CLINICAL NOTE
Anterior Neck Pain Due to Hyoid Malformation
Matthew M. Michalowicz, MD; Luis G. Izquierdo, MD; M. Peter Sorensen, MD
A
nterior neck pain often presents a challenging problem for the otolaryngologist be-
cause of the various causes. We report an unusual case of an asymmetric hyoid bone
impinging on the carotid sheath with resulting pain on head rotation. Although rare,
awareness of this condition is vital in successful treatment as surgical intervention
provides immediate and long-term resolution of the symptoms.
REPORT OF A CASE
A 21-year-old man with a several-year his-
tory of intermittent, severe right anterior
level II neck pain and swelling reported
that his symptoms worsened when he
turned his head to the right but slowly re-
solved over hours to days. The pain was
always on the right side and often caused
the patient to become nonfunctional for
days at a time. The patient became depen-
dent on narcotic medication to control this
pain. Symptoms also included right tor-
ticollis and dysphagia. On physical exami-
nation, point tenderness was located in
proximity to the superior portion of the
right lateral hyoid bone.
Computed tomography showed a sig-
nificantly asymmetric hyoid bone. The right
greater cornu of the hyoid extended later-
ally and was immediately adjacent to the
carotid sheath at the bifurcation of the ca-
rotid artery. In the Figure, the right lat-
eral portion of the hyoid bone is almost seen
wrapping around the carotid sheath at this
level with definite asymmetry compared
with the left side. The left greater cornu of
the hyoid was shorter and not closely as-
sociated with the carotid sheath. The pa-
tient was brought to the operating room for
excision of the right greater cornu of his hy-
oid bone.
The right lateral portion of the hyoid
bone was excised without complication. Af-
ter surgery, the patient had almost imme-
diate relief of the pain. There was no need
Author Affiliations: Department of Otolaryngology, Walter Reed National Military
Medical Center, Bethesda, Maryland.
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for further narcotic pain medication use. On
follow-up examination, full neck range of
motion was restored and his symptoms had
completely resolved, with no return of pain.
He is 7 years without incident.
COMMENT
Hyoid syndrome is a rare but important
cause of anterior cervical neck pain. Nir et
al1 experienced an incidence of 0.2% (2 of
1000) in their ear, nose, and throat clinic.
Due to the vague symptoms, the differen-
tial diagnosis is numerous, and these pa-
tients have often seen several primary care
physicians before they are referred to an oto-
laryngologist. Treatments during this time
typically range from reassurance to mul-
tiple antibiotic regimens without any relief
of symptoms. Many explanations have been
offered for the origin of the pain, but, to our
knowledge, there are few case reports that
involve an asymmetric hyoid bone impinge-
ment near the carotid artery bifurcation.
The hyoid syndrome, as defined by Lim2,
is a complex of chronic and recurrent fo-
cal lancinating or dull pains in the carotid
area at the level of the tip of the greater hy-
oid cornu. The syndrome is often charac-
terized by point tenderness on the outside
of the neck that may be referred to the lat-
eral part of the neck and radiating to the
ipsilateral ear. Palpation, using the method
first described by Brown3 in 1954, will dem-
onstrate point tenderness at the posterior
end of the greater horn of the hyoid. The
hyoid bone is a central point of attach-
ment for almost all muscles of the anterior
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A B
Figure. Axial computed tomography. A and B, The close association of the right greater cornu of the hyoid
bone (arrows) and the right carotid sheath. The right hyoid bone is seen wrapping around the carotid sheath.
neck and it is involved in the action
of swallowing. As a result, this may
cause the patient to have a sensation
of a foreign body, dysphagia, or tight-
ness or pressure on that side of the
neck. Recently, Colby and Del Gau-
dio4 described a stylohyoid complex
syndrome that causes neck and fa-
cial pain by an elongated hyoid, elon-
gation of the styloid process, or os-
sified stylohyoid ligament (as in Eagle
syndrome) in an attempt to consoli-
date 3 separate pathologic syn-
dromes that cause the same symp-
toms. Any of these structures can
irritate the carotid artery or cranial
nerves VII, IX, or X. Impingement of
the neurovascular bundle from an en-
larged hyoid caused our patient pain.
Previously, standard radiographs
of the cervical spine, to include the
odontoid view, were useful in dem-
onstrating variants or abnormalities
of the hyoid apparatus.5 Recent ad-
vances in computed tomographic
imaging have allowed physicians to
complete a diagnostic workup quickly
and accurately before rendering treat-
ment. In an article by Sittel et al6 in
1998, spiral computed tomography
with 3-dimensional reconstruction
was used to diagnose an elongation
and malformation of the greater cornu
of the hyoid. With a confirmed di-
agnosis and exact pathological
mechanism revealed, surgery was
performed. The surgical approach can
be accurately determined based on
correlation between a physical ex-
amination and computed tomogra-
phy. In our patient, a submandibu-
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lar approach was used to expose the
hyoid bone.
Once a diagnosis is confirmed,
multiple treatment modalities have
been proposed. Karlan et al7 and Rob-
inson et al8 described relief of point
tenderness using an injection of com-
bination corticosteroid and lido-
caine hydrochloride. In 1998, Nir et
al1 presented an article using nonste-
roidal anti-inflammatory drugs as
treatment. Ninety-one percent of pa-
tients with symptoms of less than 6
weeks experienced symptom relief,
and the authors recommended this
anti-inflammatory drug regimen for
first-line treatment. It was believed
that the symptoms in most of these
cases were caused by inflammation at
a muscular insertion point on the hy-
oid as initially described by Ernest and
Salter.9 Surgical excision of the tip of
the greater cornu should be planned
for those patients failing medical
therapy or with known malforma-
tions, as in our patient. Kopstein,5
Bhide and Dehadray,10 and Lim2 de-
scribed the surgical excision of the tip
of the greater cornu with their pa-
tients exhibiting full relief of symp-
toms immediately after surgery.
Although this specific clinical sce-
nario is rare, it does serve as a re-
minder that there are many causes to
anterior cervical neck pain. An aware-
ness that this syndrome exists is vi-
tal in successful treatment. Our pa-
tient responded well to surgical
excision of the right greater cornu of
the hyoid with immediate symptom
relief and without return of the pain.
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308
Submitted for Publication: May 12,
2011; final revision received Sep-
tember 11, 2011; accepted Novem-
ber 20, 2011.
Correspondence: Matthew M. Mich-
alowicz, MD, Department of Otolar-
yngology, Walter Reed National Mili-
tary Medical Center, 8901 Rockville
Pike, Bethesda, MD 20889-5600
(matthew.michalowicz@med.navy
.mil).
Author Contributions: Drs So-
rensen and Izquierdo had full ac-
cess to all the data in the study and
take responsibility for the integrity
of the data and the accuracy of the
data analysis. Study concept and de-
sign: Michalowicz, Sorensen, and Iz-
quierdo. Drafting of the manuscript:
Michalowicz. Critical revision of the
manuscript for important intellectual
content: Sorensen and Izquierdo. Ad-
ministrative, technical, and material
support: Michalowicz and Izquier-
do. Study supervision: Sorensen and
Izquierdo.
Financial Disclosure: None re-
ported.
Disclaimer: The views expressed in
this article are those of the authors
and do not necessarily reflect the of-
ficial policy or position of the US De-
partments of the Army, Navy, and
Defense, or the US government.
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