Clinical Communications: Adults EAGLE SYNDROME: AN INCIDENTAL FINDING IN A TRAUMA PATIENT: A CASE REPORT Jess Jewett, MD and Risa Moriarity, MD University of Mississippi Medical Center, Jackson, MS Reprint Address: Jess Jewett, MD, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216 , Abstract—Background: Eagle syndrome is a rare condi- tion characterized by an elongated styloid process that occa- sionally irritates or disrupts adjacent anatomical structures. Although this is well known in the literature, it is rarely on the forefront of the clinician’s mind. In the trauma patient, awareness of Eagle syndrome and knowledge of the anatomy associated with it may help differentiate symptoms second- ary to acute injury from the chronic symptoms of this syndrome. Objectives: To review the diagnostic and treat- ment modalities related to Eagle syndrome and its associ- ated anatomical structures germane to the trauma patient. Case Report: A 42-year-old African American man pre- sented with neck, face, head, and back pain after being as- saulted. The patient noted that he had a long history of foreign body sensation on the right side of his neck with oc- casional difficulty swallowing. On physical examination, the patient was found to have a solitary, 1-cm laceration in the left parietal scalp. The physical examination was unremark- able other than scalp hematoma and laceration. Computed tomography scans of the head, face, and cervical spine were negative for acute injury other than a small scalp he- matoma, and a markedly enlarged right styloid process, measuring approximately 8 cm, with ossification of the sty- lohyoid ligament to the level of the hyoid bone. Conclusion: In the trauma patient, awareness of Eagle syndrome and knowledge of the anatomy associated with it may help differ- entiate symptoms secondary to acute injury from the chronic symptoms of this syndrome. Ó 2014 Elsevier Inc. , Keywords—Eagle syndrome; trauma; stylohyoid liga- ment; elongated styloid process INTRODUCTION Eagle syndrome is a rare condition characterized by an elongated styloid process that occasionally irritates or disrupts adjacent anatomical structures. The syndrome was first described by Dr. Watt W. Eagle, an otolaryngol- ogist at Duke University, in 1939 (1). The normal styloid process measures approximately 2.5 cm (2). Styloid processes up to 7.5 cm in length, however, were reported by Eagle in his original paper. An elongated process is present in approximately 4% of the population, and the vast majority of these are asymptomatic. Eagle estimated the prevalence of symptoms in patients with elongated styloid processes as 0.16%. The syndrome has a female-to-male predominance of three to one. The styloid process elongation is often bilateral (1). However, when symptomatic, the symptoms are almost always unilateral. The symptoms may include aching in the throat that radi- ates to the ipsilateral ear, foreign body sensation in the throat, odynophagia, dysphonia, increased salivation, unilateral neck pain, headache, sore throat, and tinnitus. On examination, the medical practitioner can some- times palpate the styloid process in the lateral side of the neck or on examination of the throat. One should have a high level of suspicion when neurological symptoms occur with head rotation. Imaging is important and diagnostic. Visualization of the styloid process on computed tomogra- phy (CT) scan with three-dimensional reconstruction is the preferred imaging technique. Definitive treatment for RECEIVED: 13 March 2013; FINAL SUBMISSION RECEIVED: 7 June 2013; ACCEPTED: 15 August 2013 e9 The Journal of Emergency Medicine, Vol. 46, No. 1, pp. e9–e12, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2013.08.078
Transcript
The Journal of Emergency Medicine, Vol. 46, No. 1, pp. e9–e12, 2014Copyright � 2014 Elsevier Inc.
Printed in the USA. All rights reserved0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.08.078
RECEIVED: 13 MACCEPTED: 15 A
ClinicalCommunications: Adults
EAGLE SYNDROME: AN INCIDENTAL FINDING IN A TRAUMA PATIENT:A CASE REPORT
Jess Jewett, MD and Risa Moriarity, MD
University of Mississippi Medical Center, Jackson, MSReprint Address: Jess Jewett, MD, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216
, Abstract—Background: Eagle syndrome is a rare condi-tion characterized by an elongated styloid process that occa-sionally irritates or disrupts adjacent anatomical structures.Although this is well known in the literature, it is rarely onthe forefront of the clinician’s mind. In the trauma patient,awareness of Eagle syndrome and knowledge of the anatomyassociated with it may help differentiate symptoms second-ary to acute injury from the chronic symptoms of thissyndrome. Objectives: To review the diagnostic and treat-ment modalities related to Eagle syndrome and its associ-ated anatomical structures germane to the trauma patient.Case Report: A 42-year-old African American man pre-sented with neck, face, head, and back pain after being as-saulted. The patient noted that he had a long history offoreign body sensation on the right side of his neck with oc-casional difficulty swallowing. On physical examination, thepatient was found to have a solitary, 1-cm laceration in theleft parietal scalp. The physical examination was unremark-able other than scalp hematoma and laceration. Computedtomography scans of the head, face, and cervical spinewere negative for acute injury other than a small scalp he-matoma, and a markedly enlarged right styloid process,measuring approximately 8 cm, with ossification of the sty-lohyoid ligament to the level of the hyoid bone. Conclusion:In the trauma patient, awareness of Eagle syndrome andknowledge of the anatomy associated with it may help differ-entiate symptoms secondary to acute injury from thechronic symptoms of this syndrome. � 2014 Elsevier Inc.
, Keywords—Eagle syndrome; trauma; stylohyoid liga-ment; elongated styloid process
arch 2013; FINAL SUBMISSION RECEIVED: 7 June 2ugust 2013
e9
INTRODUCTION
Eagle syndrome is a rare condition characterized by anelongated styloid process that occasionally irritates ordisrupts adjacent anatomical structures. The syndromewas first described by Dr. Watt W. Eagle, an otolaryngol-ogist at Duke University, in 1939 (1). The normal styloidprocess measures approximately 2.5 cm (2). Styloidprocesses up to 7.5 cm in length, however, were reportedby Eagle in his original paper. An elongated process ispresent in approximately 4% of the population, and thevast majority of these are asymptomatic. Eagle estimatedthe prevalence of symptoms in patients with elongatedstyloid processes as 0.16%. The syndrome has afemale-to-male predominance of three to one. The styloidprocess elongation is often bilateral (1). However, whensymptomatic, the symptoms are almost always unilateral.The symptoms may include aching in the throat that radi-ates to the ipsilateral ear, foreign body sensation in thethroat, odynophagia, dysphonia, increased salivation,unilateral neck pain, headache, sore throat, and tinnitus.
On examination, the medical practitioner can some-times palpate the styloid process in the lateral side of theneck or on examination of the throat. One should have ahigh level of suspicionwhen neurological symptoms occurwith head rotation. Imaging is important and diagnostic.Visualization of the styloid process on computed tomogra-phy (CT) scan with three-dimensional reconstruction isthe preferred imaging technique. Definitive treatment for
Figure 1. Computed tomography reconstruction of the headand neck showing an 8-cmcalcified stylohyoid ligament orig-inating from the right styloid process.
Figure 2. Lateral cervical spine radiograph showing thecalcified stylohyoid ligament originating from the right sty-loid process.
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Eagle syndrome is surgical excisionof the styloid. Twosur-gical approaches exist: the intraoral and the extraoral, eachwith advantages and disadvantages (3). Several medicaltreatments have been tried with limited success, includingbenzodiazepines, steroids, and heat application (4).
CASE PRESENTATION
A middle-aged man presented with neck and back painafter being assaulted. The patient reported being punchedin the head, neck, and back, specifically the left parietalscalp and left scapula. The patient also believed thatsome of his neck pain was secondary to a cervical spinecollar placed by paramedics. He denied loss of conscious-ness, abdominal pain, chest pain, shortness of breath,vomiting, seizure, amnesia, blurred vision, focal neuro-logical deficits, and alcohol use. He also denied a historyof prior neck injury. The patient noted that he had a longhistory of foreign body sensation in the right side of hisneck with occasional difficulty swallowing. His past med-ical and family history were noncontributory. The patienthad a history of alcohol, marijuana, and crack cocaineabuse. On physical examination, the patient was foundto have a solitary, 1-cm laceration in the left parietal scalpwith minimal bleeding, as well as bilateral periorbital ec-chymoses and an abrasion over the left scapula. Therewasno tenderness along the cervical, thoracic, or lumbarspine, therewere no neurologic deficits, and the remainderof the physical examination was unremarkable. CT scansof the head, face, and cervical spines, as well as a chest x-ray study and cervical radiographs, were all negative foracute injury other than a small scalp hematoma. Of note,the patient’s CT scan of the face and cervical radiographswere positive for a markedly enlarged right styloid pro-cess, measuring approximately 8 cm, with ossificationof the stylohyoid ligament to the level of the hyoidbone. The images can be seen in Figures 1–4. Thepatient also had bilateral laryngoceles. He was given anadult tetanus booster and pain medication, and thelaceration was repaired with staples. He was observedfor 4 h in the Emergency Department (ED) and reportedfeeling better. He was then discharged with instructionsto return in 10 days for staple removal.
DISCUSSION
In the trauma patient, awareness of Eagle syndrome andknowledge of the surrounding anatomy may help identifysymptoms secondary to acute injury from the chronicsymptoms of this syndrome. An abundance of innerva-tions in the region of the styloid contributes to a myriadof complaints. The ‘‘classic’’ type of the syndrome ischaracterized by pain secondary to the stimulation of cra-nial nerves (V, VII, IX, X, XII) and may include throat
pain, foreign body sensation, dysphagia, facial pain, earpain, and voice changes (5). In the trauma setting, the pa-tient may not offer a prior history of these symptoms andthey may, therefore, be ascribed to acute injury. In the‘‘carotid artery’’ type of Eagle syndrome, the same
Figure 3. Anteroposterior cervical spine radiograph showingthe calcified stylohyoid ligament originating from the rightstyloid process.
symptoms are produced but occur only with rotation ofthe neck when the styloid process stimulates the carotidnerve plexus (5). Although imaging may be required tomake the diagnosis, knowledge of Eagle syndrome andthe symptoms associated with it will assist the physicianin evaluation of the patient’s neck and surroundinganatomical structures in the setting of trauma. As withall patients, a thorough past medical history, review ofsymptoms, and physical examination is essential.
In a trauma patient who offers a history of Eagle syn-drome, or in whom the diagnosis is madewhile in the ED,the medical practitioner should have a heightenedconcern for injury to the carotids and other structures inthe neck. An elongated styloid or ossified stylohyoid lig-ament could be fractured at any point from the styloid tothe hyoid and damage surrounding structures. The stylo-hyoid ligament lays within the anterior triangle of theneck and in zones two and three, where many importantstructures exist. Larger structures, such as the pharynx,larynx, trachea, and esophagus, are less likely to bedamaged, but still have the potential to be punctured orlacerated. Many muscles in the area surrounding the sty-loid contribute to swallowing, mastication, speaking, and
breathing. These could also potentially be injured. Theexternal carotid artery lies along the posterior border ofthe anterior triangle of the neck. A fractured elongatedstyloid could damage the external carotid or internalcarotid artery, as well as several of their branches. The ju-gular vein is also of concern because its major contribu-tories, the retromandibular, facial, and lingual veins, arewithin a concerning distance from the styloid process.A few nerves are also at risk of possible transection,including but not limited to the hypoglossal, facial, vagus,accessory, and portions of the sympathetic trunk.
Mechanism is a key historical point when examining atrauma patient with known Eagle syndrome. In particular,the effects of hyperflexion/hyperextension (whiplash) in-juries may be exacerbated in the presence of an elongatedstyloid (6). When the neck is forcefully hyperextended,the ligaments within the neck, including the stylohyoid,may undergo vigorous stress and, if calcified, may tear.When the neck is hyperflexed in a whiplash injury, theelongated styloid may fracture and produce any numberof injuries, as previously mentioned.
CONCLUSIONS
Eagle syndrome is a rare condition with many possiblecomplications ranging from discomfort to life-threatening
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injuries. The physician should have a low threshold for im-aging the cervical spine and soft tissues of the neckwithCTscan and carotid angiography if the patient reports that thesymptoms are worse than baseline, or if new symptoms arepresent.
5. Bafaqeeh SA. Eagle syndrome: classic and carotid artery types.J Otolaryngol 2000;29:88–94.
6. Miller DB. Eagle’s syndrome and the trauma patient. Significance ofan elongated styloid process and/or ossified stylohyoid ligament.Funct Orthod 1997;14:30–5.
