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Pseudodysphagia due to omohyoid muscle

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ARTICLE in DYSPHAGIA MARCH 2009

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Dysphagia
DOI 10.1007/s00455-008-9206-8
CASE REPORT
Pseudodysphagia Due to Omohyoid Muscle Syndrome
Lina Kim Heekyu Kwon Sung-Bom Pyun
Springer Science+Business Media, LLC 2008
Abstract Omohyoid muscle syndrome (OMS) is a rare
clinical condition that has the pathognomonic feature of the
appearance of a lateral neck mass when swallowing due to
dysfunction of the omohyoid muscle (OH). We present two
cases of typical OMS with electrophysiologic and dynamic
imaging studies. The study results indicate that OMS is
caused mainly by the loosening of the fascial attachment to
the intermediate tendon of the OH. The characteristic
clinical features and pathomechanism underlying OMS are
also discussed.
Keywords Deglutition
Omohyoid muscle syndrome

Dysphagia
Ultrasonography
Swallowing
electromyography
Deglutition disorders
Omohyoid muscle syndrome (OMS), or omohyoid sling
syndrome, is a rare clinical condition characterized by a
protruding lateral neck mass caused by the omohyoid (OH)
muscle when swallowing. The incidence and prevalence of
OMS are unknown, but it is interesting to note that all of
the cases of OMS reported in the literature have been from
eastern Asia [14]. In general, patients with OMS complain
of neck discomfort, dysphagia-like symptoms, and
No commercial party with a direct financial interest in the results of
the research supporting this article has or will confer a benefit upon
the authors or upon any organization with which the authors are
associated.
L. Kim
H. Kwon
S.-B. Pyun (&)
Department of Physical Medicine and Rehabilitation,
Korea University Anam Hospital, Korea University College
of Medicine, 5-Ga 126-1, Anam-Dong, Sungbuk-gu,
Seoul 136-705, Republic of Korea
e-mail: rmpyun@korea.ac.kr
cosmetic problems, and they fear that their symptoms may
be caused by a serious medical condition such as malig-
nancy. However, the clinical entity and pathogenic
mechanisms of OMS remain poorly understood, and the
majority of routine imaging and electrodiagnostic studies
performed during the resting state are not helpful in the
diagnosis, management, and exploration of the patho-
mechanism underlying OMS. We encountered two cases of
OMS and performed electrophysiologic studies and
dynamic imaging techniques in order to elucidate the
pathomechanism of OMS.
Case Reports
Case 1
A 30-year-old woman visited the Department of Otolar-
yngology because of the appearance of a left lateral neck
mass when swallowing, which she began to notice two
days prior. She had given birth to her first child several
months beforehand and had no previous history of medical
illness or trauma. She was referred to the Department of
Physical Medicine and Rehabilitation (PMR) to have the
abnormal neck mass and dysphagia evaluated. She denied
any change in voice or local tenderness in the neck. The
mass was not palpable at rest, but the X-shaped mass was
prominent when swallowing (Fig. 1a, b). The neck mass
appeared simultaneously with laryngeal elevation, and it
disappeared when the larynx returned to resting position.
Physical and neurologic examinations did not reveal any
abnormalities. The findings of plain radiograph, neck
computed tomography (CT), and videofluoroscopic swal-
lowing study (VFSS) were not remarkable. Needle
electromyography (EMG) of the bilateral OH,
123

Fig. 1 a, c Patients in the resting state. b, d Patients swallowing; the
arrows point to a protruding mass caused by tenting of the omohyoid
(OH) muscle. eh Real-time sonographic findings. The probe was
fixed on the left (affected side) lower neck area and then the muscle
movement was recorded. The arrow points to the OH. e Patient in the
resting state. f Patient at the start of swallowing. g Midstage of
swallowing. h During the end stage of swallowing. We could see that
sternocleidomastoid (SCM), and cricothyroid muscles
showed no abnormal findings, but grouped discharges of
motor unit action potentials (MUAPs) of the OH were
noted during swallowing, which was suggestive of OMS.
Case 2
A 55-year-old woman visited the PMR clinic because of
posterior neck pain that had lasted for 2 years. She had no
history of medical illness or neurologic disease, and the
findings of a neurologic examination were normal. On
close inspection, her head was tilted to the left side at rest,
and the left lateral neck mass appeared when she swal-
lowed. She noticed a bulge on the side of her neck several
years earlier and she worried that it could be caused by a
malignant condition. She did not complain of any pain,
swallowing difficulty, or change in voice. The soft neck
mass was palpable only during swallowing and disappeared
at rest (Fig. 1c, d). The clinical symptoms and signs were
suggestive of OMS.
We performed multiple tests to clarify the diagnosis and
elucidate the exact mechanism of OMS in case 2. The tests
included plain radiography of the neck, swallowing
123
L. Kim et al.: Omohyoid Muscle Syndrome
the OH pushed the SCM muscle upward, and it appeared somewhat
thickened. ik Dynamic CT scan images that show the relationship
between the OH (arrow) and the sternocleidomastoid muscle
(arrowhead). These were taken during the midswallowing stage.
The position of the OH was dislocated anterolaterally, and a surface
mass-like protrusion was noted in J and K
electromyography (EMG) [5] and needle EMG of the neck
muscles, dynamic neck computed tomography (CT), and
real-time ultrasonography (US). Swallowing EMG (Me-
delec Synergy, UK) was performed using the two-channel
recording technique described by Ertekin [6]. A surface
electrode was placed on the submentalis muscles and
connected to channel 1. The recorded responses were
amplified, rectified, and then integrated. To detect the lar-
yngeal movement, a piezoelectric sensor (Grass
instrument, USA) was placed on the cricoid cartilage at
the midline and connected to channel 2. The instrumenta-
tion settings were as follows: filter setting, 100 Hz-10 kHz;
sweep speed, 25 s/div; and sensitivity, 100 lV/div. The
surface EMG potentials and the excursion of the cricoid
cartilage were recorded while the patient drank water with
the neck in a neutral position. Dynamic CT scanning was
performed at rest and on swallowing. After taking a drink
of water, she was asked to hold her breath when the hyoid
bone reached its highest position in order to obtain the
images at the time of maximal mass protrusion. Real-time
US was performed with an ultrasound scanner (Envisor
HD Phillips) with a 7-MHz linear array transducer, and
the OH was traced during swallowing. The position and
L. Kim et al.: Omohyoid Muscle Syndrome
thickness of the OH were recorded during different stages
of swallowing.
The soft tissue view of plain radiography and VFSS
were normal. On swallowing EMG, the time parameters,
including the triggering of the swallowing reflex, rise time,
and total duration of compound muscle action potentials
(CMAPs) recorded from the submentalis muscle, and lar-
yngeal relocation time were within normal range, but the
needle EMG of the symptomatic OH showed overactive
grouped discharges of MUAPs when drinking water.
Dynamic CT confirmed the absence of a constant swelling
in the neck, as well as that of a mass in the thorax. How-
ever, successive axial neck images showed that the position
of the OH moved anterolaterally. Real-time US showed
transient bulging of the OH. The OH pushed the SCM
muscle upward and it increased in thickness (unaffected
side OH depth = 0.166 cm and affected side = 0.298 cm).
The movement and change in thickness were not apparent
in the OH on the unaffected side. Based on the results of
these studies, the protrusion was not a real mass but rather
the SCM muscle, which was passively pushed up by the
dislocated OH (Fig. 1ek).
Discussion
The OH is an infrahyoid muscle of the neck, and it is
formed when the superior and inferior bellies are united at
an angle by an intermediate tendon. It arises from the
superior border of the scapula and suprascapular ligament.
Passing superomedially, it becomes tendinous to form the
intermediate tendon, which passes through a fascial sling
attached to the medial end of the clavicle [7]. Continuing as
a slender muscle, it ascends medially from the sling to
insert into the inferior border of the hyoid bone. Functions
of the OH are debatable. Obviously, this muscle depresses
the elevated hyoid bone during swallowing. Vanneuville
et al. [8] describes OH as likely a vestige and the needle
EMG findings of the inferior belly with nearly constant
activity may be opposed to the superior belly with inter-
mittent activity. Castro et al. [9] reported that the strongest
activity of the superior belly of the OH was observed in the
placement of the tip of the tongue on the soft palate,
coincidentally with a greater dislocation of hyoid bone.
Others have shown with EMG that OH is activated during
depression of the mandible and head rotation [10], and that
fibrosis and contracture of a unilateral OH has been found
to cause torticollis [11, 12]. However, more studies are
needed to determine the functional importance of the OH
during swallowing.
OMS is a rare clinical condition that shows unmistak-
able signs of an X-shaped lateral neck mass caused by
displacement of the SCM muscle superficially due to
aberrant movement of the OH. Historically, a similar ter-
minology, omohyoid syndrome, was used in a report
published in 1969 to describe a case with characteristic
symptoms, including pain and tenderness in the neck, voice
changes, and swallowing difficulties most likely due to
acute spasm or cramping of the OH [13]. However, the
patient did not show any neck mass or anatomical dis-
configuration during swallowing. Thus, this case is not
compatible with the current concept of OMS. The first
description of a patient with OMS who showed a bilateral
neck mass during swallowing was reported in a Chinese
journal in 1978 by Ye who also reported in the English
literature in 1980 [3]. Interestingly, this rare clinical syn-
drome has been reported only in countries in eastern Asia,
including mainland China [24], Japan [14, 15], and South
Korea [1]. However, the geographical and racial distribu-
tions of OMS remain largely unknown.
There have been several hypotheses about the mechanism
responsible for OMS. The first proposed mechanism is that
OMS is caused by failure of OH to lengthen due to muscle
fiber degeneration [3]. A recent anatomical study [16]
regarding morphologies of the superior belly of OH reported
that four types of intermediate morphologies were observed
in 18 of 67 samples, and four of them were considered to be
caused by the poor development of the myofibers (type 1).
This then limits the upward movement of the hyoid bone and
results in the tenting or lifting upward and outward of the
overlying SCM muscle during the laryngeal elevation phase
of swallowing. However, this mechanism is not feasible
based on our observation. Unless the OH was actually able to
bowstring, tenting would not be possible [2].
The other hypothesis regarding OMS is that it is caused
by a failure of the fascial-retaining mechanism of the OH.
Loosened fascial attachment of the intermediate tendon
permits relatively free motion of the OH, and the elevated
SCM and underlying OH form an X-shaped tent in the
lateral neck during upward movement of the hyoid bone
when swallowing. The etiology responsible for the loos-
ening of this attachment is not known for certain, but
anatomical variation or congenital weakness in develop-
ment [2, 4], racial predisposition, chronic fatigue, or
trauma [13] may contribute to the development of OMS.
The incidence of anomalies of the OH related to the origin
and insertion, the course, and the number of bellies and
anomalies of the surrounding muscles is high [4, 1619].
Also, poor development of myofibers of the superior belly
of OH and the unclear internal margin between OH and
cervical fascia are frequent [16]. These various anatomical
factors and chronic or instant strong force to the OH may
increase the pulling force of OH from the cervical fascia
and subsequent loosening or detachment can develop.
Eventually, freed OH elevates SCM and the two muscles
form an X-shaped lateral neck mass (Fig. 2).
123

Fig. 2 Diagrams depicting failure of the fascial-retaining mechanism
of omohyoid muscle syndrome (OMS). a Omohyoid muscle (OH)
consists of superior and inferior bellies united at an angle by an
intermediate tendon (IT) and it passes behind the sternocleidomastoid
(SCM) muscle. The inferior belly (InB) inclines forward and slightly
upward and is inserted into the IT. The superior belly (SuB) originates
in the IT and is inserted into the base of the hyoid bone (H). b The OH
muscle depresses the hyoid bone after it has been elevated during
In contrast to previous reports, we performed multiple
diagnostic studies, including static and dynamic imaging
techniques and electrophysiologic studies, in order to fully
delineate every aspect of OMS. In addition, the study
results in our second case support the latter fascial-retain-
ing hypothesis. Normal VFSS and normal findings of a
swallowing EMG study in all parameters regarding the
swallowing reflex, activity of the pharyngeal muscles, and
hyoid bone movement suggested OMS as a false dysphagia
syndrome. Dynamic US and CT imaging were very useful
for the diagnosis and elucidation of the pathomechanism
underlying OMS. These studies revealed that the unre-
strained motion of the OH during swallowing resulted in
displacement of the OH from the deep to superficial neck
and pushed the overlying SCM muscle upward. At the
same time, the diameter of the OH on the symptomatic side
increased according to the elevation of the hyoid bone, and
the sound side did not show muscle enlargement. It seemed
that a normally centrally fixed OH controls upward hyoid
bone movement by lengthening contraction during swal-
lowing; however, loosening of the central attachment
causes the OH to relax, and loss of a fixation point limits
the use of this muscle as an effective eccentric contractor.
There are limited resources available for the treatment
of OMS. Because OMS is not caused by a true mass but
rather by dysfunction of the OH, the treatment was focused
on cosmetic correction and reassurance of the patient. In
one report [3], ten cases of OMS had been treated by
simple division of an intermediate tendon of the OH. The
author argued that the satisfactory results were always
123
L. Kim et al.: Omohyoid Muscle Syndrome
swallowing. The angulated course of the OH muscle is maintained by
a band of deep cervical fascia (CF). c Loosened fascial attachment of
the IT permits relatively free motion of the OH and it elevates SCM.
Underlying OH and SCM form an X-shaped tent in the lateral neck
during upward movement of the hyoid bone when swallowing. C
clavicle; CF cervical fascia; InB inferior belly of omohyoid muscle;
M mastoid process; S scapula; SCM sternocleidomastoid muscle; SuB
superior belly of omohyoid muscle
achieved after operation and one follow-up case did not
show recurrence of neck mass for 4 years. There has been
no report regarding the usefulness of botulinum toxin in
OMS, but botuliun toxin injection to the superior and
inferior bellies of OH seemed to be a promising remedy for
OMS. Also, a patients fears of having a malignant con-
dition can be alleviated by helping him/her understand the
underlying mechanism of the neck muscle interaction.
References
1. Lee DKG. Omohyoid muscle syndrome. Kor J Otolaryngol.
2002;45:3069.
2. Wong DS, Li JH. The omohyoid sling syndrome. Am J Otolar-
yngol. 2000;21:31822. doi:10.1053/ajot.2000.16161.
3. Ye BY. Omohyoid muscle syndrome: report of a case. Chin Med
J (Engl). 1980;93:658.
4. Zhang H, Zhao C, Wang D. False dysphagia caused by omohyoid
muscle syndrome: 50 cases of autopsy and 2 cases of clinical
reports. Zhonghua Wai Ke Za Zhi. 1995;33:3623.
5. Koo J, Pyun SB, Choi KH. Electrophysiologic evaluation of the
effects of volume and neck positions on swallowing. J Korean
Acad Rehabil Med. 2003;27:91721.
6. Ertekin C, Keskin A, Kiylioglu N, Kirazli Y, On AY, Tarlaci S,
et al. The effect of head and neck positions on oropharyngeal
swallowing: a clinical and electrophysiologic study. Arch Phys
Med Rehabil. 2001;82:125560. doi:10.1053/apmr.2001.25156.
7. Standring S. Grays anatomy: The anatomical basis of clinical
practice. 39th ed. Edinburgh: Elsevier Churchill Livingston;
2005.
8. Vanneuville G, Mondie JM, Scheye T, Guillot M, Dechelotte P,
Campagne D, et al. Anatomic and physiologic comments
L. Kim et al.: Omohyoid Muscle Syndrome
concerning the innervation and function of the omohyoid muscle
in man. Bull Assoc Anat (Nancy). 1986;70:559.
9. Castro HA, Resende LA, Berzin F, Konig B. Electromyographic
analysis of the superior belly of the omohyoid muscle and ante-
rior belly of the digastric muscle in tongue and head movements.
J Electromyogr Kinesiol. 1999;9:22932. doi:10.1016/S1050-
6411(98)00033-9.
10. Gehrking E, Klostermann W, Wessel K, Remmert S. Electromy-
ography of the infrahyoid musclespart 1: normal findings.
Laryngorhinootologie. 2001;80:6625. doi:10.1055/s-2001-18271.
11. Pirsig W. Congenital torticollis with dislocation of the larynx and
trachea caused by contracture of one omohyoides muscle
(authors transl). Arch Otorhinolaryngol. 1977;215:3357. doi:
10.1007/BF00463072.
12. Shih TY, Chuang JH. Fibrosis of the omohyoid musclean
unusual cause of torticollis. J Pediatr Surg. 1998;33:7412. doi:
10.1016/S0022-3468(98)90204-4.
13. Zachary RB, Young A, Hammond JD. The omohyoid syndrome.
Lancet. 1969;2:1045. doi:10.1016/S0140-6736(69)92410-6.
14. Makino K, Kinishi M, Kokubu M, Amatsu M. Omohyoid muscle
syndromeclinical, pathological and etiological studies. Nippon
Jibiinkoka Gakkai Kaiho. 1983;86:7214.
15. Shibusawa M, Nishijima W, Hentona H. A case of omohyoid
muscle syndrome. Nippon Jibiinkoka Gakkai Kaiho. 1986;89:
8338.
16. Sukekawa R, Itoh I. Anatomical study of the human omohyoid
muscle: regarding intermediate morphologies between normal
and anomalous morphologies of the superior belly. Anat Sci Int.
2006;81:10714. doi:10.1111/j.1447-073X.2006.00138.x.
17. Fukuda H, Onizawa K, Hagiwara T, Iwama H. The omohyoid
muscle: a variation seen in radical neck dissection. Br J Oral
Maxillofac Surg. 1998;36:399400. doi:10.1016/S0266-4356(98)
90668-4.
18. Hatipoglu ES, Kervancioglu P, Tuncer MC. An unusual variation
of the omohyoid muscle and review of literature. Ann Anat.
2006;188:46972. doi:10.1016/j.aanat.2006.03.004.
19. Tubbs RS, Salter EG, Oakes WJ. Unusual origin of the omohyoid
muscle. Clin Anat. 2004;17:57882. doi:10.1002/ca.20039.
Lina Kim MD
Heekyu Kwon MD, PhD
Sung-Bom Pyun MD, PhD
123