Abstract
Eagle syndrome is characterized by secondary calcification and elongation of the styloid process. Eagle syndrome is often associated with sharp, intermittent pain along the path of the glossopharyngeal nerve located in the hypopharynx and at the base of the tongue. In some cases, the stylohyoid apparatus can compress the internal and/or the external carotid arteries and their perivascular sympathetic fibres, resulting in a persistent pain radiating throughout the carotid territory. The pathogenesis of the syndrome is not understood. The authors report the case of a 52-year-old woman with post traumatic Eagle syndrome-like pain and pseudoarthrosis of the stylohyoid ligament.
The styloid process normally measures 2.5–3 cm in length and is situated at the base of the temporal bone, immediately posterior to the mastoid apex . Developing from the Reichert cartilage of the second branchial arch, the styloid process, the lesser horn of the hyoid bone and the ligament between them form the stylohyoid apparatus. When the length of the styloid process exceeds 3 cm, it is considered to be elongated and can be associated with a wide variety of symptoms that were first described by Eagle in 1937 .
Eagle originally described two morbidity forms . The first classic styloid process syndrome form is caused by the calcification of the stylohyoid complex resulting in the scar tissue impinging on cranial nerves V, VII, IX, X or XII, all of which are situated near the styloid process.
The second carotid artery Eagle syndrome form is caused by compression of the sympathetic chain in the carotid sheath. It often occurs in the absence of ossification of the stylohyoid complex. Only a slight deviation of the styloid process medially is required for the tip of the process to start impinging on an artery and cause a wide variety of symptoms .
Patients often experience a wide variety of symptoms, including pain in the throat and ear, vertigo, voice alteration, cough, dizziness, sinusitis, conjunctival injection, headaches, swallowing problems, and pain when turning the head . The symptoms often cause continuous discomfort over long periods of time and are often difficult to diagnose.
The differential diagnosis of Eagle’s syndrome may include any condition that can result in cervicofacial pain . These include temporomandibular joint (TMJ) diseases; trigeminal, sphenopalatine, and glossopharyngeal neuralgias; myofascial pain; mastoiditis; otitis; temporal arteritis; dental pain; chronic tonsillitis or pharyngitis; submandibular sialadenitis or sialolithiasis; esophageal diverticulosis; benign or malignant neoplastic disease; and pharyngeal foreign bodies . Problems that arise in the diagnosis of Eagle’s syndrome can result in various unnecessary treatments .
The calcification of the stylohyoid is often detected as an incidental feature on panoramic radiographs when consulting a dentist or an oral and maxillofacial surgeon. In most cases, the patients are over 40 years of age. Eagle syndrome occurs three times more frequently in women than in men and usually with bilateral calcification . Bilateral involvement does not always involve bilateral symptoms.
The cause of stylohyoid calcification is unknown, but it has been suggested that it may be associated with a genetic polymorphism, trauma, or early onset menopause . When the terms ‘trauma’ and ‘Eagle syndrome’ are used as search headings on PubMed, only three references emerge . On closer examination, these three papers have little to do with trauma.
Surgical and nonsurgical treatment regimens have been described. Nonsurgical treatment involves patient reassurance, the use of analgesics, or the local injection of steroid. The surgical treatment of the calcified stylohyoid is performed using two different anatomical approaches.
The transpharyngeal approach, first described by W. Eagle, is performed through a small incision in the tonsillar fossa by excising the calcified stylohyoid ligament and leaving no visible external cutaneous scar. This operative technique is associated with an increased risk of nerve and vessel injury, deep space infections, and significant postoperative oedema . Talking and swallowing are often difficult for a few days following the procedure. This approach can be difficult to perform on patients with limited mouth opening.
Some authors think that the extraoral approach is superior to the transpharyngeal approach as it provides a better view of the operative field and better wound hygiene . The extraoral approach takes longer, carries the risk of facial nerve injury, and leaves an external scar.
Case report
At the beginning of 2009, a 52-year-old woman with suspected temporomandibular dysfunction was referred by her dentist. The patient had been physically assaulted by her husband in 2006. She sustained a blow to her left shoulder resulting in a left clavicle fracture. The initial treatment comprised a clavicle brace and restricted activities for 3 weeks.
After 7 months (2007), the clavicle fracture showed no signs of healing and the patient complained of ongoing pain and difficulty in lifting her shoulder. Physical examination revealed crepitus and abnormal motion in the middle third of the left clavicle. Radiographs ( Fig. 1 A ) revealed a displaced clavicle fracture. Attempts to achieve apposition of the bone ends had been unsuccessful. In 2007, an open reduction was performed with internal fixation and cancellous bone grafting from the anterior iliac crest ( Fig. 1 B). The patient was immobilized postoperatively with a sling for 4 weeks. Follow-up examination revealed the fracture to be radiographically united.
