Stylohyoid Syndrome (Eagle Syndrome)

 

Mr. D. Muthukumaran

Assistant Professor, Department of Medical Surgical Nursing, Sri Manakula Vinayagar Nursing College

 

ABSTRACT:

Eagle syndrome or stylohyoid syndrome is a rare disease the normal anatomy of the styloid process is 2.5cm. Eagle syndrome is characterized by presence pain in the upper part of the neck due to impingement of nerve plexus around the carotid vessel or glossopharyngeal nerve. It was first reported in the year 1652 by marchetti. Tonsillectomy may cause this syndrome Irritation of the pharyngeal mucosa by direct compression of post tonsillectomy scaring (involves cranial nerves V, VII, IX, and X) unilateral throat irritation is sign of this syndrome and CT scan shows the elongated styloid process and its measurement and angulation. This can be treated with help of analgesics, corticosteroid, antibiotics and transoral approach.

 

 

 

INTRODUCTION:

Basic Anatomy:

The normal styloid process is 2.5cm long and is accepted to be elongated if exceeding 4cm. The styloid process has following attachments: styloglosus muscle, stylohyoid muscle, stylopharyngeus muscle, and stylomandibular and stylohyoid ligament laterally it related to parotid gland and facial nerve across its base. The carotid vessels traverses its tip.

 

Definition:

Syndrome characterized by the presence of pain in the upper Part of the neck due to abnormally elongated styloid process or calcification of stylohyoid ligament impinging on the nerve plexus around the carotid vessel and/ or the glossopharyngeal nerve.

 

HISTORY:

1.     Ossification of the stylohyoid ligament was first reported in 1652 by Marchetti.

2.     In 1937, Eagle presented the first two cases of symptomatic elongated styloid process.

 

Messer and Abramson recommended surgical removal of the elongated styloid process

 

INCIDENCE:

It is most commonly occurs in the age group of 30 -50. 10% of peoples suffered through the rare disease compare to the men more common for the women.

 

AETIOLOGY:

1.     Due to elongated of the styloid process or calcification of the stylohyoid apparatus irritating the nerve plexus around the carotid plexus.

2.     Irritation of the glossopharyngeal nerve and Cervical symphathetic plexus

3.     Osteitis, periostitis

4.     Tonsillectomy

 

 

 

CLASSIFICATION:

EAGLE CLASSIFICATION (1937)

STYLOHYOID SYNDROME:

Follows tonsillectomy and presents with a dull ache in the upper part of the neck and radiating to the ear.

 

STYLOCAROTID SYNDROME:

Presents as pain in the neck, eye and ear due to irritation of the carotid vessels.

 

 

 

PATHOGNESIS:

Traumatic fracture of the styloid process causing proliferation of granulation tissue which may place pressure on the surrounding tissues

 

Degenerative and inflammatory changes in the tendinous portion of the styloid insertion called insertion tendinosis

 

Irritation of the pharyngeal mucosa by direct compression of post tonsillectomy scaring (involves cranial nerves V, VII, IX, and X)

 

Impingement on the carotid vessels, producing irritation of the sympathetic nerves in the carotid sheath

 

 

SIGNS:

Palpation of the tonsillar area aggravates the pain and some around the carotid vessels leading to bradycardia.

 

SYMPTOMS:

1.     Unilateral throat irritation aggravated on swallowing.

2.     Unilateral foreign body sensation in the throat

3.     Upper neck pain (due to irritation of glossopharyngeal nerve)

4.     Ear pain (referred pain due to irritation of glossopharyngeal nerve)

5.     Vasovagal attack (due to irritation of the nerve plexus around the carotid vessels leading to bradycardia)

6.     Tinnitus, dysphagia

 

INVESTIGATIONS:

1.     Bimanual palpation of tonsillar fossa

2.     Plain x-ray of skull anterior posterior view with open mouth, Caldwell view or x-ray of neck lateral view reveals the elongated styloid process.

3.     Orthopantomogram (An Orthopantomogram is an X-ray image of your whole mouth, including your upper and lower jaw and teeth)

4.     CT scan shows the elongated styloid process and its measurement and angulation.

5.     3D –CT scan with measurement and angulation of the styloid process.

 

TREATMENT:

1.     Administer analgesics, corticosteroid, antibiotics, anticonvulsants and antidepressants

2.     Local infiltration with lidocaine 0.25%

3.     Exicision of the elongated styloid process is the treatment modality. Transoral approach is preferred over transcervical approach.

 

TRANSORAL APPROACH:

Performed under general anesthesia.

 

Procedure:

A routine tonsillectomy is performed. At this stage the elongated styloid process can be palpated through the musculature of the tonsil bed. The separation of the superior constrictor muscle exposes the styloid process and the muscle fibers over it, which is divided to expose the process properly. The periosteum over the styloid process is incised and the tip/ Angulation of the styloid process is fractured and removed.

 

ADVANTAGES OF INTRAORAL APPROACH:

1.     Avoids external scar

2.     Less surgical time

 

DISADVANTAGES:

1.     Risk of deep space neck infection

2.     Poor visualization of the surgical field

3.     Major risk of iatrogenic injury to main neurovascular structures.

 

EXTRAORAL APPROACH:

ADVANTAGES:

1.     Better visualization of the surgical field

2.     Better operative sterility

 

DISADVANTAGES:

1.     Time consuming

2.     Risk of injury to facial nerve branches

3.     Neck scar

 

COMPLICATIONS:

a)     Facial nerve injury

b)    Infection

c)     Hemorrhage

 

NURSING CARE:

1.     Monitor vital signs

2.     Watch for signs of bleeding

3.     Maintain the patient in nil per oral

4.     Administer oral analgesics to relief pain

5.     Administer oral antibiotics as per the order

6.     Cold throat gargle after each feed for 7 days.

 

REFERENCES:

1.      Pl Dhingara (2013) Textbook of Diseases of Ear Nose and Throat & Head and Neck Surgery, 6^th Edition, Elsevier, Page no. 272

2.      Zakir Hussain (2016), Textbook of Otorhinolaryngology, 4^th Edition, Paras Medical Publisher, Page. No (824-826).

3.      Bokhari MR, Bhimji SS. Eagle Syndrome. 2017 Jun.

4.      Moffat DA, Ramsden RT, Shaw HJ. The styloid process syndrome: aetiological factors and Surgical Management. J Laryngol Otol. 1977

5.      Kaufman SM, Elzay RP, Irish EF. Styloid process variation. Radiologic and clinical study. Arch Otolaryngol.:460-3.

6.      Lindeman P. The elongated styloid process as a cause of throat discomfort. Four case reports. J Laryngol Otol. 1985):505-8. .

7.      Correl R, Jensen J, Taylor J et al. Mineralization of the stylohyoid-stylomandibular ligament complex: A radiographic incidence study. Oral Surg Oral Med Oral Pathol. 1979. 286-291.

8.      Langlais RP, Miles DA, Van Dis ML. Elongated and mineralized stylohyoid ligament complex: a proposed classification and report of a case of Eagle's syndrome. Oral Surg Oral Med Oral Pathol. 1986 527-32. .

9.      Montalbetti L, Ferrandi D, Pergami P, et al. Elongated styloid process and Eagle's syndrome. Cephalalgia. 1995.

10.   Monsour PA, Young WG. Variability of the styloid process and stylohyoid ligament in Panoramic Radiographs. Oral Surg Oral Med Oral Pathol. 1986 522-6. 

 

 

Received on 08.10.2019         Modified on 15.10.2019

Accepted on 20.10.2019       ©A&V Publications All right reserved