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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 26  |  Issue : 3  |  Page : 302-305

Unique asymptomatic long bilateral calcified styloid process: A case report


1 Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan, India
2 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Shree Guru Gobind Singh Tricentenary (SGT) University, Gurgaon, Haryana, India

Date of Submission18-Aug-2014
Date of Acceptance05-Nov-2014
Date of Web Publication19-Nov-2014

Correspondence Address:
Sahil Maghu
Tehsil - Amer, Kukas, National Highway-11C, Jaipur - 303 101, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.145012

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   Abstract 

Styloid process has a close proximity to many vital neurovascular structures in the neck, making it clinically significant. It is said to be elongated if its length is more than 3 cm. Only 4% of the general population has been found to have elongated styloid process, most of which are asymptomatic. An unusual case of a calcified styloid process measuring, 8 cm on the right side and 6.75 cm on the left side, viewed on a digital orthopantomograph as well as on a computed tomographic scan is reported in this article.

Keywords: Computed tomography, Eagle′s syndrome, elongated styloid process, pseudoarticulated


How to cite this article:
Desai VD, Maghu S, Sharma R, Koduri S. Unique asymptomatic long bilateral calcified styloid process: A case report . J Indian Acad Oral Med Radiol 2014;26:302-5

How to cite this URL:
Desai VD, Maghu S, Sharma R, Koduri S. Unique asymptomatic long bilateral calcified styloid process: A case report . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2022 May 22];26:302-5. Available from: https://www.jiaomr.in/text.asp?2014/26/3/302/145012


   Introduction Top


Styloid process in Greek means "standing pillar." It is a slender projection attached to the base of the skull extending downward, forward, and medially. [1] Styloid process is composed of connective tissue in adults and is derived from the first and second branchial arches in four distinct segments: Tympanohyal, stylohyal, ceratohyal, and hypohyal segments. The styloid process develops from the tympanohyal and stylohyal segments that fuse at puberty. [2]

Diagnosis of elongated styloid process is made by bimanual palpation of tonsillar fossa (normal styloid process is not palpable), orthopantomography (OPG), and computed tomographic (CT) imaging. [3] The length of the styloid process varies from 2.5 to 3 cm. [4] Literature reveals that the length of the styloid process may vary greatly on the right and left sides in the same individual. [5] Langlais et al., [6] Sokler and Sandev, [7] and Öztaş and Orhan[8] have proposed various classifications for evaluating the length of the styloid process. Males show higher predilection for an elongated styloid process. [9] Symptomatic patients are usually over 40 years of age. [4] The longest recorded elongated styloid process so far that caused symptoms and hence underwent surgery is around 6.5 cm, [10] although in an adult human dry skull, a length of up to 8 cm has been recorded. [11] In a study by Okabe et al., in 659 individuals, the lengths of the bilateral styloid processes on panoramic radiographs ranged from 0.0 to 153.0 mm. [12] The authors present a case of asymptomatic elongated styloid process (which was an inadvertent radiographic finding) which could be the longest reported till date in northern India.


   Case Report Top


A 55-year-old male patient reported to the Department of Oral Medicine and Radiology with the chief complaint of bleeding gums since last 6 months. Medical and family history was not contributory. Though the patient had no deleterious habit of smoking or chewing tobacco in any form, he kept a relatively poor oral hygiene and it was his first dental visit. On general physical examination, the patient was moderately built and nourished, with no obvious abnormalities. Intraoral examination revealed features of chronic generalized periodontitis. With the patient's written consent, an OPG was taken to evaluate the status of the underlying alveolar bone. The OPG showed generalized loss of alveolar bone and an unusual presentation of an elongated styloid process bilaterally [Figure 1] and [Figure 2]. According to the classification given by Langlias et al., [6] the pattern of calcification was continuous type on the right side (Type I) and pseudoarticulated type on the left side (Type II) [Figure 3], [Figure 4], [Figure 5]. The patient was subjected to CT imaging for further detailed evaluation of the elongated styloid process. The length of the styloid process was then measured from the cleft between the lower margin of the tympanic plate of the temporal bone in the skull to its tip in the bony end, on OPG as well as the CT image by the method mentioned by Jung et al. [13] The total length of "calcified styloid complex" on the right side was found to be 8 cm and that on the left side was 6.75 cm. Even though a radiographic diagnosis of elongated styloid was made, carotid artery calcification, tonsiloliths, and lymph node calcifications were kept as radiographic differential diagnoses. The patient was advised complete blood investigations, which also included serum calcium and total serum cholesterol. All the values were within normal range. Patient's height, weight, blood pressure, heart rate, and heel density, which were evaluated by a general physician, were also non-contributory. The periodontal status of the patient was assessed by the community periodontal index of treatment needs (CPITN) index. As the elongated styloid was an unusual asymptomatic imaging finding in this case, the patient was educated about the anatomic variation; however, no treatment was advised for the same. Complete oral prophylaxis was advised, and the patient was kept on constant monitoring and follow-up. Patient was asked to report if any symptom of pain in the neck during rotation or dysphagia was noticed.
Figure 1: Image of OPG showing the length of calcified (elongated) styloid on the right side

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Figure 2: Image of OPG showing the length of calcified (elongated) styloid on the left side

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Figure 3: CT image of elongated styloid on the right side

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Figure 4: 3D reconstructed CT image showing bilateral elongated styloids (anteroposterior view)

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Figure 5: 3D reconstructed CT image showing bilateral elongated styloids overlapping each other in the image (lateral view)

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   Discussion Top


In 1949, Eagle described the homonymous syndrome characterized by an elongated styloid process. [14] The elongation of styloid process is considered an anomaly which can be accompanied by calcification of the stylohyoid and stylomandibular ligaments. [10] A number of theories have been suggested correlating the anatomy, embryology, and physiology with respect to the occurrence of an elongated styloid process. "Theory of reactive hyperplasia" suggests that if the styloid process is appropriately stimulated by pharyngeal trauma, ossification may continue from its tip against the stylohyoid ligament. "Theory of anatomic variance" suggests that the styloid process and the stylohyoid ligament are normally ossified, and the elongation process is simply an anatomical variation. "Dysendocrine theory" suggests that the anatomic variation may be transmitted as a genetic trait. [15] Some other theories state that the persistence of cartilaginous analog of the styloid may cause congenital elongation of the styloid. Calcification of the stylohyoid ligament may occur due to an unknown mechanism and growth of osseous tissue at the insertion of the stylohyoid ligament may also cause its elongation. [3]

An elongated styloid process is not symptomatic in all cases. [3] Although symptomatic patients are usually over 40 years of age, [4] the present patient was 55 years old and asymptomatic. Eagle syndrome is always accompanied with symptoms like dysphagia, foreign body sensation, neck pain during rotation, and facial and carotid pain. [16] In the literature, varying sex predilection rates have been reported for an elongated styloid process. According to More et al., males show higher predilection for an elongated styloid process, [9] whereas the reports by Ferrario et al. and Okabe et al. show higher female predilection. [12] Length of the styloid process has been found to increase with age. Although the longest recorded elongated styloid process in a symptomatic patient is around 6.5 cm, [10] an elongated styloid process with a length of up to 8 cm has been reported in an adult human dry skull. [11] Okabe et al. have reported the lengths of the bilateral styloid processes ranging from 0.0 to 153.0 mm. [12] In the present case, the length was 8 cm on the right side and 6.75 cm on the left side. To the best of our knowledge, the present case could be the longest reported elongated styloid process till date in northern India.

Three-dimensional CT is the best modality to view the length of the styloid process and provides accurate estimation of length, as seen in the present case. The anteroposterior view shows the presence or absence of bilateral involvement and deviation. Surgical and non-surgical modalities exist as the treatment options for symptomatic elongated styloids. A pharmacological approach with transpharyngeal infiltration of steroids under local anesthesia can relieve the symptoms, but styloidectomy is the treatment of choice. [17]


   Conclusion Top


As variations and changes are the rule of nature, differences exist anatomically in all human beings also. It is essential that oral physicians should be aware of the anatomical variations of the styloid process and should have a thorough knowledge of the associated symptoms so as to differentiate it from atypical facial pain or pain of dental origin. The case presented here is unique in that it reports the longest elongated styloid process in the English literature till date in northern India. However, no correlation of elongated styloid with any systemic condition could be made in this case, except for poor oral hygiene.

 
   References Top

1.Chaurasia BD. Deep structures in the neck: Styloid apparatus. In: Chaurasia BD, editor. Human Anatomy, Regional and Applied Dissection and Clinical Head and Neck, Brain. 4 th ed. Vol. 3. New Delhi: CBS Publisher; 2004. p. 200.  Back to cited text no. 1
    
2.Rodríguez-Vázquez JF, Mérida-Velasco JR, Verdugo-López S, Sánchez-Montesinos I, Mérida-Velasco JA. Morphogenesis of the second pharyngeal arch cartilage (Reichert's cartilage) in human embryos. J Anat 2006;208:179-89.  Back to cited text no. 2
    
3.Murtagh RD, Caracciolo JT, Fernandez G. CT findings associated with Eagle syndrome. AJNR Am J Neuroradiol 2001;22:1401-2.  Back to cited text no. 3
    
4.Balcioglu HA, Kilic C, Akyol M, Ozan H, Kokten G. Length of the styloid process and anatomical implications for Eagle's syndrome. Folia Morphol (Warsz) 2009;68:265-70.  Back to cited text no. 4
    
5.Worth HM. Principles and Practice of Oral Radiologic Interpretation. Chicago: Year Book Medical Publishers; 1963. p. 27.  Back to cited text no. 5
    
6.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. 6
    
7.Sokler K, Sandev S. New classification of the styloid process length-- Clinical application on the biological base. Coll Antropol 2001;25:627-32.  Back to cited text no. 7
    
8.Öztaº B, Orhan K. Investigation of the incidence of stylohyoid ligament calcifications with panoramic radiographs. J Investig Clin Dent 2012;3:30-5.  Back to cited text no. 8
    
9.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. 9
[PUBMED]  Medknow Journal  
10.Krishnasamy S. Elongated styloid process- A case report. Online J Otolaryngol 2012;2.  Back to cited text no. 10
    
11.Kolagi SI, Herur A, Mutalik A. Elongated styloid process- Report of two rare cases. Int J Anat Var 2010;3:100-2.  Back to cited text no. 11
    
12.Okabe S, Morimoto Y, Ansai T, Yamada K, Tanaka T, Awano S, et al. Clinical significance and variation of the advanced calcified stylohyoid complex detected by panoramic radiographs among 80-year-old subjects. Dentomaxillofac Radiol 2006;35:191-9.  Back to cited text no. 12
    
13.Jung T, Tschernitschek H, Hippen H, Schneider B, Borchers L. Elongated styloid process: When is it really elongated? Dentomaxillofac Radiol 2004;33:119-24.  Back to cited text no. 13
    
14.Piagkou M, Anagnostopoulou S, Kouladouros K, Piagkos G. Eagle's syndrome: A review of the literature. Clin Anat 2009;22:545-58.  Back to cited text no. 14
    
15.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. 15
    
16.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. 16
    
17.Eagle WW. The symptoms, diagnosis and treatment of the elongated styloid process. Am Surg 1962;28:1-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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