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 Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 74-77

Eagle syndrome: Orthodontist's perspective

Department of Orthodontics and Dentofacial Orthopaedics, A.J. Institute of Dental Sciences, NH-17, Kuntikana, Mangalore, Karnataka, India

Date of Web Publication17-Apr-2017

Correspondence Address:
K Sindhuja
Department of Orthodontics and Dentofacial Orthopaedics, A.J. Institute of Dental Sciences, NH-17, Kuntikana, Mangalore - 575 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijor.ijor_35_16

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The objective of the article is to report a case of Eagle syndrome in an orthodontic patient. A 20-year-old patient reported to the Department of Orthodontics with a chief complaint of crowding in upper and lower teeth and difficulty in mouth opening. Detailed history and radiographs led to the diagnosis of elongated styloid process also termed as “Eagle syndrome.”

Keywords: Three-dimensional cone-beam computed tomography, Eagle syndrome, Reichert's cartilage

How to cite this article:
Sindhuja K, Hegde G, Rai R, Sorake A, Suvarna N. Eagle syndrome: Orthodontist's perspective. Int J Orthod Rehabil 2017;8:74-7

How to cite this URL:
Sindhuja K, Hegde G, Rai R, Sorake A, Suvarna N. Eagle syndrome: Orthodontist's perspective. Int J Orthod Rehabil [serial online] 2017 [cited 2021 Aug 1];8:74-7. Available from: https://www.orthodrehab.org/text.asp?2017/8/2/74/204632

  Introduction Top

The styloid process is a bony projection, located anterior to the stylomastoid foramen, with the tip pointing downward, forward, and medially and averaging from 20 to 25 mm in length. The tip of the styloid process is situated between the internal and external carotid arteries, lateral to the pharyngeal wall, and immediately behind the tonsillar fossa.[1]

Attachments of styloid process include three muscles and two ligaments. Stylopharyngeus muscle attaches medially at the base of the process, stylohyoid muscle is attached laterally on the central part of the process, and styloglossus muscle originates from the anterior part of the process. The muscles are innervated by glossopharyngeal, facial, and hypoglossal nerve.[1]

The stylohyoid ligament extends from the tip of the styloid process to the lesser cornua of the hyoid bone, and the stylomandibular ligament commences under the attachment of styloglossus muscle and terminates at the angle of mandible.[1]

Embryonic origin of styloid process is from Reichert's cartilage which is a derivative of second branchial arch, i.e., hyoid arch.[2],[3]

Eagle syndrome is a condition in which an elongated styloid process or calcified stylohyoid ligament causes occasional pain in the neck, a feeling of a foreign body (in the throat), or various retromandibular-cervical pains.

This elongation was first described in 1652 by the Italian surgeon Pietro Marchetti. In 1937, Watt Eagle coined the term stylalgia to describe the pain associated with elongation of styloid process and presented two cases with symptomatology of elongated styloid process,[4] hence the name Eagle syndrome.

Some commonly used synonyms for Eagle syndrome are elongated styloid process syndrome, styloid process and carotid artery syndrome, stylohyoid syndrome, styloid process neuralgia, stylalgia.[5]

  Case Report Top

A 20-year-old female patient reported to the Department of Orthodontics with a chief complaint of irregularly placed upper and lower front teeth, difficulty in mouth opening, and occasional pain on mastication and swallowing.

Detailed evaluation of the symptoms revealed that patient experienced pain occasionally on mastication and swallowing which regressed on its own. The patient also revealed occasional pain bilaterally in the neck and temporal region.

Intraoral examination revealed crowding of upper and lower anterior teeth, deep bite, retained deciduous lower left second molar, missing upper left and lower right second molar, and angles class II division 2 subdivision malocclusion with increased curve of Spee and reduced mouth opening [Figure 1],[Figure 2],[Figure 3].
Figure 1: Intra oral photograph-right lateral view

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Figure 2: Intraoral photograph: Left lateral view

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Figure 3: Intra oral photograph: Frontal view

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Radiographic evaluation, i.e., panoramic radiograph (orthopantomogram), revealed bilateral elongated styloid process [Figure 4]. Further investigation included cone-beam computed tomography (CBCT) for detailed evaluation of the styloid process. The right styloid process was measured to be 40 mm, and left styloid process was curved with irregular calcification and a length of 39.6 mm [Figure 5],[Figure 6],[Figure 7].
Figure 4: Panoramic radiograph showing elongated styloid process

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Figure 5: Cone-beam computed tomography image

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Figure 6: Three-dimensional cone-beam computed tomography of right styloid process

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Figure 7: Three-dimensional cone-beam computed tomography of left styloid process

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The patient was referred to the Department of ENT for evaluation and further treatment.

  Discussion Top

The exact etiology of Eagle syndrome is not known although it is considered to be congenital.[6],[7],[8] Elongated styloid process is one of the causes of craniocervical and referred facial pain.[9],[10] Massey conducted a study on 2000 samples and found that only 11 cases showed elongation of styloid process more than 40 mm.[11]

Prevalence of elongated styloid process was found to be four times more in males than females, and in 75% of cases, the elongation was bilateral.[12]

Around 4% of the population is predicted to have an elongated styloid, but only 4–10% of this group is symptomatic.[13]

Various theories have been put forward for explaining the symptoms associated with elongated styloid process:[14] (1) Fracture of styloid process, compressing the adjacent structures, (2) inflammation of ligaments, (3) compression of adjacent nerves and vessels, and (4) irritation of pharyngeal mucosa by the elongated styloid.

The symptoms associated with this syndrome can vary in every case depending on the pathophysiology, and some of the common symptoms associated are craniocervical pain, neuralgias, reduced mouth opening, limited lateral movements of neck secondary to pain, and discomfort. Less commonly observed symptoms are changes in voice, hypersalivation, and alteration in taste.[3]

Orthodontic implications

The major concerns for orthodontists treating a patient with Eagle syndrome are hypersalivation [15] and reduced mouth opening, both of which are observed in this patient. These symptoms cause difficulty in isolation during moisture sensitive procedures such as bonding and reduced access to the posterior segments due to limited mouth opening. In cases with styloid process, more than 40 mm is advised for resection before beginning of orthodontic treatment. Hypersalivation can be controlled during bonding appointments by either prescribing anti-sialagogues or moisture control agents such as cotton rolls or Dri-angle pads.

The referred pain due to elongated styloid is sometimes misdiagnosed as temporomandibular joint pain, dental pain, or idiopathic jaw pain.[16]

Treatment modalities

The treatment of elongated styloid depends on the severity of the symptoms associated. Both surgical and nonsurgical approaches are used for treatment; nonsurgical procedure includes palliative therapies such as administration of antiepileptics and antihistamines, vasodilators, neuroleptics, antidepressants, and tranquilizers.[17]

Localized administration of corticosteroids diluted with local anesthetics is other commonly used treatment option.[18]

Surgical excision of the styloid is advised in cases of fracture of the styloid process [19] and in cases where elongation is more than 40 mm and presents with severe symptoms.

  Conclusion Top

Assessment of styloid process is usually overlooked during routine examination. Detailed history of patients' chief complaint, careful clinical evaluation of the symptoms, and use of advanced diagnostic aids such as CBCT will help the clinician in accurate diagnosis of the patient's symptoms.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Teki S, Latha A, Babu S, Kumara L, Prasad S, Vasanthi A. Eagle's syndrome elongated styloid process. IOSR J Dent Med Sci 2013;5:31-3.  Back to cited text no. 1
Kolagi S, Herur A, Mutalik A. Elongated styloid process – Report of two rare cases. Int J Anat Var 2010;3:100-2.  Back to cited text no. 2
Rodríguez-Vázquez JF, Mérida-Velasco JR, Verdugo-López S, Sánchez-Montesinos I, Mérida-Velasco JA. Morphogenesis of the second pharyngeal arch cartilage (Reichert's cartilage) in human embryos. J Anat 2006;208:179-89.  Back to cited text no. 3
Eagle WW. Symptomatic elongated styloid process; report of two cases of styloid process-carotid artery syndrome with operation. Arch Otolaryngol 1949;49:490-503.  Back to cited text no. 4
Härmä R. Stylalgia: Clinical experiences of 52 cases. Acta Otolaryngol 1966:Suppl 224:149.  Back to cited text no. 5
Steinmann EP. Styloid syndrome in absence of an elongated process. Acta Otolaryngol 1968;66:347-56.  Back to cited text no. 6
Das S, Suhaimi FH, Othman F, Latiff AA. Anomalous styloid process and its clinical implications. Bratisl Lek Listy 2008;109:31-3.  Back to cited text no. 7
Nanjundaiah K, Radhika PM, Shankar V, Prathap KJ. Elongated styloid process: A report of two cadaveric cases. Int J Anat Res 2014;2:431-3.  Back to cited text no. 8
Ghosh LM, Dubey SP. The syndrome of elongated styloid process. Auris Nasus Larynx 1999;26:169-75.  Back to cited text no. 9
Prasad KC, Kamath MP, Reddy KJ, Raju K, Agarwal S. Elongated styloid process (Eagle's syndrome): A clinical study. J Oral Maxillofac Surg 2002;60:171-5.  Back to cited text no. 10
Massey EW. Facial pain from an elongated styloid process (Eagle's syndrome). South Med J 1978;71:1156-9.  Back to cited text no. 11
Cawich SO, Gardner M, Shetty R, Harding HE. A post mortem study of elongatedstyloid processes in a Jamaican population. Internet J Biol Anthropol 2009;3:1.  Back to cited text no. 12
Restrepo S, Palacios E, Rojas R. Eagle's syndrome – Imaging clinic. Ear Nose Throat J 2002;81:700-1.  Back to cited text no. 13
Murtagh RD, Caracciolo JT, Fernandez G. CT findings associated with Eagle syndrome. AJNR Am J Neuroradiol 2001;22:1401-2.  Back to cited text no. 14
Soldati AB, Miguelote C, Quero C, Pereira R, Santos R, Soares C. Eagle's syndrome. Arq Neuropsiquiatr 2013;71:265-6.  Back to cited text no. 15
Taheri A, Firouzi-Marani S, Khoshbin M. Nonsurgical treatment of stylohyoid (Eagle) syndrome: A case report. J Korean Assoc Oral Maxillofac Surg 2014;40:246-9.  Back to cited text no. 16
Gervickas A, Kubilius R, Sabalys G. Clinic, diagnostics, and treatment peculiarities of Eagle's syndrome. Stomatol Balt Dent Maxillofac J 2004;6:11-3.  Back to cited text no. 17
Jain S, Bansal A, Paul S, Prashar DV. Styloid-stylohyoid syndrome. Ann Maxillofac Surg 2012;2:66-9.  Back to cited text no. 18
[PUBMED]  [Full text]  
Pithon MM. Eagle's syndrome in an orthodontic patient. Am J Orthod Dentofacial Orthop 2012;141:113-5.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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