Uncommon Presentation of Styloid Process Fracture: Diagnostic and Therapeutic Insights
The styloid process extends anteriorly and inferiorly from the petrosal aspect of the temporal bone. Elongated styloid process or calcified stylohyoid ligament causes Eagle’s syndrome. Patient’s with Eagle syndrome present with recurrent throat pain, dysphagia, foreign body sensation, change in voice and facial pain. Rare cases have been reported because of the fracture of the styloid process. A new case is reported and the differential diagnosis is discussed.
Case report
A man, 37 years of age, was referred to our department with throat pain radiating to the clavicle and the chest. The patient underwent 3D-CT imaging. He had a history of neck trauma 12 years earier.
His general examination was not significant. Oropharyngeal examination was normal. Medical history were highly suggestive of Eagle’s syndrome. Therefore 3D-CT was ordered. Right styloid process fracture was seen.
The styloid chain consists of the styloid process, the stylohyod ligament, and lesser cornu of the hyoid bone.(1) The styloid process, the thin and long osseous part of the temporal bone, lies caudally, medially, and anteriorly towards the maxillo-vertebro-pharyngeal recess, which involves the carotid arteries, intrnal jugular vein, facial nerve, glossopharyngeal nerve, and the vagal and hypoglossal nerves(2).
Eagle first described Eagle’syndrome with two distinct types in 1949(3). In the classic form, which characteristically develops in patients after tonsillectomy, persistent throat pain and globus pallidus are the main features. In the second type, known as carotis artery syndrome, the carotids are intermittently compressed. Our patient had persistent throat pain radiating to his chest and clavicle.
In a number of cases, Eagle’s syndrome has developed after fracture of the styloid process. Most fractures result from trauma, though several publications have reported characteristic syptoms after spontaneous avulsion fractures caused by sudden laughter, coughing, and epileptic seizures.(4-5)
The mineralized section of the styloid process or the stylohyoid ligament is rigid and are more subjected to fracture secondary to traumatic injury.(6) Mangano & Nylander reported a case of Eagle’s syndrome that occured after an automobile accident and caused by cervicopharyngeal trauma.(7)
Similar cases of traumatic Eagle syndrome have been reported by previous studies.(8,9) Our patient had a history of trauma he sustained 12 years before.
This case was treated conservatively. But a number of other treatments exist. Medical management icludes pain killers and local infiltration of hydrocortisone with bupivacaine. Surgical intervention can be made by intraoral and extraoral approaches. Under general anesthesia fractured free part can be removed.
About The Eagle Syndrome
Etiology of Eagle Syndrome
Often follows trauma, tonsillectomy, or may occur idiopathically.
Symptoms of Eagle Syndrome
- Throat pain or sensation of a foreign body in the throat
- Pain when turning the head, swallowing, or speaking
- Referred pain to the ear (otalgia)
- Facial pain or headache
- Dysphagia (difficulty swallowing)
- In vascular Eagle Syndrome: dizziness, syncope, or transient ischemic attacks due to internal carotid artery compression
Diagnosis of Eagle Syndrome
- Clinical suspicion based on symptoms
- Palpation of the elongated styloid process through the tonsillar fossa
- Imaging: CT scan with 3D reconstruction is the gold standard
Eagle syndrome should be considered in the differential diagnosis of patient’s who had servical, oropharyngeal pain. The diagnosis can be confirmed by radiography.
Treatment Options For Eagle Syndrome
Conservative management: analgesics, anti-inflammatory medications
Surgical resection (styloidectomy): via intraoral or external approach in refractory cases
Does tonsillectomy increase the risk of eagle syndrome?
Yes, tonsillectomy may increase the risk of developing Eagle Syndrome in certain individuals, although it does not directly cause it in everyone (source link >> Eagle Syndrome - StatPearls - NCBI Bookshelf).
Here's how tonsillectomy is related to Eagle Syndrome:
Post-Tonsillectomy Scarring or Fibrosis:
The removal of the tonsils can lead to scar tissue formation in the tonsillar fossa.
If the styloid process is already elongated, scarring can cause it to become fixed or more prominent, leading to compression of nearby nerves or vessels.
Loss of Soft Tissue Buffer:
The tonsils normally act as a soft tissue cushion. Their removal may leave the elongated styloid process closer to the pharyngeal mucosa, making it easier to palpate and more likely to irritate surrounding structures.
Triggering Symptom Onset:
Some patients with an elongated styloid process remain asymptomatic for years. Tonsillectomy may act as a trigger that brings on symptoms, such as throat pain or otalgia, due to local inflammation or tissue disruption.
Surgical Trauma Hypothesis:
The surgery might also lead to reactive ossification or calcification of the stylohyoid ligament, another proposed mechanism behind Eagle Syndrome.
📌 Important: Not all patients who undergo tonsillectomy develop Eagle Syndrome, and not all with elongated styloid processes are symptomatic. It’s the combination of anatomic predisposition and post-surgical changes that may lead to symptomatic Eagle Syndrome.
References
Chi J, Harkness M: Elongated styloid process: a report of three cases. N Z Dent J. 1999 Mar;95(419):11-3.
Fini G,Gasparini G, Filippini F, Becelli R, Marcotullio D. The long styloid process syndrome or Eagle’s syndrome. J Craniomaxillofac Surg 2000;28:123-127.
Eagle WW. Symptomatic elongated styloid process: report of two cases of styloid process-carotid artery syndrome with operation. Arch Otolaryngol 1949;49:490-503.
Babbitt JA. Fracture of the styloid process and its tonsillar fossa complications with report of a case. Ann Otol Rhinol laryngol 1933;42:789-98.
Steinmann EP. A new light on the pathogenesis of the stylois syndrome. Arch Otolaryngol 1970;91:171-4.
Babad MS: Eagle’s syndrome caused by traumatic fractureof a mineralized stylohyoid ligament—literature review and a case report. Cranio 1995 Jul;13(3):188-92.
Manganaro AM, Nylander J: Eagle’s syndrome: aclinical report and review of the literature. Gen Dent. 1998 May-Jun;46(3):282-4.
Perez Carro L, Nurez MP: Fracture of the styloid process of the temporal bone. A case report. Int Orthop. 1995;19(6):359-60.
Scroeder WA Jr.: Traumatic Eagle’s syndrome. Otolaryngol Head Neck Surg. 1991 Mar; 104(3):371-4.
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