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Prosthetic implications of Eagle's syndrome
Prosthetic
implications
of Eagle’s
syndrome
James D. Phillips, D.M.D.,* and A. H. Shawkat, B.D.S., D.M.D., University of Louisville, School of Dentistry, Louisville, Ky.
&SC.**
lhe d’ iagnosis of Eagle’s syndrome (an elongated styloid process or a calcified stylohyoid ligament) is difficult to establish unless the dentist develops a degree of suspicion. Without adequate clinical examination and radiographs, the patient might be subjected to incorrect diagnosis and improper treatment, because the symptoms of Eagle’s syndrome may be similar to those produced by wearing a dental prosthesis. The styloid process is a slender, cylindrical spur of bone fused with the interior aspect of the temporal bone immediately in front of the stylomastoid foramen. It consists of two parts: the basal part, which in the adult patient is concealed by the tympanic part, and a projecting portion. The projecting portion gives attachment to three muscles and two ligaments. The stylopharyngeus muscle arises near the base of the bone from the medial and slightly posterior aspect; the stylohyoid muscle from the posterior and lateral aspects near the middle; and the styloglossus muscle from the front near the tip. The tip is continuous with the stylohyoid ligament that runs down to the lesser cornu of the hyoid bone. A band of soft tissue, the stylomandibular ligament, passes from the process belolv the origin of the styloglossus muscle to the angle of the mandible. The styloid process, stylohyoid ligament, and lesser cornu of the hyoid bone are derived embryologically from the hyoid or second branchial area.’ SYMPTOMS
RELATED
TO STYLOID
PROCESSES
Elongated styloid processes. In 1940, Fritz” reported that elongated styloid processes were a cause of obscure throat symptoms. In addition, ossification or calcification of the stylohyoid ligament and stylomandibular ligament has been described.“. ’ Symptoms associated with elongated processes range from obscure complaints of neuralgia and mild discomfort involving the throat to dysphagia, dysphonia, and sharp radiating pain.5, ‘; Eagle” described two distinct syndromes as being attributed to the symptomatic elongated styloid process. The more common syndrome relates symptoms to the pharynx and hypopharynx, with referred pain to the ear. The second or styloid process/carotid artery syndrome presents syrnptoms related to the pattern of distribution of either the internal or external carotid artery. Symptoms, in *Assistant **Associate
614
Professor, Professor
Division of Dental and Head, Division
Radiology. of Dental
Radiology
Prosthetic
Fig.
1. An example
of bilateral
implications
elongation
of Eagle’s
of the styloid
syndrome
615
processes.
this case, result from impingement of the process on the vessels, which affects the circulation and produces irritation of sympathetic nerves in the artery sheath. Donohue5 described a pain syndrome involving up to four cranial nerves (fifth, seventh, ninth, and tenth) which occurs during mastication when the mucosa is irritated by being drawn over the elongated, painful process. Balasubramanian,7 in 1964, suggested that the most plausible cause of pain was related to the entire stylohyoid head. Continuous movement of the hyoid bone prevents union. The proliferation of granulation tissue then causes pressure on the surrounding structures; resulting in pain. According to most investigators, the normal length of the styloid process ranges from 2 to 3 cm. On occasion, dry skulls exhibit elongated styloid processes (Fig. 1). Few studies mentioned the prevalence of elongated styloid processes and attached ossified or calcified ligaments. Eagle” reported that approximately 4 per cent of the population have elongated styloid processes, whereas Fritz2 referred to the finding as being a common one. Likewise, in reports on the calcification or ossification of the stylohyoid ligaments, occurrence of the phenomenon has been found to vary from extremely rare7 to very common.” A study of panoramic radiographs of 484 hospital patients was conducted to determine the length of the styloid process. The mean radiographic lengths of the right and left sides were found to be 29.9 mm. and 29.5 mm., respectively. There was no significant correlation of styloid length and age of the patient to clinical symptoms,’ although this condition appears to exist most frequently in persons 30 years of age and older.lO The classic syndrome. The classic syndrome, as described by Eagle,G produces a typical sequence of symptoms occurring after tonsillectomy. There is pain in the throat throughout convalescence and in ensuing years. Patients often believe that
616
Phillips
Fig. 2. (A) ments. (B)
an.d Shawkat
Radiographs A panoramic
of the right and left rami reveal bilateral radiograph shows the calcified stylohyoid
calcified ligament.
stylohyoid
liga-
their throats did not heal after tonsillectomy. They may have the sensation of a foreign body, such as cotton, a wool fiber, or even metallic substances, lodged in the throat. There may be difficulty and pain on swallowing. Frequently, the pain is referred to the ear on the side of the elongated process. The difficulty in swallowing may involve not only the pharyngeal muscles but also the constrictor muscle of the upper part of the esophagus and hypopharynx. The pharyngeal symptoms are dull, nagging pain which becomes much worse during the act of deglutition and a possible
Volume Number
34 6
Prosthetic
implications
of
Eagle’s
syndrome
617
sharp pain in the pharynx. The pain is no way comparable to the momentary, stabbing pains of severe character that occur in cases of glossopharyngeal neuralgia. The pharyngeal pains are due to the stretching or fibrosis that occur3 during the postoperative (tonsillectomy) healing in the sensory nerve endings of the fifth, seventh, ninth, and tenth cranial nerves, all the branches of which serve the involved region. It is rare for the patient to have symptoms of the classic type when the tonsils have not been removed. Styloid process/carotid artery syndrome. The other syndrome elaborated upon by Eagle6 is the styloid process/carotid artery syndrome, The symptoms of this syndrome may occur whether or not the tonsils have been removed. Any styloid process, especially the elongated one with a tip deviating medially or laterally may cause considerable pressure on the internal or external carotid artery, not only impairing function by diminishing the lumen, but also causing pronounced symptoms by irritation of the sympathetic nerve fibers, which form a rich supply to the walls of the carotid artery. The pinching of the carotid artery will cause pain along the distribution pattern of the artery. This is of diagnostic significance, because the regions of the head supplied by the two carotid arteries are different. Impairment of the internal carotid artery will cause parietal pain and symptoms along the distribution of the ophthalmic artery. When the external carotid artery is impaired, pain will occur below the level of the eyes and along the routes normally supplied by the several branches of the external carotid artery. DIAGNOSIS
OF ELONGATED
STYLOID
PROCESSES
The diagnosis of an elongated styloid process or calcified stylohyoid ligament presents no difficulty. Classic symptoms arising after a tonsillectomy point to this diagnosis which may be easily confirmed by gentle palpation and radiographs. The radiographic examination should consist of a posteroanterior projection, right and left lateral oblique projections, and a panoramic projection. For proper palpation, the slightly curved index finger is introduced into the partly open oral cavity and gently inserted into the tonsillar fossa. The finger should not contact the base of the tongue, initiating the gag reflex. The palpation procedure is simple and easily tolerated if the gag reflex is avoided. If firm resistance is encountered in the tonsillar fossa, it can only be an elongated styloid process or a calcified stylohyoid ligament. Continued palpation will elicit the same pain and symptoms as experienced by the patient. Treatment of this condition is by surgical amputation of the process. Reported results of fracturing the process laterally have not been satisfactory in most instances.ll TREATMENT
OF A PATIENT
A 53-year-old white woman was first seen on April 9, 1972. Her chief complaint was of intermittent pain in the floor of the mouth and tonsillar areas, bilaterally. She felt that her lower removable partial denture was causing the discomfort and intermittent pain. At times, the pain would radiate into her neck and both ears. She feeling in her throat. The symptoms had complained also of an occasional “itching” begun four years previously, and two mandibular removable partial dentures had been constructed in hopes of alleviating this discomfort. She had been examined
618
Phillips
J. Prosthct. Dexmbm.
and Shawkat
Fig. 3. A calcified
stylohyoid
ligament
has been
Dent. 1975
amputated.
two otolaryngologists, and a neurologist, but the previously by a general physician, etiology of the symptoms was not established. Except for a tonsillectomy and an adenoidectomy at age 13 years, without postoperative complications, her past history was noncontributory. Clinical examination disclosed a well-fitting, distal-extension base, removable partial denture which caused no irritation of the buccal or lingual vestibular mucosa. Bilateral tenting of the mucosa of the anterior tonsillar pillars was noted. These areas were sensitive to palpation, and the sharp tips of the styloid process or calcified stylohyoid ligaments could be identified immediately beneath the surface of the mucosa. Panoramic and lateral oblique projections revealed bilateral calcified stylohyoid ligaments (Fig. 2) The patient was referred to an otolaryngologist for consultation. The diagnosis was confirmed, and the decision was made to bilaterally reduce the calcified stylohyoid ligaments by a surgical procedure. On April 27; 1972; the patient was hospitalized. .\n endotracheal general anesthetic was administered. A vertical incision, approximately 2 cm. in length, was made in the left anterior tonsillar prllar, directly over the calcified stylohyoid ligament. Blunt dissection exposed the calcified ligament, and it appeared to be free of muscle attachments. The calcified ligament was madr to protrude through the incision by depressing the surrounding soft tissues. Approximately 2.1 cm. of the calcified ligament were amputated with a rongeur forceps (Fig. 3). The stump was smoothed, and the wound leas closed with o-plain sutures. Following closure of the left side, a second vertical incision was made in the anterior tonsillar pillar on the right side, directly, over the calcified stylohyoid ligament. The ligament was palpated but appeared to have been fractured some time during the procedure. Due to the proximity of tire carotid artcry and its branches, it was decided to leave the fractured ligament alone, as it was movable. Closure was per-
Volume Number
34 6
Prosthetic
implications
of
Eagle’s
syndrome
619
formed as on the left side, and it was decided that, if symptoms persisted on the right side, another surgical procedure would be undertaken at a later date. The patient tolerated the procedure well. Following the operation, there was slight edema in the retromandibular and submandibular regions. This swelling completely subsided within 48 hours. Six weeks later, the patient’s lower removable partial denture was relined. Since then, the patient has been seen twice at six-month intervals and is in good health and free of all previous symptoms. Speech patterns are improved. SUMMARY
Eagle’s syndrome can produce symptoms that may be easily confused with those resulting from wearing a prosthetic restoration. The symptoms resulting from elongated styloid processes and methods of diagnosis and treatment of these processes were described. A patient with Eagle’s syndrome has been presented. The symptoms were initially suspected to be due to an ill-fitting mandibular removable partial denture. Further clinical and radiographic examination led to the diagnosis of Eagle’s syndrome, and surgical correction was done. The prosthodontist should consider surgery as a possible treatment when the symptoms of the syndrome cannot be attributed to a prosthetic restoration. Various radiographic projections and panoramic radiography are valuable in confirming the presence of a calcified stylohyoid ligament or an elongated styloid process. The treatment
authors acknowledge of the patient.
the
valuable
assistance
of
Fielding
W.
Daniel,
M.D.,
in
the
References I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Schaeffer, J. P., editor: Morris’ Human Anatomy, ed. 10, New York, 1951, Blakiston Division/McGraw-Hill Book Company, Inc., p. 150. Fritz, M.: Elongated Styloid Process, Arch. Otolaryngol. 31: 911-918, 1940. Ennis, L. R. M., and Berry, H. M.: Dental Roentgenology, Philadelphia, 1959, Lea & Febiger, Publishers. Stafne, E. C.: Oral Roentgenographic Diagnosis, Philadelphia, 1963, W. B. Saunders Company. W. B.: Styloid Syndrome, J. Can. Dent. Assoc. 25: 283-286, 1959. Donohue, Eagle, W. W.: Symptomatic Elongated Styloid Process, Arch. Otolaryngol. 49: 490-503, 1949. Balasubramanian, S.: The Ossification of the Styloid Ligament and Its Relation to Facial Pain, Br. Dent. J. 116: 108-111, 1964. Lavine, M. H., Stoopack, J, C., and Jerrold, T. L.: Calcification of the Stylohyoid Ligament, Oral Surg. 25: 55-58, 1968. Kaufman, S. M., Elzay, R. P., and Irish, E. F.: Styloid Process Variation. Radiologic and Clinical Study, Arch. Otolaryngol. 91: 460-463, 1970. Eagle, W. W.: Elongated Styloid Processes; a Report of Two Cases, Arch. Otolaryngol. 25: 584-587, 1937. Eagle, W. W.: Elongated Styloid Process; Further Observations and a New Syndrome, Arch. Otolaryngol. 47: 630-640, 1948. UNIVERSITY
OF LOUISVILLE
OF DENTISTRY LOZJISVILLE, KY. 40201 SCHOOL
implications
of Eagle’s
syndrome
James D. Phillips, D.M.D.,* and A. H. Shawkat, B.D.S., D.M.D., University of Louisville, School of Dentistry, Louisville, Ky.
&SC.**
lhe d’ iagnosis of Eagle’s syndrome (an elongated styloid process or a calcified stylohyoid ligament) is difficult to establish unless the dentist develops a degree of suspicion. Without adequate clinical examination and radiographs, the patient might be subjected to incorrect diagnosis and improper treatment, because the symptoms of Eagle’s syndrome may be similar to those produced by wearing a dental prosthesis. The styloid process is a slender, cylindrical spur of bone fused with the interior aspect of the temporal bone immediately in front of the stylomastoid foramen. It consists of two parts: the basal part, which in the adult patient is concealed by the tympanic part, and a projecting portion. The projecting portion gives attachment to three muscles and two ligaments. The stylopharyngeus muscle arises near the base of the bone from the medial and slightly posterior aspect; the stylohyoid muscle from the posterior and lateral aspects near the middle; and the styloglossus muscle from the front near the tip. The tip is continuous with the stylohyoid ligament that runs down to the lesser cornu of the hyoid bone. A band of soft tissue, the stylomandibular ligament, passes from the process belolv the origin of the styloglossus muscle to the angle of the mandible. The styloid process, stylohyoid ligament, and lesser cornu of the hyoid bone are derived embryologically from the hyoid or second branchial area.’ SYMPTOMS
RELATED
TO STYLOID
PROCESSES
Elongated styloid processes. In 1940, Fritz” reported that elongated styloid processes were a cause of obscure throat symptoms. In addition, ossification or calcification of the stylohyoid ligament and stylomandibular ligament has been described.“. ’ Symptoms associated with elongated processes range from obscure complaints of neuralgia and mild discomfort involving the throat to dysphagia, dysphonia, and sharp radiating pain.5, ‘; Eagle” described two distinct syndromes as being attributed to the symptomatic elongated styloid process. The more common syndrome relates symptoms to the pharynx and hypopharynx, with referred pain to the ear. The second or styloid process/carotid artery syndrome presents syrnptoms related to the pattern of distribution of either the internal or external carotid artery. Symptoms, in *Assistant **Associate
614
Professor, Professor
Division of Dental and Head, Division
Radiology. of Dental
Radiology
Prosthetic
Fig.
1. An example
of bilateral
implications
elongation
of Eagle’s
of the styloid
syndrome
615
processes.
this case, result from impingement of the process on the vessels, which affects the circulation and produces irritation of sympathetic nerves in the artery sheath. Donohue5 described a pain syndrome involving up to four cranial nerves (fifth, seventh, ninth, and tenth) which occurs during mastication when the mucosa is irritated by being drawn over the elongated, painful process. Balasubramanian,7 in 1964, suggested that the most plausible cause of pain was related to the entire stylohyoid head. Continuous movement of the hyoid bone prevents union. The proliferation of granulation tissue then causes pressure on the surrounding structures; resulting in pain. According to most investigators, the normal length of the styloid process ranges from 2 to 3 cm. On occasion, dry skulls exhibit elongated styloid processes (Fig. 1). Few studies mentioned the prevalence of elongated styloid processes and attached ossified or calcified ligaments. Eagle” reported that approximately 4 per cent of the population have elongated styloid processes, whereas Fritz2 referred to the finding as being a common one. Likewise, in reports on the calcification or ossification of the stylohyoid ligaments, occurrence of the phenomenon has been found to vary from extremely rare7 to very common.” A study of panoramic radiographs of 484 hospital patients was conducted to determine the length of the styloid process. The mean radiographic lengths of the right and left sides were found to be 29.9 mm. and 29.5 mm., respectively. There was no significant correlation of styloid length and age of the patient to clinical symptoms,’ although this condition appears to exist most frequently in persons 30 years of age and older.lO The classic syndrome. The classic syndrome, as described by Eagle,G produces a typical sequence of symptoms occurring after tonsillectomy. There is pain in the throat throughout convalescence and in ensuing years. Patients often believe that
616
Phillips
Fig. 2. (A) ments. (B)
an.d Shawkat
Radiographs A panoramic
of the right and left rami reveal bilateral radiograph shows the calcified stylohyoid
calcified ligament.
stylohyoid
liga-
their throats did not heal after tonsillectomy. They may have the sensation of a foreign body, such as cotton, a wool fiber, or even metallic substances, lodged in the throat. There may be difficulty and pain on swallowing. Frequently, the pain is referred to the ear on the side of the elongated process. The difficulty in swallowing may involve not only the pharyngeal muscles but also the constrictor muscle of the upper part of the esophagus and hypopharynx. The pharyngeal symptoms are dull, nagging pain which becomes much worse during the act of deglutition and a possible
Volume Number
34 6
Prosthetic
implications
of
Eagle’s
syndrome
617
sharp pain in the pharynx. The pain is no way comparable to the momentary, stabbing pains of severe character that occur in cases of glossopharyngeal neuralgia. The pharyngeal pains are due to the stretching or fibrosis that occur3 during the postoperative (tonsillectomy) healing in the sensory nerve endings of the fifth, seventh, ninth, and tenth cranial nerves, all the branches of which serve the involved region. It is rare for the patient to have symptoms of the classic type when the tonsils have not been removed. Styloid process/carotid artery syndrome. The other syndrome elaborated upon by Eagle6 is the styloid process/carotid artery syndrome, The symptoms of this syndrome may occur whether or not the tonsils have been removed. Any styloid process, especially the elongated one with a tip deviating medially or laterally may cause considerable pressure on the internal or external carotid artery, not only impairing function by diminishing the lumen, but also causing pronounced symptoms by irritation of the sympathetic nerve fibers, which form a rich supply to the walls of the carotid artery. The pinching of the carotid artery will cause pain along the distribution pattern of the artery. This is of diagnostic significance, because the regions of the head supplied by the two carotid arteries are different. Impairment of the internal carotid artery will cause parietal pain and symptoms along the distribution of the ophthalmic artery. When the external carotid artery is impaired, pain will occur below the level of the eyes and along the routes normally supplied by the several branches of the external carotid artery. DIAGNOSIS
OF ELONGATED
STYLOID
PROCESSES
The diagnosis of an elongated styloid process or calcified stylohyoid ligament presents no difficulty. Classic symptoms arising after a tonsillectomy point to this diagnosis which may be easily confirmed by gentle palpation and radiographs. The radiographic examination should consist of a posteroanterior projection, right and left lateral oblique projections, and a panoramic projection. For proper palpation, the slightly curved index finger is introduced into the partly open oral cavity and gently inserted into the tonsillar fossa. The finger should not contact the base of the tongue, initiating the gag reflex. The palpation procedure is simple and easily tolerated if the gag reflex is avoided. If firm resistance is encountered in the tonsillar fossa, it can only be an elongated styloid process or a calcified stylohyoid ligament. Continued palpation will elicit the same pain and symptoms as experienced by the patient. Treatment of this condition is by surgical amputation of the process. Reported results of fracturing the process laterally have not been satisfactory in most instances.ll TREATMENT
OF A PATIENT
A 53-year-old white woman was first seen on April 9, 1972. Her chief complaint was of intermittent pain in the floor of the mouth and tonsillar areas, bilaterally. She felt that her lower removable partial denture was causing the discomfort and intermittent pain. At times, the pain would radiate into her neck and both ears. She feeling in her throat. The symptoms had complained also of an occasional “itching” begun four years previously, and two mandibular removable partial dentures had been constructed in hopes of alleviating this discomfort. She had been examined
618
Phillips
J. Prosthct. Dexmbm.
and Shawkat
Fig. 3. A calcified
stylohyoid
ligament
has been
Dent. 1975
amputated.
two otolaryngologists, and a neurologist, but the previously by a general physician, etiology of the symptoms was not established. Except for a tonsillectomy and an adenoidectomy at age 13 years, without postoperative complications, her past history was noncontributory. Clinical examination disclosed a well-fitting, distal-extension base, removable partial denture which caused no irritation of the buccal or lingual vestibular mucosa. Bilateral tenting of the mucosa of the anterior tonsillar pillars was noted. These areas were sensitive to palpation, and the sharp tips of the styloid process or calcified stylohyoid ligaments could be identified immediately beneath the surface of the mucosa. Panoramic and lateral oblique projections revealed bilateral calcified stylohyoid ligaments (Fig. 2) The patient was referred to an otolaryngologist for consultation. The diagnosis was confirmed, and the decision was made to bilaterally reduce the calcified stylohyoid ligaments by a surgical procedure. On April 27; 1972; the patient was hospitalized. .\n endotracheal general anesthetic was administered. A vertical incision, approximately 2 cm. in length, was made in the left anterior tonsillar prllar, directly over the calcified stylohyoid ligament. Blunt dissection exposed the calcified ligament, and it appeared to be free of muscle attachments. The calcified ligament was madr to protrude through the incision by depressing the surrounding soft tissues. Approximately 2.1 cm. of the calcified ligament were amputated with a rongeur forceps (Fig. 3). The stump was smoothed, and the wound leas closed with o-plain sutures. Following closure of the left side, a second vertical incision was made in the anterior tonsillar pillar on the right side, directly, over the calcified stylohyoid ligament. The ligament was palpated but appeared to have been fractured some time during the procedure. Due to the proximity of tire carotid artcry and its branches, it was decided to leave the fractured ligament alone, as it was movable. Closure was per-
Volume Number
34 6
Prosthetic
implications
of
Eagle’s
syndrome
619
formed as on the left side, and it was decided that, if symptoms persisted on the right side, another surgical procedure would be undertaken at a later date. The patient tolerated the procedure well. Following the operation, there was slight edema in the retromandibular and submandibular regions. This swelling completely subsided within 48 hours. Six weeks later, the patient’s lower removable partial denture was relined. Since then, the patient has been seen twice at six-month intervals and is in good health and free of all previous symptoms. Speech patterns are improved. SUMMARY
Eagle’s syndrome can produce symptoms that may be easily confused with those resulting from wearing a prosthetic restoration. The symptoms resulting from elongated styloid processes and methods of diagnosis and treatment of these processes were described. A patient with Eagle’s syndrome has been presented. The symptoms were initially suspected to be due to an ill-fitting mandibular removable partial denture. Further clinical and radiographic examination led to the diagnosis of Eagle’s syndrome, and surgical correction was done. The prosthodontist should consider surgery as a possible treatment when the symptoms of the syndrome cannot be attributed to a prosthetic restoration. Various radiographic projections and panoramic radiography are valuable in confirming the presence of a calcified stylohyoid ligament or an elongated styloid process. The treatment
authors acknowledge of the patient.
the
valuable
assistance
of
Fielding
W.
Daniel,
M.D.,
in
the
References I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Schaeffer, J. P., editor: Morris’ Human Anatomy, ed. 10, New York, 1951, Blakiston Division/McGraw-Hill Book Company, Inc., p. 150. Fritz, M.: Elongated Styloid Process, Arch. Otolaryngol. 31: 911-918, 1940. Ennis, L. R. M., and Berry, H. M.: Dental Roentgenology, Philadelphia, 1959, Lea & Febiger, Publishers. Stafne, E. C.: Oral Roentgenographic Diagnosis, Philadelphia, 1963, W. B. Saunders Company. W. B.: Styloid Syndrome, J. Can. Dent. Assoc. 25: 283-286, 1959. Donohue, Eagle, W. W.: Symptomatic Elongated Styloid Process, Arch. Otolaryngol. 49: 490-503, 1949. Balasubramanian, S.: The Ossification of the Styloid Ligament and Its Relation to Facial Pain, Br. Dent. J. 116: 108-111, 1964. Lavine, M. H., Stoopack, J, C., and Jerrold, T. L.: Calcification of the Stylohyoid Ligament, Oral Surg. 25: 55-58, 1968. Kaufman, S. M., Elzay, R. P., and Irish, E. F.: Styloid Process Variation. Radiologic and Clinical Study, Arch. Otolaryngol. 91: 460-463, 1970. Eagle, W. W.: Elongated Styloid Processes; a Report of Two Cases, Arch. Otolaryngol. 25: 584-587, 1937. Eagle, W. W.: Elongated Styloid Process; Further Observations and a New Syndrome, Arch. Otolaryngol. 47: 630-640, 1948. UNIVERSITY
OF LOUISVILLE
OF DENTISTRY LOZJISVILLE, KY. 40201 SCHOOL