|Year : 2015 | Volume
| Issue : 4 | Page : 612-615
Eagle's syndrome: Report of two cases
Altaf Hussain Chalkoo, Nusrat Nazir Makroo, Gowhar Yaqub Peerzada
Department of Oral Medicine and Radiology, Government Dental College, Srinagar, Jammu and Kashmir, India
|Date of Submission||04-Jun-2015|
|Date of Acceptance||18-May-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Nusrat Nazir Makroo
Department of Oral Medicine and Radiology, Government Dental College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Eagle's syndrome is a diagnostic dilemma. Sometimes, it is diagnosed as an accidental finding whereas at other times, it is diagnosed as a syndrome based on complex clinical and radiological findings. Elongated styloid process can impinge on a number of nerves and vessels in the adjoining area, and symptoms can easily be confused with a variety of orofacial pain conditions. Hence, for the treatment and management of such cases, proper diagnosis is very important, and a dentist should always keep Eagle's syndrome in mind while encountering patients with chronic orofacial pain.
Keywords: Eagle′s syndrome, panoramic radiography, stylohyoid ligament, styloid process
|How to cite this article:|
Chalkoo AH, Makroo NN, Peerzada GY. Eagle's syndrome: Report of two cases. J Indian Acad Oral Med Radiol 2015;27:612-5
| Introduction|| |
Eagle's syndrome is an aggregate of symptoms that includes recurrent throat pain, foreign body sensation, dysphagia, and/or facial pain as a direct result of an elongated styloid process or calcified stylohyoid ligament. Although approximately 4% of the population is thought to have an elongated styloid process, only a small percentage (between 4% and 10.3%) of this group is thought to actually be symptomatic. No data could be found to correlate the degree of elongation of the styloid to the severity of symptoms. 
| Case Reports|| |
A 32-year-old female who was normotensive, nondiabetic, and euthyroid reported to our postgraduate department of oral medicine and radiology with a chief complaint of pain on swallowing since 6 years. Pain was aggravated by opening mouth and turning head side to side. The patient often used to have sore throat, and submandibular lymphnodes on the left side were enlarged. Fine-needle aspiration cytology revealed reactive lymphnodes with serous salivary inclusions. All hematological investigations were under normal limits. Orthopantomogram (OPG) [Figure 1], mastoid Towne's view of skull, lateral view of skull [Figure 2], and computed tomography (CT) [Figure 3] revealed elongated styloid processes. On CT, length of the left styloid process was 31 mm and the right styloid process was 29.6 mm. The patient was put on conservative methods of treatment as she was not willing for surgical treatment. Oral medication was begun with the administration of piroxicam 20 mg tablet once daily for a period of 15 days along with hot fomentation and physiotherapeutic neck exercises, especially upper cervical stretches. After this regimen, the patient reported with no symptoms. At present, the patient is on physiotherapeutic exercises and regular follow-up.
A 45-year-old male patient reported to our department with a chief complaint of pain in a tooth on the right side of lower jaw. On intraoral examination, there was carious second molar. While examining the right submandibular area for any lymphadenopathy, a bony hard cord-like structure was palpable which was also palpable from tonsillar fossa on the right side. OPG [Figure 4] revealed calcified stylohyoid ligament on the right side, hence the diagnosis of Eagle's syndrome was confirmed. As it was an incidental finding and there were no symptoms associated with it, no further investigations were performed, but the patient was recalled every month for follow-up.
| Discussion|| |
Eagle's syndrome is defined as the symptomatic elongation of the styloid process or mineralization of the stylohyoid ligament complex. It can present as a variety of different symptoms which can mislead the dentist in diagnosing the condition.  Diagnosis is made both radiographically and by physical examination. Palpation of the styloid process in the tonsillar fossa is indicative of elongated styloid, in that processes of normal length are not normally palpable. Palpation of the tip of the styloid should exacerbate the existing symptoms. If highly suspicious for Eagle's syndrome, confirmation can be made by radiographic studies.  Most frequently, an OPG is used to determine whether the styloid process is elongated. In reviewing these radiographs, it should be noted that the normal length of the styloid in an adult is approximately 2.5 cm,  whereas an elongated styloid is generally 3 cm in length. 
The stylohyoid apparatus is formed by the styloid process, stylohyoid ligament, and the lesser horn of the hyoid bone. Embryologically, it is derived from the Reichert's cartilage of the second branchial arch.  The length of the styloid process is variable. Eagle documented that the average length of styloid ranges from 2.5 to 3.0 cm. , Kaufman et al.  reported that 30 mm is the upper limit for normal styloid process. In radiological studies, the normal length of the styloid process is reported to be no longer than 25 mm. 
Langlais et al.  have classified elongated styloid process as Type I which is uninterrupted and elongated styloid process, Type II which is a pseudoarticulation between styloid process and stylohyoid ligament, and Type III in which there are interrupted segments of the mineralized ligament, creating the appearance of multiple pseudoarticulations. The elongated styloid process is also classified as calcified outline having thin radiopaque border with central radiolucency that constitutes the majority of the process; partially calcified having thicker radiopaque outline and almost complete opacification, but small, sometimes discontinuous radiolucent cores, nodular complex having knobby or scalloped outline which may be partially or completely calcified with varying degrees of central radiolucency, and completely calcified in which there is a totally radiopaque process with no evidence of radiolucent interior.  Case one had Type I styloid on both sides, whereas case two had Type III styloid on the right side.
Several imaging modalities have been used for the diagnosis of Eagle's syndrome which include OPG, lateral head and neck radiographs, Towne's radiographs, lateral oblique radiograph of mandible, anteroposterior skull radiograph, and CT lateral view radiographs of the skull. CT lateral view radiographs of the skull can be substituted for OPGs and an antero-posterior view radiograph should be obtained to determine whether there is any lateral deviation of the styloid.  However, the complete details of length, angulation, and relation to adjacent structures can be obtained from a CT scan by formulating a three-dimensional-CT. 
The pathophysiological mechanism of symptoms is debated as well. Theories include the following:
- Traumatic fracture of the styloid process causing proliferation of granulation tissue, which places pressure on the surrounding structures 
- Compression of adjacent nerves, the glossopharyngeal, lower branch of the trigeminal, or chorda tympani
- Degenerative and inflammatory changes in the tendinous portion of the stylohyoid insertion, called insertion tendonitis
- Irritation of the pharyngeal mucosa by direct compression or post-tonsillectomy
- Scarring (involves cranial nerves V, VII, IX, and X)
- Impingement of the carotid vessels, producing irritation of the sympathetic nerves in the arterial sheath. 
The differential diagnosis of elongated styloid process should include glossopharyngeal and sphenopalatine neuralgia, temporomandibular joint disease, migraine headaches, temporal arteritis, myofacial pain dysfunction syndrome, impacted molar teeth, and faulty dental prostheses. 
Treatment of Eagle's syndrome is both surgical and nonsurgical. Nonsurgical treatments include re-assurance, nonsteroidal anti-inflammatory medications, and steroid injections. Surgical treatment is by one of the two methods. Otolaryngologist W. Eagle preferentially used a transpharyngeal approach through which the elongated portion of the styloid process was removed.  Although this technique does avoid external scarring, it has been heavily criticized because of the increased risk of deep space neck infection and poor visualization of the surgical field (must be performed through the mouth). , Alternatively, the elongated portion can be removed by an extra-oral approach. Although both procedures are effective in removing an elongated styloid process, the extra-oral approach is thought to be superior because of the decreased risk of deep space neck infection and better visualization of the surgical field. , Steinmann has reported good results with an injection of a steroid solution or a long-acting anesthetic at the lesser horn of the hyoid bone or the inferior aspect of tonsillar fossa. 
| Conclusion|| |
Elongated styloid process should be kept in mind when the clinician is facing a case of orofacial pain originating from the third molar region, neck pain, dull-aching headaches, dysphagia, or temporomandibular joint pain. Careful palpation of the postauricular region, mastoid region, and tonsillar fossa along with panoramic radiography will confirm the diagnosis of elongated styloid process. Pain in Eagle's syndrome does not depend on the length of styloid process.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]