# A Rare Cause for Cervical Pain: Eagle's Syndrome

Authors: Massimo Politi; Corrado Toro; Giulia Tenani
Journal: International Journal of Dentistry
 (2009)

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## Abstract

Patients with pharyngodynia and neck pain symptoms can lead to an extensive differential diagnosis.
Eagle's syndrome must be taken in account. Eagle defined “stylalgia” as an autonomous entity related to abnormal length of the styloid process or to mineralization of the stylohyoid ligament complex.
The stylohyoid complex derives from Reichert's cartilage of the second branchial arch. The styloyd process is an elongated conical projection of the temporal bone that lies anteriorly to the mastoid process.
The incidence of Eagle's syndrome varies among population. Usually asymptomatic, it occurs in adult patients. It is characterized by pharyngodynia localized in the tonsillar fossa and sometimes accompanied by disphagia, odynophagia, foreign body sensation, and temporary voice changes. In some cases, the stylohyoid apparatus compresses the internal and/or the external carotid arteries and their perivascular sympathetic fibers, resulting in a persistent pain irradiating in the carotid territory. The pathogenesis of the syndrome is still under discussion.


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## Body

## 1. Introduction

It was Eagle in 1937 that first defined “stylalgia” as an autonomous entity related to abnormal
length of the styloid process or to mineralization of the stylohyoid ligament
complex [1–3].The stylohyoid
complex is made of styloid process, stylohyoid ligament, and the small cornus
of the hyoid bone. All these structures are derivate
from Reichert’s cartilage of the second branchial arch. The styloid process is
an elongated conical projection of the temporal bone that lies anteriorly to the
mastoid process, between the internal and external carotid arteries, and
laterally the tonsillar fossa. In this space, the internal carotid artery, the
internal jugular vein, the facial, glossopharyngeal, vagus, and hypoglossal
nerves are located. From the styloid process, the stylohyoid, the styloglossal, and the
stylopharyngeal muscles, and the stylohyoid and the stylomandibular ligaments originate [4, 5].The normal length
of the styloid process is individually variable, but in the majority of
patients it is about 20 mm [6]. The incidence of Eagle’s syndrome varies among population, but the main incidence is 4% of
the general population [2, 7]. Usually asymptomatic, it occurs in adult
patients ranged from 30 to 50 years [5]. Females are affected more often than
males [4]. Rarely, the anatomical condition is associated with cervical pain.Eagle primarily
described two syndromes [1]:(1)
Classic styloid syndrome: it frequently
follows tonsillectomy and is characterized by pharyngodynia localized in the tonsillar
fossa and sometimes accompanied by disphagia, odynophagia,
hypersalivation, foreign body sensation, and more rarely by temporary
voice changes;(2)
The stylo-carotid syndrome: it is not
correlated with tonsillectomy. In this condition, the stylohyoid apparatus
compresses the internal and/or the external carotid arteries and especially
their perivascular sympathetic fibers, resulting in a persistent pain irradiating in the
carotid territory.Pathogenesis is
still being debated. Surgical trauma or local chronic irritation could cause
osteitis and periosteitis of the stylohyoid complex with consequent reactive
ossifying hyperplasia [1, 3]. The persistence of mesenchymal elements is able
to produce osseous tissue in adults [8]. Residues of Reichert’s cartilage, as a
consequence of trauma or mechanical stress during the development of the
styloid process, can cause osseous metaplasia [9, 10]. The anatomic anomaly of
the styloid process could be genetically transmitted as a recessive autosomal character
[8]. Abnormal development of the styloid process is also associated with
malformation of the atlanto-occipital hinge [11, 12]. Ossification of the
stylohyoid ligament should be also related to endocrine disorders in
postmenopausal women [13].Eagle’s syndrome is
treated surgically and nonsurgically [14]. A pharmacological approach by
transpharingeal infiltration of steroids or anesthetics in the tonsillar fossa
has been used [15], but styloidectomy is the treatment of choice. Styloidectomy
can be performed by an intra- or an extraoral approach [4, 16]. The intraoral
approach may result in a restricted operative field, in the possibility of an
incomplete control over many important vascular and nervous structures and in
the risk of deep cervical infections. On the other hand, external surgical
approach results in cutaneous scars, longer hospitalization, and risks of
facial nerve injuries. The treatment’s choice usually depends on the experience
of the surgeon.


## 2. Report of a Case

A 42-year-old
female came to our Institution to evaluate pharyngodynia and foreign body sensation at the
right sight of the throat for over 1 year. The patient was very compliant, and
during the oropharingeal examination an elongated styloid process could be
palpated intraorally posterior to the right tonsillar fossa. Palpation elicited
painful sensation. The Orthopantomography showed the elongation of the right
styloid process. For a complete study of the case, CT scans were taken for
better defining length, angulation, and anatomical relationships of the styloid
process. CT scans revealed a 3, 1 cm in length right styloid process (Figure1). A
diagnosis of Eagle’s classic styloid syndrome was made and an intraoral
surgical treatment under general anesthesia was planned. During the surgical
procedure the tip of the styloid process was identified by palpation. Due to the retruded position to the right tonsillar fossa, the
tonsillectomy was not planned. The muscles of the pharyngeal wall were
dissected, separated, and retracted. Then, an incision was made on the
periosteum at the tip of the styloid process. The periosteum was stripped from
the tip and the styloid process was exposed (Figure 2). 1 cm of his caudal part was
excised (Figure 3) and the pharyngeal wall was sutured. Tonsillectomy was not
required and haemorrhage did not occur. Amoxicillin was administered once
preoperatively and once postoperatively. The patient was discharged on
postoperative day 2. 1 year after
surgery, the patient was symptom-free.Figure 1
preoperative CT scan showing
elongation of the right styloid process.Figure 2
intraoperative view of the
surgical field. The distal third of the styloid process is completely exposed.Figure 3
1 cm resected from the distal
part of the styloid process.


## 3. Discussion

Patients with
vague head and neck pain symptoms can lead to an extensive differential
diagnosis [14]. Medical history is the main guide for the diagnosis of Eagle’s syndrome.
The patient’s description of the symptoms is very important. Then, it is
necessary to make a local examination palpating the tonsillar fossa, which
should reveal a bony formation and should exacerbate pain aggravating symptoms
with local tenderness. Usually patients have temporary relief of symptoms from
the local infiltration of lidocaine. Radiological examination confirms the
diagnosis: an orthopantomography and CT scans are required [4, 5, 7, 15].Many factors can
determine changes in the structure of the styloid process and it may vary in
shape, position, and size [1, 3, 8, 13]. A wide variety of symptoms have been
attributed to elongation of the styloid process [1].Using CT scans is indicated for diagnosis,
although also an accurate case history, local examination, and orthopantomography
are required [4, 5, 7, 15]. The surgical treatment is the first choice in the
literature [4, 15, 16]. When it is possible, the transoral approach is
preferable. An intraoral approach results in a safe, simple, and less time
consuming procedure than an extraoral approach and there is an absence of
visible scars. We suggest the transoral approach in cases of Eagle’s syndrome with
palpable styloid process.When dealing with
cases of cervical pain, the possibility of an Eagle syndrome should be considered.



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