Surgical management of patients with Eagle syndrome☆
Introduction
Eagle syndrome, first described by Watt Eagle in 1937, is the symptomatic elongation of the styloid process and/or calcification of the stylohyoid ligament [1]. An elongated styloid process is defined as a length of at least 25 mm, though only 4–10% of patients with elongated processes report pain, and it is often an incidental finding on imaging [2]. While there is no correlation between the degree of elongation of the styloid process and the severity of the symptoms, Okur et al. reports that an increase in medial angulation of the styloid process may be responsible for symptomatic presentations [3,4]. The frequency of this syndrome is estimated to be 4–8 per 10,000 people [5]. It is characterized by a pattern of pain in the head and neck region that commonly includes several, but not all of the following symptoms: odynophagia, dysphagia, tinnitus, cervicofacial pain, and globus sensation [6]. The etiology of pain associated with Eagle syndrome can be multifactorial, but in most cases is the result of compression of various cranial nerves (V, VII, IX, and X) or local chronic inflammation leading to osteitis, periostitis, and/or tendinosis [7,8]. One rare but well-characterized contributing factor is post-tonsillectomy fibrosis at the styloid apex that can compress neighboring nervous structures [9].
Eagle syndrome is a diagnosis of exclusion that can be corroborated by a thorough history and presentation with typical symptoms, physical exam that reveals a palpable styloid process in the tonsillar fossa, and a neck CT scan or panorex that reveals consistent anatomy [3,10]. Injection of lidocaine along the styloid process can be useful in establishing the diagnosis [6]. The diagnosis is confirmed if the lidocaine injection leads to temporary, quick-onset relief of symptoms. While the literature does address the surgical management of Eagle syndrome, there is no definitive consensus on whether the transoral or transcervical approach is superior [[11], [12], [13]]. Furthermore, the indications for surgical intervention are not standardized; thus, surgical treatment of Eagle syndrome has led to mixed results.
The objective of this study was to evaluate patients diagnosed with Eagle syndrome treated surgically at our tertiary care institution. We sought to characterize this patient population and assess their outcomes following surgical intervention, such as changes in pain severity and frequency of adverse events. Finally, we aimed to identify patient characteristics that predict better responses to surgery.
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Materials and methods
We conducted a retrospective cohort study of 21 patients who were diagnosed with Eagle syndrome and treated with surgical resection of the styloid process at a single tertiary care institution between January 2011 and June 2017. Patients were evaluated for a spectrum of complaints including pain in the neck, throat, or ear, headache, and dysphagia. Complete data were collected for all 21 patients. These patients were identified based on ICD-9 and ICD-10 diagnosis codes. Patients were diagnosed
Results
A total of 21 patients were identified as having been diagnosed with and surgically treated for Eagle syndrome during the enrollment period (Table 1). The median age among these patients was 43 years, while there was a near-even gender split (52% female). The vast majority of patients were white (90%), not Hispanic (90%), married (76%), and never smoked (71%). The median BMI was 27.6, while the median ZIP-code-derived median income was $55,212. The two types of Eagle syndrome that have been
Discussion
This retrospective study shows that while Eagle syndrome is a relatively uncommon diagnosis with a variable presentation, there are several trends in the patient population. An understanding of these trends can help guide clinicians in their own management of Eagle syndrome patients. Among the patients treated for Eagle syndrome included in this study, complaints of neck, throat, and ear pain stood out as prominent features, while symptoms like facial pain or headache were less common. Facial
Conclusions
This study highlights the importance of familiarity with the typical presentation of Eagle syndrome and discusses the outcomes associated with surgical intervention. Transoral and transcervical styloidectomy were both associated with significant pain improvement and minimal adverse effects. In particular, patients experiencing neck or jaw pain benefitted the most from surgery. Future studies with larger, multicenter patient populations are required to establish evidence-based treatment
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Cited by (28)
Does Transcervical Styloidectomy for Eagle Syndrome Improve Quality of Life?
2022, Journal of Oral and Maxillofacial SurgeryCitation Excerpt :Spearman’s rank correlation coefficient between the length of resected specimen and postoperative NPRS pain score also showed no statistical relationship (P = .79) (Table 2). Previous studies have shown that styloidectomy reduces neck or ear pain symptoms in patients with Eagle syndrome.19 With this study, we aim to highlight which QoL domains are affected in order to demonstrate the efficacy of styloidectomy in improving QoL among Eagle syndrome patients.
Endoscope-Assisted Surgery of the Elongated Styloid Process Using the Retroauricular Approach: An Anatomic Study for Clinical Application
2021, Journal of Oral and Maxillofacial SurgeryCitation Excerpt :The traditional method of shortening the SP using the transcervical approach involves an incision parallel to the anterior edge of the SCM or a curved incision 2 cm from the inferior edge of the mandible, and the length is 4 to 6 cm. After incising the skin and subcutaneous tissue, the parotid tissue and SCM are pulled to expose the submandibular triangle for the operation.3,5,6 This surgical procedure is an open approach, and the incision is long and in a prominent position in the neck; thus, surgical field exposure is not sufficiently clear.
Surgical management of Eagle syndrome: A 17-year experience with open and transoral robotic styloidectomy
2020, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :This data closely mirrors that by Hardin et al. in their retrospective review of 21 patients treated with either transcervical or non-TORS, transoral styloidectomy [20]. They similarly found that almost half of patients reported ear and throat pain; however, their rate of neck pain was much higher—specifically, 80% versus 37% in the present study [20]. These results are important as a large percentage of referred patients who are ultimately diagnosed with ES may come from dentistry after TMJ has been ruled out as a cause for jaw or facial pain [21].
Commentary on Surgical management of patients with Eagle syndrome
2019, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryImportant factor for pain relief in patients with eagle syndrome: Excision technique of styloid process
2019, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryEagle Syndrome: An Unusual Cause of Axial Neck Pain: A Case Report
2024, JBJS Case Connector
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None of the authors have any conflicts of interest, financial or otherwise.
IRB approval (Study #15-744) was obtained prior to study initiation.