Stylohyoid Ligament Research Articles

Konik Işınlı Bilgisayarlı Tomografide Rastlantı Bulgusu Olarak Görülen Yumuşak Doku Kalsifikasyonları: Bir Retrospektif Çalışma

Objective: It was aimed to retrospectively evaluate the soft tissue calcifications (STCs) in cone-beam computed tomography (CBCT) images. Material and Methods: CBCT images (Planmeca Romexis®, 3D Mid Planmeca Oy, Helsinki, Finland) of 1,566 patients (54.2% females; 45.8% males) were collected from the database of Department of Dentomaxillofacial Radiology. The hyperdense masses were examined. Patients with head and neck trauma or a history of surgery were excluded. If present, soft tissue calcifications were classified according to type, locations, distribution, age, and gender using descriptive statistics and chi-square tests. Results: Of the 1,566 patients, 390 (24.9 %) showed calcifications. The mean age of these patients was 47.3±16.1. The frequency of STCs was 48.7% in males and 51.3% in females. Tonsilloliths (53.6 %) were found to be common, followed by ossified stylohyoid ligament (29.5%), pineal gland calcification (3.6%) and sialolith (2.8%). No statistically significant differences were recorded between genders (p>0.05). STCs were detected either bilaterally (51.1%) or unilaterally (48.9%). The frequency of the STCs according to age groups: Tonsillolith was seen mostly in individuals older than 55-year-old (40.7%), whereas ossified stylohyoid ligament was seen in patients younger than 35-year-old (36.5%). Conclusion: STCs may often be incidentally diagnosed on CBCT images. Clinicians should recognize the characteristics of STCs, particularly regarding early diagnoses of certain systemic diseases.

Eagle’s Syndrome in Children: A Case Report

Eagle’s syndrome is a collection of symptoms caused by styloid process elongation or calcification of the stylohyoid ligament, measuring more than 2.5 centimeters. It is a radio-clinical entity characterized by a heterogeneous polymorphic symptomatology most often involving headaches, facial pain, dysphagia and a foreign body sensation in the throat. Its management is mainly surgical. It is a rarely diagnosed condition in children. Here we report a typical case of Eagle’s syndrome which was diagnosed in a 14-year-old child with a history of chronic right unilateral pharyngeal discomfort, odynophagia and oropharyngeal foreign body sensation. CT scan showed a long left styloid process. The patient underwent surgical removal of the elongated styloid process externally. The outcome was favorable after surgery.

Intra-Oral Approach For Eagle Syndrome (Case Report)

Eagle syndrome occur due to calcification of the stylohyoid ligament or elongation of styloid process, which then produce a pain in the jaw, back of throat, base of the tongue, ears, neck and face as well as difficulty swallowing and sensation of having a foreign object in the throat. Classic eagle syndrome is present on only one side; however, it may be present on both sides.

Morphological Characteristic and Incidence of Elongate Styloid Process in South Indian Population: A Case Series

Introduction: Styloid process is a slender osseous projection, cylindrical and sharp projection of the temporal bone, located in front of stylomastoid foramen. Styloid process is from Reichert’s cartilage of the second branchial arch, this is a part of the splanchnocranium. This is Connected to the hyoid bone through the Stylohyoid ligament. The morphology of the Styloid process is due to hormonal and genetic changes. Orthopantomography is a radiographic method used to visualise mandibles. It also provides a rotational view of the jaw. The aim of the study is to analyse the elongation of the Styloid process in the South Indian population.
 Materials and Methods: The study was conducted in dental institutions with convenience sampling. The random orthopantomogram sample was collected from a dental institution. Total number of orthopantomogram involved in the study was 80 (40-males and 40-females) that is used to examine elongation of the Styloid process in the South Indian population. The minimised sampling bias is done by stratification according to age and gender.
 Statistical Analysis: The data were analysed by using SPSS software. The probability value p< 0.05 is considered as significant and the value p>0.05 was considered as not significant.
 Results: This study showed various types of Styloid processes in males and females. However we concluded that there is a difference in shape of Styloid processes. The most common type of the Styloid process found in males is pseudo articulated (32.5%) whereas in females the most common type of Styloid process found is uninterrupted (37.5%)
 Conclusion: From the current study we have concluded that the pseudo articulated Styloid process is more in males whereas uninterrupted is more in females. Only retrospective studies were done so far. Therefore in future studies with live models and larger sample size should be conducted.

The Eagle Has Landed: an unusual case of Eagle’s syndrome

Eagle’s syndrome refers to a group of characteristic symptoms affecting the oropharynx and neck that are caused by regional compression of structures due to a calcified stylohyoid ligament or an elongated styloid process. Of its two types, the former type is more common than the latter, but carotid artery dissection as a result of an elongated styloid is exceptionally rare. Following an extensive literature review, we present a case of carotid artery dissection causing multiple strokes secondary to direct compression from an elongated styloid process. Managed surgically through excision of the elongated styloid and post-operative rehabilitation, the patient recovered well and was discharged on anti-thrombotic medication, preventing further potentially detrimental attacks.

Impact of Different Evaluation Methods for Diagnostic Tasks in Panoramic Radiography

The aim of this study was to evaluate the observers’ diagnostic performance in panoramic radiography using monitor, tablet, X-ray image view box, and against window daylight as a visualization method in different diagnostic tasks. Thirty panoramic radiography were assessed by three calibrated observers for each visualization method, in standardized light conditions, concerning dental caries, widened periodontal ligament space, and periapical bone defects from the four first molars; mucosal thickening and retention cysts in maxillary sinus; and stylo-hyoid ligament calcification and atheroma. A five-point confidence scale was used. The standard-reference was performed by two experienced observers. Diagnostic values using window light were significantly lower for caries and periapical bone defect and retention cyst, stylo-hyoid ligament calcification detection (p<0.05). For atheroma detection, X-ray image view box, tablet, and widow light had lower accuracy than the evaluation on the monitor (p<0.05). Observer’s diagnostic performances are worsened using window light as an evaluation method for panoramic radiography for dental, sinus, and calcification disorders, while the monitor was the most reliable method.

Eagle Syndrome Unmasked by Acute Parotitis

Eagle Syndrome is elongation of the styloid process or calcification of the stylohyoid ligament that causes chronic neck and throat pain often precipitated by turning the head and frequently requires surgical treatment. However, Eagle Syndrome can also present acutely due to infections of the head and neck. In these cases, treatment of the infection with antibiotics and steroids can resolve symptoms. We highlight a case in which the patient developed acute parotitis and the cervicofacial soft tissue edema from infection caused the patient to have symptomatic Eagle Syndrome with throat pain and dysphagia due to a previously asymptomatic ossified stylohyoid ligament. Including Eagle Syndrome as part of the differential resulted in a non-surgical treatment plan with full remission of the patient’s symptoms.

Abstract 1122‐000020: Assessing Correlation Between Styloid Length and Internal Carotid Artery Dissection in EAGLE Syndrome Patients

Introduction : Eagle Syndrome (ES) also known as styloid–carotid artery syndrome is a caused by elongation of the styloid process or calcification of the stylohyoid ligament. Usually, normal stylohyoid process is 2.5 cm in length. However, it is classified as an elongated styloid process if its length is more than 2.5 cm. Carotid Artery dissection which is a significant cause of ischemic stroke in all age groups is a known rare complication of ES. Goal of our study is to assess for correlation between degree of styloid process lengthening and grades of Carotid and Vertebral Dissections in adult population. Methods : Retrospective database review of adult patients with known cervical dissections (traumatic and non‐traumatic) were analyzed from Level I Comprehensive Stroke Center. Patients in pediatric age group (less than age 18 years) were excluded. Deidentified patient information including patient’s age, demographics, past medical history, mechanism of injury (if applicable) prior to initial clinical presentation, initial clinical presentation, methodology for diagnosis of cervical dissection (Internal Carotid vs External Carotid vs Vertebral Arteries) along with measurements of stylohyoid ligaments and degrees of dissections bilaterally were retrieved and analyzed. Data analysis was performed by using IBM SPSS Statistics Software 28.0. Results : Total number of patients were 111 (N). Mean age of patients was 52.97 (±16 years). Demographic distribution: African Americans (47/111), Caucasians (62/111) and Others (2/111). Gender distribution: Males (55/111) and Females (56/111). Mechanisms of injury based on available data were as follows: Mechanical Fall (21); MVC (21) and other mechanisms (12). 43/111 patients did have a headache as compared to 68/111 who did not during initial clinical presentation. Imaging confirmation for arterial dissection was performed via MRA (6/111); CTA (98/111) and DSA (7/111). Average styloid length for patients with Eagle syndrome was 3.1 cm vs non‐Eagle group which was 2.38 cm. In Non‐Eagle Syndrome group (Styloid length <2.5 cm), average grades of arterial dissections were as follows: Left Vertebral Artery dissection‐2.1; Left Internal Carotid Artery‐2.1; Right Internal Carotid Artery‐0.40 and Right Vertebral Artery‐2.5. For Eagle Syndrome patients (Styloid length >2.5 cm), average grade of arterial dissections were as follows: Left Vertebral Artery‐2.6; Left Internal Carotid Artery‐3.38; Right Internal Carotid Artery dissection‐2.3 and Right vertebral artery dissection‐1. Based on statistical analysis (paired samples T‐test), styloid length of more than 2.5 cm was significantly correlated with left internal carotid artery dissection (p value 0.012; p<0.05***). For dissections in other arteries including Right Internal Carotid (p value 0.91), Right Vertebral (p value 0.12) and Left vertebral (p value 0.488) no statistical significance was found when both groups were compared. Conclusions : From our study we can conclude that in patients with EAGLE syndrome styloid length more than 2.5 cm is significantly correlated with higher risk of Left Internal Carotid Artery dissection.

Etio‐histomorphogenesis of styloid enlargement—A novel and extensive light microscopic analysis of 10 cases of Eagle’s syndrome

AbstractAim & ObjectivesTo carry out detailed light microscopic analysis of excised specimen of elongated styloid processes (ESPs) from patients suffering from Eagle's syndrome (ES). To thus gain a clear and precise insight into the aetiology, origin, development and progression of styloid enlargement, and to accurately hypothesize the underlying histopathological mechanisms bringing about their thickening and elongation.Study Design & SettingThis 3‐year study was conducted in 10 patients of ES, who were treated by transoral styloidectomy. The excised ESPs were subjected to a systematic and comprehensive histological analysis of sections from their base, mid and apical thirds.Material & MethodsImaging and diagnostic workup, operative procedure, postsurgical protocols and regimen, tissue processing and analysis of excised specimen were the same in all patients.ResultsImmature woven bone trabeculae and dystrophic calcifications were found within fibrocollagenous mesenchymal condensations of the stylohyoid ligament (SL) at the apical region of the ESPs, and in the tendinous insertions of the styloid group of muscles into the ESPs, indicative of their osseous metaplasia as a form of reactive response.ConclusionRepetitive stress, traction or traumatic stimuli brought to bear upon the apices and lateral surfaces of styloid processes via tendinous insertions of the SL and styloid group of muscles, as a result of neck and hyoid movements, are likely to serve as triggering factors, stimulating an osseous metaplasia of connective cells within these mesenchymal structures as well as in the periosteal fibrous tissue, into osteoblasts and osteocytes. This reactive response is followed by osteogenesis and laying down of woven bone at these sites, resulting in increase in length and circumference of the SPs and their attendant, associated clinical sequelae.

Improvement of methods of diagnosis the hypertrophy of the styloid process of the temporal bone and stylohyoid syndrome in an outpatient and polyclinic conditions using functional tests

The Eagle's syndrome is a disease is caused by irritation of the nervous, vascular and muscular structures the surround the subcutaneous process of the temporal bone. A syndrome manifested by chronic pain at the deep part of the lateral region of the face, which irradiates in to the root of the tongue, pharynx and ear, dysphagia, symptoms of disorders of the circulation of the brain. Symptoms of Eagle’s syndrome are founding various otolaryngological, dental, neurological diseases. Aim: due to the lack of information on the development and course of the stylohyoid syndrome, conservative treatment and the complexity of diagnosis, the anatomical features of the hypertrophied styloid process, their length and angles of deviation and the need for local impact on the process, the stylohyoid ligament and the neurovascular bundle, to varying degrees presenting to the styloid process, it becomes necessary to develop the most effective and simple method for diagnosis a hypertrophied styloid process and to optimize the need for CT examination with contrasting of the great vessels of the neck and performing functional tests. Materials and methods: Over the past 9 years, we examined and treated 184 patients. The appeals were random, with no specific focus. Of these, there were 133 women (72.3%), men – 51 (27.7%); age – from 25 to 70 years old: 25-30 years old – 15 people (8.1%), 30-45 years old – 116 (63%), 45-60 years old – 38 (20.6%), 60-70 years old – 15 (8.1%); the duration of the disease is from 1 to 10-15 years. Our work was aimed at improving and simplifying the diagnosis of the hypertrophied styloid process during the initial treatment of the patient in an outpatient and polyclinic conditions using functional tests, determining the need to refer patients to CT examination to visualize the relationship of the elongated styloid process with the main vessels of the neck, the possibility of pressure of the append age on the vessels and nerves of the neck, both at rest and in the movement of the head and neck, the development of impaired blood circulation in the brain due to impaired blood flow through the arteries and impaired out flow through the veins, and the development of corresponding symptoms in addition to those described in the literature. Due to the difficulty of diagnosing hypertrophy of the styloid process of the temporal bone in an outpatient and polyclinic conditions and the lack of awareness of practical otolaryngologists about this problem, we proposed a scheme for examining patients with suspicion of this problem.

Completely Ossified Bilateral Stylohyoid Ligaments in a Patient Undergoing Hemodialysis.

Completely Ossified Bilateral Stylohyoid Ligaments in a Patient Undergoing Hemodialysis.

A Rare Case of Eagle Syndrome Associated with Tonsil Hypertrophy: Case Report with Literature Review

Eagle’s syndrome, or stylohyoid complex syndrome, is a rare facial pain syndrome characterised by latero-cervical pain radiating to the face, pharyngeal pain increased by swallowing, linked to an abnormal enlargement of the styloid or calcification of the stylo-hyoid ligament. The incidence of the presentation is about 4 to 8 per 10,000 individuals. The establishment of the diagnosis is a challenge in itself as we need to differentiate it from the neuralgias of cranial nerve such as glossopharyngeal neuralgia and superior laryngeal neuralgias. The surgical management of the Eagle syndrome consists in the shortening of the elongated styloid process, with the surgical access by intra oral or cervical. We report a case of a 28-yearold men admitted to our otorhinolaryngology department with sharp neck pain and a sensation of having a foreign body in the throat. Physical examination found bilateral tonsilar hypertrophia, with palpation of a solid immobile structure. CT scan with 3D reconstruction revealed elongated styloid processes with ossification of the left stylo-hyoid ligament. The patient was treated by tonsillectomy with excision of styloid processes by intra oral approach.

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.

Elongated Styloid Process- An Unusual Finding- A Case Study

Styloid process is approximately 2.5 cm to 3cm in length and its tip is located lateral to tonsillar fossa between external and internal carotid arteries. Elongation of Styloid process or calcification of stylohyoid ligament leads to Eagle syndrome which causes excruciating throat pain, facial pain, dysphagia, or foreign body sensation. It may be present unilaterally or bilaterally with an overall prevalence of 4% in adults out of which 0.16% are symptomatic with symptoms.

Eagle’s syndrome as a differential diagnosis in odynophagia

Eagle’s syndrome is characterised by elongation of the styloid process or calcification of the stylohyoid ligament. It most commonly manifests as persistent unilateral pharyngeal pain. This clinical pearl will further detail its history, anatomy, presentation and management.

Evaluation of Stylohyoid Complex Patterns on Digital Panoramic Radiographs in the Local Population in Ilam, Iran

Background: Stylohyoid ligament ossification is a complication that is repeatedly and accidentally observed on panoramic radiographs and may be the cause of some symptoms. Accordingly, awareness of this incidence enables the clinicians in the accurate diagnosis of head and neck pains while avoiding unneeded therapy. Methods: This was a descriptive cross-sectional study. The number of samples was 196 people who referred to an oral and maxillofacial radiology center in Ilam in 2020. Information was completed by a checklist which consisted of two parts, including a questionnaire (age, gender, history of maxillofacial trauma, history of maxillofacial surgery, and pregnancy) and a second part (including the ossification of the stylohyoid complex, its length, involved side, and the process category according to Langlais classification). Differences between the groups were compared by Student’s t test, Welch’s t test, or chi-square test (P<0.05). Results: The results revealed the influence of age on the calcification and elongation patterns of the styloid process while no significant association was found between gender and elongation and calcification patterns. The ossification of the stylohyoid complex was unilateral and bilateral in 24 (40.6%) and 35)59.3%) patients. Finally, the ossification of the stylohyoid complex was bilateral in 17 patients (48.6%) aged 40-59 years. Conclusions: The evaluation of stylohyoid complex patterns using panoramic radiography is essential, especially in patients with related symptoms. Further studies are needed to completely understand the underlying mechanism of the ossification of the styloid process and to assess different types of the styloid process and the relation between them in patients.

The Prevalence of Soft Tissue Calcifications in the Head and Neck Region Using CBCT among Egyptian Population

Background: calcifications may be physiological or pathological. Understanding about soft tissuecalcifications help to reach appropriate diagnosis and take the right decision whether treatment, referral,further investigations or do nothing.Aim: To detect the prevalence of soft tissue calcifications using (CBCT) scans in the Egyptian population.Method: Retrospective Data Analysis was performed on (417) CBCT patients’ scans collected from thedatabase available at the Oral & Maxillofacial Radiology department,Faculty of Dentistry, Cairo University.Data collection of patient sex and age was made. Data was assessed for presence or absence of calcification,type of calcification, sidedness and single or multiple occurring.Results: There were (94) scans detected with calcifications within the whole sample size (417 scans).The prevalence was (22.54%). There were (141) calcifications detected in the (94) scans. The soft tissuecalcifications detected were calcified stylohyoid ligament, tonsilloliths, sialoliths, laryngeal cartilagecalcification, carotid artery calcification and only one case of ethmoidal sinolith. There were 3 cases withoutcertain final diagnosis.Conclusions: The prevalence of calcifications seen on CBCT images is not uncommon, dental practitionersshould be aware of their presence. Their detection during routine dental examination should be made toensure the broad evaluation of the patients.

The effect of styloid process medial angulation on Eagle's syndrome's self-reported symptoms: A preliminary cross-sectional study

The aim of this study was to investigate whether the medial angulation of the styloid process (SP), regardless of its length, has an association with self-reported symptoms of Eagle's syndrome. In this cross-sectional study, we measured the length and medial angulation of the SP, including ossification of the stylohyoid ligaments, in archived cone beam computed tomography scans. Patients with valid contact details were interviewed by telephone and asked about the clinical symptoms related to Eagle's syndrome. Eighty-eight patients participated in this study. Their median age was 39.0 years and ranged from 18 to 75 years. Thirty-one (35.2%) of the participants reported cervicalgia with at least one other symptom related to Eagle's syndrome. The mean length and angulation of the right SP were 37.2 mm and 36.3°, respectively, with both readings showing positive correlation with the left SP (r=0.746 and r=0.670, respectively; P < .001). Medial angulation of the SP was a predictor of Eagle's syndrome self-reported symptoms (odds ratio, 1.082; 95% confidence interval, 1.003-1.167; P=.042), adjusted for SP length and the patient's age. Self-reported clinical symptoms of Eagle's syndrome appear to be more associated with the medial angulation of the SP than with its length. Further research on larger samples is needed to establish the medial angulation cutoff angle and the specific symptoms that are attributed to that angulation.

Histopathological Analysis of Elongated Styloid Processes: A New Light on Etiopathogenesis of Eagle's Syndrome.

There exists paucity in recorded literature on the detailed microscopic appearance of elongated styloid processes (ESPs) in patients with Eagle's syndrome (ES). Although literature is replete with numerous conflicting and inconclusive theories, the exact cause, mechanism of origin, development and progression of styloid apparatus enlargement remains unclear and ambiguous. To carry out detailed histopathogical examination of excised specimen of ESPs in a patient with ES, with the objective to determine its precise etiomorphogenesis, and to analyse the role of possible triggering factors. Light microscopic examination was carried out of the base, mid- and apical thirds of transorally excised ESPs in a 45-year-old patient with ES. Woven bone trabeculae were found emanating from tendinous insertions of the styloid group of muscles at the mid third of the ESPs. Apical region of the ESPs showed fibro-collagenous mesenchymal tissue with numerous, haphazardly scattered trabeculae of woven bone traversing it. Presence of deeply staining reversal lines all along the length of the ESPs was suggestive of multiple micro-fractures from recurrent traumatic/traction forces, and repeated attempts at repair and ossification. It is proposed that mesenchymal structures composing the stylohyoid ligament at its attachment, and tendinous insertions of styloid muscles into the ESPs are stimulated to undergo metaplastic alterations, by repetitive stress, traction or traumatic stimuli brought to bear upon them, from muscular contractions. This osseous metaplasia of connective cells within them, followed by dystrophic bone deposition, brings about SP thickening and lengthening with their attendant and associated clinico-pathological sequelae.

Refractory neck pain due to Eagle syndrome.

Eagle syndrome, named after Watt W. Eagle, who described the first cases in 1937, is an uncommon syndrome (4-8/10,000 persons) resulting from the styloid process's elongation or mineralization of the stylohyoid ligament.1Badhey A. Jategaonkar A. Anglin Kovacs A.J. Kadakia S. De Deyn P.P. Ducic Y. et al.Eagle syndrome: a comprehensive review.Clin Neurol Neurosurg. 2017; 159: 34-38Crossref PubMed Scopus (54) Google Scholar The typical symptoms are throat and neck pain radiating into the ear, which can be wrongly attributed to various facial neuralgias. A 64-year-old woman had presented to the otolaryngology clinic with a slowly progressive intermittent dull pain in the upper neck of 10 years' duration. The pain was localized to the tonsillar fossa and radiated to the jaw, ear, neck, throat, and oropharynx. It was worsened by head movement and accompanied by dysphagia, a foreign body sensation, a sore throat, and voice changes. She had no history of trauma. The patient had undergone several consultations during the 10-year period, including otolaryngology, family practice, neurology, neurosurgery, psychiatry, and dentistry, with various interventions performed (ie, steroid injection in the temporomandibular joint, radiofrequency ablation, stellate ganglion block, lignocaine infusion, posterior auricular nerve block) without relief. A computed tomography angiogram demonstrated a 4-cm-long styloid process at the level of the mid-internal carotid artery (A and B). Cervical neck incision and styloidectomy were planned. We exposed the common carotid artery and cranial nerves and retracted the posterior belly of the digastric to peel the tendinous attachment around the styloid process toward the mastoid posteriorly and mandible anteriorly for easy separation. The distal end of the styloid process was found to lie close to the hypoglossal, glossopharyngeal, and vagus nerves (C). A 2.5-cm excision of the styloid process was performed. She had complete resolution of the symptoms postoperatively. She had provided written informed consent for the report of her case details and images. The styloid process normally measures 2.5 to 3 cm. However, when its length is >3 cm, the patient will become symptomatic owing to the subsequent pressure on the adjacent structures.1Badhey A. Jategaonkar A. Anglin Kovacs A.J. Kadakia S. De Deyn P.P. Ducic Y. et al.Eagle syndrome: a comprehensive review.Clin Neurol Neurosurg. 2017; 159: 34-38Crossref PubMed Scopus (54) Google Scholar Cervical neck surgery with styloidectomy is the definitive treatment. An alternative approach includes the intraoral transtonsillar route. However, this approach has been associated with high risks, including uncontrolled bleeding and cranial nerve injury because it limits visualization of the important structures.2Strauss M. Zohar Y. Laurian N. Elongated styloid process syndrome: intraoral versus external approach for styloid surgery.Laryngoscope. 1985; 95: 976-979Crossref PubMed Google Scholar