The clinical and radiological aspect of Eagles syndrome

Name: Kelvin Bird Id # 0012448

Abstract: Eagle syndrome or styloidcarotid artery syndrome, symptoms brought on by compression of regional structures by elongation of the styloid process by usually more than 30mm or ossification of the stylohyoid or stylomandibular ligaments. Watt Eagle, an otorhinolaryngologist described it for the first time in 1937, dividing it into two subtypes or forms: The classic form and the vascular one. The symptoms vary greatly, ranging from cervicofacial pain to cerebral ischemia, depending on the underlying pathogenetic mechanism and the anatomical structures compressed or irritated by the styloid process. The syndrome generally follows tonsillectomy or trauma. Diagnosis is confirmed by radiological findings. Palpation of the styloid process in the tonsillar fossa and infiltration with anesthesia are also used in making the diagnosis. The treatment is primarily surgical; however, some conservative treatments have also been used. The current literature on Eagle's syndrome is reviewed, highlighting its often underestimated frequency and its clinical importance.

Introduction The styloid process is a cylindrical, long cartilaginous bone located on the temporal bone. The normal styloid process length is approximately 2030 mm. The muscles and ligaments which have a role in mastication and swallowing are attached to the styloid process. There are many nerves and vessels such as carotid arteries adjacent to the styloid process. Both the styloid process and the stylohyoid ligament develop from the Reicherts cartilage (second pharyngeal arch). The styloid process elongation can be assumed if either the styloid or the adjacent stylohyoid ligament ossification shows an overall length in excess of 30 mm. Elongated styloid process is known as Eagles syndrome when it causes clinical symptoms as neck and cervicofacial pain. It is supposed that this symptoms and signs are due to the compression of the styloid process on some neural and vascular structures. Symptoms such as dysphagia, tinnitus, and otalgia may occur in patients with this syndrome. It may also cause stroke due to the compression of carotid arteries. The symptoms due to this syndrome can be confused with some disorders including a wide variety of facial neuralgias, oral, dental and, temporomandibular diseases. Therefore, a detailed differential diagnosis for SPE should be done.

Clinical Features The clinical presentation can be challenging as it relates to establishing a causative relationship between the styloid process or stylohyoid ligament and symptoms. In order to simplify this process the syndrome is be divided into two main sub type with the associated symptoms 1. due to compression of cranial nerves 2. due to compression of carotid artery Patients can have symptoms related to compression and irritation of cranial nerves in the region (cranial nerves V, VII, IX and X)

facial pain while turning the head dysphagia foreign body sensation

pain on extending tongue change in voice sensation of hypersalivation tinnitus or otalgia

On palpation of the styloid process tip, symptoms should ideally be exacerbated. Additionally compression of the carotid artery may also produce vascular / ischaemic symptoms as well as pain along the artery to the supplied territory (thought to be mediated by the sympathetic plexus) including

mechanical compression
o o

visual symptoms syncope

sympathetic plexus irritation

o o

eye pain parietal pain

Radiographic features The normal length of the adult styloid in an adult thought to be approximately 25mm while an elongated styloid is considered > 30mm. Elongation can be unilateral or bilateral Panoramic radiograph and Computed tomography can both be used to assess the styloid process / stylohyoid ligament complex. It has also been proposed that in cases when mechanical vascular compression is potentially the cause of ischemic symptoms that angiographic examination (CT angiography or catheter angiography) obtained with the patient's head positioned to reproduce symptoms may demonstrate mechanical stenosis of the carotid artery .

Treatment Treatment of Eagle syndrome is both surgical and nonsurgical. Nonsurgical treatments include reassurance, nonsteroidal anti-inflammatory medications, and steroid injections. Surgical treatment is by one of 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 extraoral approach. Although both procedures are effective in removing an elongated styloid process, the extraoral approach is thought to be superior because of the decreased risk of deep space neck infection and better visualization of the surgical field.

References

Eagle WW. Elongated styloid processes: report of two cases. Arch Otolaryngol 1937; 25:584 587 Eagle WW. Elongated styloid process:symptoms and treatment. Arch Otolaryngol 1958; 67:172 176.