of these patients underwent a surgical resection of the SP. The success and complications in these patients are evaluated in this study. In seven patients, the problems disappeared or at least diminished, which is consistent with data from the literature. Postoperative complications such as deficit of the marginal branch of the facial nerve (n. VII), limited sticking the tongue out (n. XII), and velopharyngeal insufficiency (n. IX) occurred in three patients. The wide spectrum of clinical manifestations makes ES a condition that should be considered in the differential diagnosis of temporomandibular joint disorders, post-traumatic conditions, or complicated eruption of wisdom teeth or their extraction. ES can be treated conservatively or (mostly) surgically. Surgical treatment can be relatively successful and effective, but it is necessary to respect the anatomical placement of the SP, which can be associated with the development of complications, especially in cases with extremely long SP.

“Winged” Eagle’s syndrome: neurophysiological findings in a rare cause of spinal accessory nerve palsy. Illustrative cases

BACKGROUND Eagle’s syndrome (ES) classically describes dysphagia, globus sensation, and otalgia from an elongated and calcified styloid process or stylohyoid ligament. Compression of the spinal accessory nerve (SAN) has not been reported as an associated feature of ES or related variants. OBSERVATIONS The authors describe two cases of an atypical “winged” variant with SAN palsy resulting from compression by a posteriorly angulated or calcified styloid process. Both patients exhibited lateral scapular winging and atrophy of the trapezius and sternocleidomastoid muscles. Electrophysiological studies demonstrated motor unit preservation; therefore, surgical exploration, styloidectomy, and SAN decompression were performed through a transcervical approach. Postoperatively, both patients had improvements in pain and shoulder mobility, the return of muscle strength, and electrophysiological evidence of trapezius reinnervation. LESSONS Compression of the SAN, which can be identified both clinically and on electrodiagnostic testing, is an atypical finding that can result from a posteriorly angulated or calcified styloid process. This winged variant of ES should be included in the differential for SAN palsy, and a multidisciplinary approach is recommended for assessment and management.

A case report of Eagle’s syndrome: The union of the styloid process and the hyoid bone

The Eagle’s Syndrome is a rare condition found in 4% of the general population. It is caused by elongation of the styloid process and/or calcification of the stylohyoid ligament. Clinical image depends on, which structures, including nerves, blood vessels, soft tissues, have been compressed by the styloid process. Symptoms include otopharyngeal, neurological and vascular manifestations. The diagnosis of the Eagle’s syndrome might be incidental in asymptomatic patients as well. The authors present a case of a patient with the Eagle’s Syndrome, who has suffered from undefined throat discomfort for 6 years. Computed tomography (CT) showed an excessively elongated styloid process reaching the hyoid bone to contribute to a newly formed joint. This opened the pathway for further diagnostics and treatment but, most importantly, solving patient’s health problem, bothering her for many years.

Dişsiz Hastaların Panoramik Radyograflarında Yumuşak Doku Kalsifikasyonlarının Değerlendirilmesi

Aim: It is aimed to evaluate the prevalence, and types of soft tissue calcifications (STCs) on panoramic radiographs of edentulous patients.
 
 Material and Methods: 1308 images were randomly selected from patients who applied to Necmettin Erbakan University for various dental problems in 2020 and 2021. In these radiographs, tonsillolith, sialolith, calcified atherosclerotic plaque (CAP), and stylohyoid ligament calcification (SLC), calcified lymph node, phleboliths, antroliths, rhinoliths, and triticeous and thyroid cartilage calcifications were evaluated. Data were categorized according to gender, systemic disease and calcification type. Descriptive statistics were determined for all parameters. The status of the data according to gender, age group and systemic disease were analyzed by chi-square test (p

Novel Finding: Hyo-mandibular Ligament- A Cadaveric Study

Abstract Background: Many anatomical variations have been described in the deep neck; several of these are associated with the hyolarynx complex, consisting of the styloid process, hyoid bone, stylohyoid ligament, and thyroid, cricoid, and arytenoid cartilages as well as their associated ligaments. Methodology: An anterolateral deep dissection of the neck was performed bilaterally in 37 donors. Results: A novel ligament was found to connect the lesser horns of the hyoid bone to the angle of the mandible bilaterally in seven body donors (a total of 14 sides). To the best of our knowledge, the presence or function of a ligament connecting the lesser horns of the hyoid bone to the mandible has never been previously described or reported. Due to its proximal and distal attachment sites, we have termed this finding a “hyomandibular ligament.” Conclusion: This unique finding is clinically relevant and may add insight into the structural and functional variations of the deep neck. Knowledge of this structure and similar anatomical variations may provide an explanation for idiopathic difficulties, chewing or swallowing as a by-product of limited hyoideal mobility.

Chronically misdiagnosed Eagle's syndrome, treated through transoral styloidectomy: a rare case report.

A 39-year-old man who is a farmer and a driver was presented with complaints of ongoing, excruciating discomfort in the back of his left ear. Before the exam, he took a variety of drugs, various drugs 2 years without receiving a definitive diagnosis. Axial, coronal, and sagittal computed tomography scans of both petrous bones were analyzed, and the results showed aberrant styloid process elongation and calcification of the stylohyoid ligament. ES, shares many symptoms with other regional illnesses. Physicians frequently misdiagnose cases of ES and treat them without providing a conclusive diagnosis or treatment. ES diagnosis can be difficult for otolaryngologists and primary care providers due to its similarity with other regional illnesses. However, surgical intervention can result in consistent and significant symptomatic improvement when correctly diagnosed. The case presented in the report was successfully diagnosed as ES and treated surgically through transoral approach styloidectomy.

Eagle’s Syndrome: a Systematic Review

<b>Introduction:</b> Eagle’s syndrome (ES) is a rare condition characterized by an elongated styloid process or a calcified stylohyoid ligament. It manifests itself with many symptoms related to anatomical involvement and caused by compression of regional structures, such as temporomandibular disorders, ear pathologies, and facial pain.</br></br> <b>Material and methods:</b> Major online medical databases, including PubMed, Embase, Scopus, and Web of Science were searched to gather all studies regarding symptoms, diagnosis, treatment, coexistence with other diseases and anatomical aspects of the ES.</br></br> <b>Results:</b> A total of 56 studies were included in this systematic review and divided into 5 categories: (1) anatomy and prevalence (n = 19); (2) symptoms (n = 9); (3) diagnosis (n = 8); (4) treatment (n = 20); (5) coexistence with other diseases (n = 5).</br></br> <b>Conclusion:</b> Considering the prevalence of ES and its nonspecific symptoms, it can often lead to misdiagnosis. Hence, all physicians and dentists shall include the ES in the differential diagnosis of cervicofacial and pharyngeal pain.

Evaluation of Stylohyoid Ligament Calcifications in the Central Anatolian Region

This study aims to determine the prevalence of the elongated styloid process (ESP) on panoramic radiographs in a Turkish subpopulation and to investigate the relationship between SP lengths and the age and gender of individuals. Digital panoramic radiographs of 1000 patients who applied to Necmettin Erbakan University, Faculty of Dentistry, Dentomaxillofacial Radiology Clinic for the first examination between January 2020 and January 2022 were obtained from the database and examined. Individuals were evaluated by dividing them into three groups according to their age SP lengths were measured on both sides, and those greater than 30 mm were contemplated elongated. The data were evaluated in the SPSS V.21 program. In 1000 evaluated patients, ESP of >30 mm was detected in 304 individuals. It was determined that SP length did not differ according to age groups, gender, and systemic disease (p<0.05). Panoramic radiographs are useful, economical, and easily reachable diagnostic equipment in the diagnosis of symptomatic or asymptomatic ESP. Furthermore, it would be more useful to evaluate the prevalence of ESP with larger sample groups and advanced imaging methods.