TEACHING POINTS
■ Eagle syndrome, first described by W. W. Eagle in 1937, often goes undetected and is classified as a rare disease.
■ The cause of Eagle syndrome is an elongated, ossified styloid process. Symptoms include neck pain, dysphagia, headache, and a myriad of other complaints.
■ Diagnosis is made through a high index of suspicion and radiographic studies.
■ An anatomically rich teaching case, involvement varies and is associated with the diversity of symptoms at presentation.
■ Treatment options include nonsurgical approaches such as NSAIDs, massage therapy, and corticosteroid injections, as well as transpharyngeal and extraoral surgical interventions.
CASE
A 53-year-old male presented to the family medicine clinic with complaints of a headache, difficulty swallowing, dizziness, and a feeling of constant pain in his neck for the past 10 to 15 years. He stated that he had daily "sharp, boring" pain in his right eye, headache, bilateral jaw pain, difficulty opening his mouth, and shooting pain in his right ear. The patient also had pain when he extended his tongue, spasms of the cheek and tongue, and a feeling of hypersalivation. He described constant pain in the neck and jaw areas that varied from 3 to 9 on a 10-point pain scale and averaged from 5 to 7 daily.
The patient's medical history was significant for a motor vehicle accident in 1982 that resulted in head, neck, and spinal injuries. His surgical history following the accident included a bilateral condylar shave within the temporomandibular joint (TMJ), meniscus reconstruction, and reattachment of ligaments surrounding the TMJ. Additionally, a lumbar (L4, L5) diskectomy was performed with subsequent spinal fusion of those vertebrae.
The patient reported daily nausea, weight loss of 30 lb over the past 3 years, blurred vision, right eye pain, and severe right ear pain with jaw spasms. He said he had chronic bilateral headaches and neck and shoulder pain, especially on the right side of his body. Dysphagia with liquids and solids was present, during which he said he experienced a foreign body sensation, choking while eating, and frequent hoarseness. He also reported difficulty with range of motion (ROM) of the neck, especially in rotation, and lower back pain that radiated to the right pelvic region, buttock, lateral leg, and foot. Neurologically, he complained of dizziness, numbness, and tingling in the thigh, calf, and third, fourth, and fifth toes on the right side. He denied numbness or tingling in the head and neck region. Since the accident, the patient had been chronically depressed and stated that he had severe mood changes and became antisocial when the pain was extreme. During those occasions, he isolated himself in his bedroom for extended periods of time and did not attend to activities of daily living (eg, grooming).
The patient appeared rather stiff during conversation. Examination revealed ptosis of the right eyelid. ROM of the neck was decreased in all movements. No temporal or carotid bruits were appreciated. TMJ was tender to palpation bilaterally with no clicks or subluxations. There was minimal movement of the TMJ in both opening and glide. The tongue protruded only to the lower labial border, and tongue strength was decreased bilaterally. Mouth opening was 23 mm. A palpable, extremely tender elongated mass in the right and left tonsillar fossa was greater on the right side. The trachea was minimally mobile without tug. The differential diagnosis included trigeminal neuralgia, glossopharyngeal neuralgia, nervus intermedius neuralgia, nasopharyngeal mass/lesion, vascular compromise (atherosclerosis), TMJ problems, and Eagle syndrome.
Panoramic plain film imaging demonstrated that the patient's right styloid process measured 85 mm and the left measured 55 mm (Figure 1). CT revealed elongation of the styloid processes bilaterally with some impingement of the right carotid artery (Figures 2, 3, and 4). Plain films and CT confirmed a diagnosis of styloid-carotid artery Eagle syndrome due to the presence of elongated styloid processes.
