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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 27  |  Issue : 4  |  Page : 516-519

A study on assessment of the length of styloid process in digital panoramic radiographs


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 Submission03-Jun-2015
Date of Acceptance24-May-2016
Date of Web Publication19-Aug-2016

Correspondence Address:
Dr. Nikita Gupta
Department of Oral Medicine and Radiology, Maharishi Markandeshwar Dental College, Mullana, Ambala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.188691

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   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 Top


The term "styloid process" was derived from Greek, meaning a pillar. [1] 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. [2],[3] 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. [3],[4],[5] 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. [6],[7] 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. [5] 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. [6],[7] Although there are many suggested hypotheses, the exact etiology of calcified and ossified SP is unknown. [7],[8],[9] ES is diagnosed by both radiographical and physical examination. Computed tomography is useful for complementary information to that provided by panoramic radiographs. [10],[11]


   Materials and Methods Top


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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Figure 3: Styloid process measuring more than 30 mm on the left side

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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 Top


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 1: Mean length of the right and left styloid process


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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].
Table 3: Type of styloid process according to Langlais' classification


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   Discussion Top


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. [9] 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. [8]

In our study, as done by Erol, [12] 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.[13] 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. [14] and More and Asrani. [15] However, this finding differed from a study by Ferrario et al., who found an increased incidence in females. [16]

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 [15] and Shah et al. [17] 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. [18] 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. [19]


   Conclusion Top


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.

Acknowledgement

Department of Oral Medicine and Radiology, Government Dental College and Research Institute, Bengaluru (Karnataka), India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Eagle WW. Elongated styloid process; further observations and a new syndrome. Arch Otolaryngol 1948;47:630-40.  Back to cited text no. 1
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2.
Monsour PA, Young WG. Variability of the styloid process and stylohyoid ligament in panoramic radiographs. Oral Surg Oral Med Oral Pathol 1986;61:522-6.  Back to cited text no. 2
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Chourdia V. Elongated styloid process (Eagle′s syndrome) & severe headache. Indian J Otolaryngol Head Neck Surg 2002;54:238-41.  Back to cited text no. 3
    
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Ilgüy M, Ilgüy D, Güler N, Bayirli G. Incidence of the type and calcification patterns in patients with elongated styloid process. J Int Med Res 2005;33:96-102.  Back to cited text no. 4
    
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Sadaksharam J, Singh K. Stylocarotid syndrome: An unusual case report. Contemp Clin Dent 2012;3:503-6.  Back to cited text no. 5
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Langlais RP, Miles DA, Van Dis ML. Elongated and mineralized stylohyoid ligament complex: A proposed classification and report of a case of Eagle′s syndrome. Oral Surg Oral Med Oral Pathol 1986;61:527-32.  Back to cited text no. 7
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Beder E, Ozgursoy OB, Karatayli Ozgursoy S. Current diagnosis and transoral surgical treatment of Eagle′s syndrome. J Oral Maxillofac Surg 2005;63:1742-5.  Back to cited text no. 8
    
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Eagle WW. Elongated styloid processes: Report of two cases. Arch Otolaryngol 1937;47:584-7.  Back to cited text no. 9
    
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Sandev S, Sokler K. Styloid process syndrome. Acta Stomatol Croat 2000;34:451-6.  Back to cited text no. 10
    
11.
Gokce C, Sisman Y, Ertas ET, Akgunlu F, Ozturk A. Prevalence of styloid process elongation on panoramic radiography in the Turkey population from cappadocia region. Eur J Dent 2008;2:18-22.  Back to cited text no. 11
    
12.
Erol B. Radiological assessment of elongated styloid process and ossified stylohyoid ligament. J Marmara Univ Dent Fac 1996;2:554-6.  Back to cited text no. 12
    
13.
Kaufman SM, Elzay RP, Irish EF. Styloid Process variation Radiologic and clinical study. Arch Otolaryngol 1970;91:460-3.  Back to cited text no. 13
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Sudhakara Reddy R, Sai Kiran Ch, Sai Madhavi N, Raghavendra MN, Satish A. Prevalence of elongation and calcification patterns of elongated styloid process in south India. J Clin Exp Dent 2013;5:e30-5.  Back to cited text no. 14
    
15.
More CB, Asrani MK. Evaluation of the styloid process on digital panoramic radiographs. Indian J Radiol Imaging 2010;20:261-5.  Back to cited text no. 15
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Ferrario VF, Sigurta D, Daddona A, Daloca L, Miani L, Tafura F et al. Calcification of the stylohyoid ligament: Incidence and morphoquantitative evaluation. Oral Surg Oral Med Oral Pathol 1990;69:524-9.  Back to cited text no. 16
    
17.
Shah SP, Praveen NB, Syed V, Subhashini AR. Elongated styloid process: A retrospective panoramic radiographic study. World J Dent 2012;3:316-9.  Back to cited text no. 17
    
18.
Bozkir MG, Boga H, Dere F. The evaluation of elongated styloid process in panoramic radiographs in edentulous patients. Turk J Med Sci 1999;29:481-5.  Back to cited text no. 18
    
19.
Anbiaee N, Javadzadeh A. Elongated styloid process: Is it a pathologic condition? Indian J Dent Res 2011;22:673-7.  Back to cited text no. 19
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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