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SHORT COMMUNICATION  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 283-285
A patient with Eagle syndrome: Radiological and scintigraphic evaluation


1 Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Erciyes University, Kayseri, Turkey
2 Department of Endocrinology and Metabolism, Faculty of Medicine, Mustafa Kemal University, Hatay, Turkey, Turkey
3 Department of Nuclear Medicine, Faculty of Dentistry, Erciyes University, Kayseri, Turkey
4 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Izmir Katip Celebi University, Izmir, Turkey

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Date of Submission02-Feb-2011
Date of Decision06-Aug-2011
Date of Acceptance19-Nov-2011
Date of Web Publication3-Sep-2012
 

   Abstract 

A 42-year-old man who had been having otalgia and facial and neck pain for 6 months presented for a routine dental examination. He had suffered two head traumas, the first 20 years ago and the second 4 years ago. A panoramic radiograph (PR) was taken as a screening film after the clinical examination. Bilateral styloid process elongation (SPE) was detected, and the patient was diagnosed as having Eagle syndrome. The styloid process (SP) length was 78 mm on the right and 74 mm on the left on multislice computed tomography (MSCT). Bone scan of the cranium showed normal uptake of radiotracer in the cranial bones and some little activity was detected as a silhouette in the localization of SPE in planar and SPECT images. To the best of our knowledge, this is the first case investigating SPE by bone scintigraphy in a patient with Eagle syndrome.

Keywords: Computed tomography, Eagle syndrome, panoramic radiography, scintigraphy, styloid process elongation

How to cite this article:
Yildiray S, Cumali G, Ismail C, Elif TE. A patient with Eagle syndrome: Radiological and scintigraphic evaluation. Indian J Dent Res 2012;23:283-5

How to cite this URL:
Yildiray S, Cumali G, Ismail C, Elif TE. A patient with Eagle syndrome: Radiological and scintigraphic evaluation. Indian J Dent Res [serial online] 2012 [cited 2020 Sep 22];23:283-5. Available from: http://www.ijdr.in/text.asp?2012/23/2/283/100442

   Case Report Top


A 42-year-old man who had been having otalgia and facial and neck pain for 6 months presented for a routine dental examination. He had allergic dermatitis in remission and history of recurrent bilateral otitis media for 7 years. He had suffered two head traumas, the first 20 years ago and the second 4 years ago. He had been smoking 1-2 packs of cigarettes a day for 25 years. He did not drink alcohol.

On clinical examination, the maxillary jaw was partially edentulous. In the mandibular jaw, the right first molar tooth had been extracted. The left third molar's clinical crown was fully carious but its roots were in the jaw. A panoramic radiograph (PR) was taken as a screening film after the clinical examination. The PR showed that the maxillary jaw was partially edentulous. In the mandibular jaw, the left first molar was absent and the left third molar's roots were in the jaw without evidence of any clinical crown. Bilateral styloid process elongation (SPE) was also detected on the PR [Figure 1]. Based on this finding and the history of otalgia and facial and neck pain for 6 months we diagnosed Eagle syndrome.
Figure 1: Ossification of the complete stylo-hyoid chain, extending from stylo-hyoid process to hyoid bone, on panoramic radiography in a patient with Eagle syndrome.

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In the current case, the styloid process (SP) length was 78 mm on the right side and 74 mm on the left side on multislice computed tomography (MSCT). The mediolateral angling (MLA) on MSCT was 69.6° on the right side and 72.6° on the left side. The anteroposterior angling (APA) was 94.6°. No aberrant deviation in the SP was detected [Figure 2]. Bone scan of the cranium revealed normal uptake of radiotracer in the cranial bones and some little activity can be determined as a silhouette in the localization of SPE in planar and SPECT images in the present case [Figure 3] and [Figure 4].
Figure 2: Three-dimensional volume-rendered images show bilateral styloid process elongation in a patient with Eagle syndrome.

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Figure 3: A little activity detected as a silhouette in the location of the elongated styloid processes in the planar image on bone scintigraphy in a patient with Eagle syndrome.

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Figure 4: A little activity as a silhouette in the location of the elongated styloid processes in the SPECT image on bone scintigraphy in a patient with Eagle syndrome.

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   Discussion Top


Eagle syndrome is diagnosed on the basis of radiographical and physical findings. In normal individuals the SP is not palpable in the tonsillar fossa. If it is palpable it is indicative of SPE. Also, palpation of the tip of the SP should exacerbate the existing symptoms in cases of Eagle syndrome. If the findings are highly suspicious for Eagle syndrome, confirmation can be done by radiographical imaging. [1] Most commonly, a PR is used to determine whether the SP is elongated. CT is useful for complementary information. [2] Although there are many hypotheses, the exact etiology of calcified and ossified SPE is unknown. [3]

Although PRs have an important role in demonstrating the variations of the SP, they are not able to show the orientation and dimensions of this bone. [2] On the other hand, MSCT provides reliable visualization of these features. [2] In the current case, the SP length was 78 mm on the right and 74 mm on the left side on MSCT.

Many reports have shown that SPE may not be the only reason for the symptoms, and different authors have suggested that factors such as MLA, APA, and bending of the SP head are also important. [2] The mean value for MLA has been reported to be 69.5°-72.7°. The MLA in our case was 69.6° on the right side and 72.6° on the left side, which is within normal limits. The mean value for APA has been reported to be 93.5°±6.9°. The APA of our case was 94.6°, which is within these limits. It has been reported that the tip of the elongated SP may bend medially or laterally and may cause nerve irritation due to a compression effect. [2] However, there was no abnormal deviation in the present case.

Bone scintigraphy can identify new areas of bone growth or breakdown. It can be used to evaluate damage to bones, detect cancer that has spread (metastasized) to bones, and monitor other conditions that can affect the bones (e.g., infection and trauma). A bone scan may be done initially to help determine the location of an abnormal bone in complex bone structures such as the foot or spine. Follow- up evaluation may then be done with CT or magnetic resonance imaging (MRI). [4] In the current case, bone scan of the cranium showed normal uptake of radiotracer in the cranial bones and some little activity can be determined as a silhouette in the localization of SPE in planar and SPECT images. Thus, although radiographic imaging may be sufficient for patients with Eagle syndrome who have normal bone structure, if there is any complication involving this bone (e.g., tumor, [5] osteomyelitis, [4] fracture, [6] etc.) bone scintigraphy can be useful due to its high sensitivity. [4]

In the literature, there are many case reports of patients with history of pain in the throat, radiating to the head, neck, and ear. In most cases, the pain was stated to be more on turning the head towards the affected side or when swallowing or opening the mouth; [7] this was true in this patient also. There are also reports of patients with elongated SP who suffer transient ischemic attacks on turning the head, with the attack resolving once the head returned to the neutral position. Imaging studies have shown focal flow restriction and these patients have been reported to have symptoms such as aphasia, visual disturbances, weakness, and syncope; [8] these features were not present in this case. Although it is rare, compression of both carotid sinuses by bilaterally elongated SPs can occur, potentially even leading to sudden death from vagus-mediated cardiac inhibition. [9] Also, there has been a report of distal extracranial internal carotid artery aneurysm developing in a patient with a prominent styloid process, with repetitive trauma apparently resulting in aneurysm formation. [10] A recent study has also reported the development of an external carotid artery pseudoaneurysm as a result of Eagle syndrome. In the same study, traumatic injury to the carotid artery from the elongated styloid process was reported to cause carotid dissection, aneurysm, or pseudoaneurysm. [8] The relationship between an elongated SP and the development of such complications need to be thoroughly investigated in future studies.


   Conclusion Top


SPE found as an incidental finding may be important clinically in any patient with or without systemic disease. SPE resulting in facial and neck pain is known as Eagle syndrome. This syndrome is diagnosed on the basis of both radiographical and clinical findings. PR is generally used to determine whether the SP is elongated; CT is useful for complementary information. MSCT can demonstrate the dimensions and orientation of an elongated SP, and bone scintigraphy is very important for the evaluation of abnormal bone structure in patients with Eagle syndrome.

This is the first case where bone scintigraphy has been used in a patient with Eagle syndrome. Bone scintigraphy can be important in cases of Eagle syndrome for detecting abnormal bone structure such as is caused by tumor, osteomyelitis, or fracture. This patient had normal bone structure, but when abnormal bone structure is present or in situations with increase in osteoblastic activity, we suggest that the bone scan may be more helpful than MSCT for the differential diagnosis of SPE in patients with Eagle syndrome.

 
   References Top

1.Rechtweg JS, Wax MK. Eagle's syndrome: A review. Am J Otolaryngol 1998;19:316-21.  Back to cited text no. 1
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2.Ramadan SU, Gokharman D, Tuncbilek I, Kacar M, Kosar P, Kosar U. Assessment of the stylohoid chain by 3D-CT. Surg Radiol Anat 2007;29:583-8.  Back to cited text no. 2
    
3.Sisman Y, Gokce C, Tarim Ertas E, Sipahioglu M, Akgunlu F. Investigation of elongated styloid process prevalence in patients with torus palatinus. Clin Oral Investig 2009;13:269-72.  Back to cited text no. 3
[PUBMED]    
4.Elgazzar HA, Silberstein EB. Skeletal scintigraphy in non-neoplastic osseous disorders. In: Henkin RE, Bova D, Dillehay GL, Halama JR, Karesh SM, Wagner RH, et al. (editors). Nuclear Medicine, 1 st ed. Philadelhia: Mosby; 2006. p. 1121-281.  Back to cited text no. 4
    
5.Mirza N, Crumley R. Facial paralysis in a benign osseous parotid tumor: A case report. Otolaryngol Head Neck Surg 1993;108:367-71.  Back to cited text no. 5
[PUBMED]    
6.Atsu SS, Tekdemir I, Elhan A. The coexistence of temporomandibular disorders and styloid process fracture: A clinical report. Prosthet Dent 2006;95:417-20.  Back to cited text no. 6
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7.de Souza Carvalho AC, Magro Filho O, Garcia IR Jr, de Holanda ME, de Menezes JM Jr. Intraoral approach for surgical treatment of Eagle syndrome. Br J Oral Maxillofac Surg 2009;47:153-4.  Back to cited text no. 7
[PUBMED]    
8.Dao A, Karnezis S, Lane JS 3rd, Fujitani RM, Saremi F. Eagle syndrome presenting with external carotid artery pseudoaneurysm. Emerg Radiol 2011;18:263-5.  Back to cited text no. 8
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9.Zuber M, Meder JF, Mas JL.Carotid artery dissection due to elongated styloid process. Neurology 1999;53:1886-7.  Back to cited text no. 9
[PUBMED]    
10.Sundt TM Jr, Pearson BW, Piepgras DG, Houser OW, Mokri B. Surgical management of aneurysms of the distal extracranial internal carotid artery. J Neurosurg 1986;64:169-82.  Back to cited text no. 10
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Correspondence Address:
Sisman Yildiray
Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Erciyes University, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.100442

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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