|Year : 2015 | Volume
| Issue : 4 | Page : 516-519
A study on assessment of the length of styloid process in digital panoramic radiographs
Nikita Gupta1, Mubeen Khan2, Laxmi Gurunath Doddamani3, Nisha Kampasi4, Neera Ohri5
1 Department of Oral Medicine and Radiology, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Haryana, India
2 Department of Oral Medicine and Radiology, Government Dental College and Research Institute, Bengaluru, India
3 Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India
4 Department of Dentistry, University of Minnesota, Minneapolis, Minnesota, United States of America
5 Department of Dental surgery, Government Dental Hospital, Kangra, Himachal Pradesh, India
|Date of Submission||03-Jun-2015|
|Date of Acceptance||24-May-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Nikita Gupta
Department of Oral Medicine and Radiology, Maharishi Markandeshwar Dental College, Mullana, Ambala, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The styloid process (SP) is an anatomical structure whose clinical importance is not well understood. Aims and Objectives: This study aimed to study the type of SP as per Langlais' classification and to assess the feasibility of digital panoramic radiographs in measuring the length of SP. Materials and Methods: Eighty digital panoramic radiographs of patients with dental problems were retrieved from archives of our department as soft copies. The radiographs were taken using a digital panoramic system. The radiographic length of SP was measured on both sides using measurement toolbars on accompanying analysis software. The type of elongation patterns of SP was classified as per Langlais' classification. Finally, the data were subjected to statistical analysis. Results: The average length of the left and right side SPs was 29.1882 ± 6.86 and 28.16 ± 6.44, respectively. Majority of patients were found to be asymptomatic, and Langlais' Type I elongated SP was more common than others. Conclusion: Digital panoramic radiographs are valuable tools in early detection of elongated SP. Digital radiographs help in avoiding a misdiagnosis of tonsillar pain or pain of dental, pharyngeal, or muscular region.
Keywords: Digital panoramic radiographs, Eagle′s syndrome, styloid process
|How to cite this article:|
Gupta N, Khan M, Doddamani LG, Kampasi N, Ohri N. A study on assessment of the length of styloid process in digital panoramic radiographs. J Indian Acad Oral Med Radiol 2015;27:516-9
|How to cite this URL:|
Gupta N, Khan M, Doddamani LG, Kampasi N, Ohri N. A study on assessment of the length of styloid process in digital panoramic radiographs. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Nov 20];27:516-9. Available from: http://www.jiaomr.in/text.asp?2015/27/4/516/188691
| Introduction|| |
The term "styloid process" was derived from Greek, meaning a pillar.  The styloid process (SP) is a cylindrical bony projection arising from the lower surface of the petrous portion of the temporal bone in front of stylomastoid foramen. , The apex of the SP is clinically important because it is located between internal and external carotid arteries, just lateral to the tonsillar fossa within the lateral pharyngeal wall. The SP provides the origin attachments for several muscles such as the styloglossus, stylohyoid, and stylopharyngeus muscles and for ligaments such as the stylohyoid and stylomandibular ligaments. ,, SP normally measures about 25 mm in length although it varies in length from person-to-person and even from side to side in the same person. , The SP length which is longer than 30 mm was considered to be elongated SP. The elongated SP is a known cause of acute or chronic cervical and craniofacial pain.  The SP elongation is known as Eagle's syndrome (ES) when it causes clinical symptoms such as vague facial pain, especially while swallowing, turning the head or opening the mouth, dysphagia, dysphonia, otalgia, headache, and dizziness. , Although there are many suggested hypotheses, the exact etiology of calcified and ossified SP is unknown. ,, ES is diagnosed by both radiographical and physical examination. Computed tomography is useful for complementary information to that provided by panoramic radiographs. ,
| Materials and Methods|| |
A total of 80 digital panoramic radiographs which were available as soft copies in the archival records of our Radiology Department were selected for the study. The study was conducted in full accordance with ethical principles and was independently reviewed and approved by the ethical board of the institution. All radiographs had been taken up for routine dental examination of patients. Panoramic radiographs were selected based on set selection criteria. Panoramic radiographs of patients above 18 years of age and in which SP was clearly evident as well as patients with clinical signs and symptoms of elongated SP were included in the study. Digital panoramic radiographs having positioning and magnification errors, pregnant patients, and patients with multiple calcifications and ossification were excluded from the study. All radiographs were obtained from digital panoramic system (Kodak CS-9000 C, Carestream Health India Private Limited, Mumbai, India) using charged coupled device sensors under standard exposure factors (KVp of 90, duration of 13 s, and current of 9 mA). The apparent length of SP was measured on both sides from caudal margin of tympanic plate to tip of SP using measurement tools on Masterview analysis software (4.5.1). The magnification factor used for the machine was 1.9 [Figure 1]. If the stylohyoid and/or stylomandibular ligament were ossified, they were measured along with SP as part of elongated SP. SP measuring more than 30 mm was considered elongated, and type of SP was measured as per Langlais' classification [Figure 2] and [Figure 3]. Patients reported with clinical signs and symptoms of elongated SP were also recorded.
|Figure 1: Measurement of length of styloid process using Masterview analysis software (4.5.1)|
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|Figure 2: Morphological classification of type of styloid process by Langlais et al. (Type I: Uninterrupted, Type II: Pseudoarticulated, Type III: Segmented)|
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The collected data were entered in a spreadsheet and were analyzed using statistical analysis software (SAS 9.2, SAS Institute, Cary, North Carolina, USA; SPSS 15.0, IBM Corporation, Armonk, New York, USA; Stata 10.1, StataCorp LP, College Station, Texas, USA; Med Calc 9.0.1, MedCalc Software bvba, Ostend, Belgium; Systat 12.0, Systat Software, Inc., San Jose, California, USA and R environment version 2.11.). The one-way ANOVA test was used for analysis.
Statistically, significant figures were as follows:
- +Suggestive significance (0.05 < P < 0.10)
- * Moderately significant (0.01 < P ≤ 0.05)
- **Strongly significant (P ≤ 0.01).
| Results|| |
In the present study, mean length of SP on the right and left side was found to be 29.1882 ± 6.86 and 28.16 ± 6.44, respectively [Table 1]. In male patients, mean length of SP on panoramic radiographs on the right side was 30.53 ± 6.80 and on the left side was 28.7 ± 6.75 [Table 2]. In female patients, mean length on the right side was 26.9 ± 6.49 and on the left side was 27.27 ± 5.92 [Table 2].
|Table 2: Mean length of the right and left styloid process in both genders |
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According to Langlais' classification, 91.5% of SP was of Type I and 8.5% of SP was of Type II [Table 3]. Our study showed unilateral elongation in 21.5% and bilateral elongation in 78.5% [Graph 1]. In our study, 80.3% patients were found to be asymptomatic, 11.3% patients had difficulty in swallowing, 5.6% patients had otalgia, 1.4% patients had foreign body sensation in the throat, and 1.4% patients had otalgia as well as foreign body sensation in the throat [Graph 2].
| Discussion|| |
Variation is the law of nature. Every human is unique anatomically to such an extent that even identical twins are not alike. The SP is normally a cylindrical bone which arises from the temporal bone in front of the stylomastoid foramen. The attached structures include stylopharyngeus, stylohyoid, and styloglossus muscles and stylohyoid and stylomandibular ligaments. "Elongated SP," a term used since a publication by Eagle in reports concerning findings in dentomaxillofacial and ear-nose-throat patients. Eagle's definition was "the normal SP measures between 2.5 and 3 cm." His method of measurement was not described, but his examples showed lateral radiographs of the skull.  At present, reports concerning the SP and measurements of its length are mostly based on panoramic radiographs. The signs and symptoms with this syndrome are due to the anatomic relationship between SP and its surrounding structures. The symptoms can be confused with some disorders including a wide variety of facial neuralgias and oral, dental, and temporomandibular diseases. 
In our study, as done by Erol,  we used panoramic radiographs of the patients to enable us to identify any elongated SP. Out of 80 digital panoramic radiographs, maximum were found to be in age group of 26-33 years. Mean length of SP on the right and left side was 29.1882 ± 6.86 and 28.16 ± 6.44, respectively. Eagle has reported that the normal SP measures 2.5-3 cm whereas Kaufman et al. have reported 30 mm as the upper limit for normal SP. Study conducted in India (More and Israni) have shown that the average length of the left styloid was 25.41 ± 6.32 mm and that of the right styloid was 25.53 ± 6.62 mm.
Our study showed that in male patients, mean length of SP on panoramic radiographs on the right side was 30.53 ± 6.80 and on the left side was 28.7 ± 6.75. In female patients, mean length on the right side was 26.9 ± 6.49 and on the left side was 27.27 ± 5.92. Male patients had longer SP than female patients. These results were in accordance with studies done by Sudhakara Reddy et al.  and More and Asrani.  However, this finding differed from a study by Ferrario et al., who found an increased incidence in females. 
Our study showed that according to Langlais' classification, Type I elongated SP was more common (91.5%) than Type II styloid (8.5%). Similar results were obtained by More and Asrani  and Shah et al.  Our study showed unilateral elongation in 21.5% and bilateral elongation in 78.5%, irrespective of age, gender, and type. It was also found that bilateral elongation was frequently seen in males (72.5%) compared to females. This is consistent with the study conducted by Bozkir et al. who noted that bilateral elongation was more common in males.  There were 80.3% patients who were found to be asymptomatic, 11.3% patients had difficulty in swallowing, 5.6% patients had otalgia, 1.4% patients had foreign body sensation in the throat, and 1.4% patients had otalgia as well as foreign body sensation in the throat. Similar results were obtained by Anbiaee and Javadzadeh. 
| Conclusion|| |
Digital panoramic radiography is useful for detection of an elongated SP or ossification of stylohyoid ligaments in patients with or without symptoms and can thus avoid misinterpretation of symptoms such as tonsillar pain or pain of dental, tonsillar, and pharyngeal region.
Department of Oral Medicine and Radiology, Government Dental College and Research Institute, Bengaluru (Karnataka), India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]