Eagle's Syndrome: A Master of Mimicry in Head and Neck Disorders

e-ISSN: 0976-822X, p-ISSN:2961-6042 Available online on http://www.ijcpr.com/ International Journal of Current Pharmaceutical Review and Research 2025; 17(7); 576-582 Nayak et al. International Journal of Current Pharmaceutical Review and Research 576 Original Research Article Eagle's Syndrome: A Master of Mimicry in Head and Neck Disorders Puneeth Nayak S.1, Rajat R. Shiraguppi2, Umang Aggarwal3, Anil S. Harugop4 1Associate Professor, Department of ENT, Head and Neck Surgery, BGS Global Institute of Medical Sciences and Hospital, Bengaluru, Karnataka 2Junior Resident, Department of ENT, Head and Neck Surgery, BGS Global Institute of Medical Sciences and Hospital, Bengaluru, Karnataka 3Senior Resident, Department of ENT, Head and Neck Surgery, Lal Bahadur Shastri Hospital, Khichripur, Delhi 4Professor, Department of ENT, Head and Neck Surgery, J. N. Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka Received: 01-05-2025 / Revised: 16-06-2025 / Accepted: 07-07-2025 Corresponding Author: Dr. Puneeth Nayak S Conflict of interest: Nil Abstract Background: Eagle syndrome is a rare condition caused by elongation of the styloid process or calcification of the stylohyoid ligament, leading to compression of adjacent neurovascular structures and varied head and neck symptoms. Materials and Methods: A total of 45 patients with chronic neck pain, dysphagia, and foreign body sensation were evaluated. Radiographic imaging revealed elongated styloid processes (3.5–4.5 cm) in all cases, with bilateral involvement in 28 patients and unilateral in 17 patients. Results: All patients underwent surgical management, resulting in significant symptom relief postoperatively. Intraoral approach was followed in all cases in our research. Conclusion: Although Eagle syndrome remains under-diagnosed, it should be considered in patients presenting with chronic head and neck pain, especially when conventional treatments fail. While conservative medical management may offer temporary relief, surgical excision of the elongated styloid process provides definitive treatment and long-term symptomatic improvement. Keywords: Eagle’s syndrome, Stylalgia, Chronic neck pain, Styloidectomy. This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0) and the Budapest Open Access Initiative (http://www.budapestopenaccessinitiative.org/read), which permit unrestricted use, distribution, and reproduction in any medium, provided original work is properly credited. Introduction Eagle syndrome is a condition in which there is a painful sensation in the head and neck region due to elongation of the styloid process or calcification of the stylohyoid ligament. It is a rare condition and most of the patients may be asymptomatic; however, when these ossified structures exert pressure on the various structures in the head and neck there can be a wide range of symptoms, including pharyngeal discomfort, painful neck movements, change in voice, painful tongue movements, increased secretion of saliva, otalgia, and headache[1]. Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa[2] .Typical styloid processes are between 2.5 and 3.0 cm in length. Lengths greater than 3 cm are considered elongated[3]Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Eagle’s syndrome has also been referred to as: stylohyoid syndrome, elongated styloid process syndrome, stylalgia, styloid-stylohyoid syndrome, styloid dysphagia, chronic styloid angina, temporal rheumatic styloiditis, stylocarotid syndrome and the Garel-Bernfeld syndrome[4] .Eagle syndrome was named after Watt W. Eagle, an otolaryngologist at Duke University, who described the first cases in 1937.He reported two cases of a series of uncomfortable symptoms, including pain in the throat, foreign body sensation on the affected side, reflex otalgia, headache and hypersalivation[5] .He described two variants of the styloid process syndrome: the classic styloid syndrome presenting International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 577 with symptoms of atypical facial pain; and the second variant—the stylocarotid artery syndrome, which may precipitate transient ischaemic attack/stroke[6] . In the classic type, elongation of the styloid process causes pain in the neck aggravated by chewing and yawning with a persistent foreign body sensation in the throat. In the carotid type, elongation of the styloid process exerts pressure on the neurovascular structures in the neck, causing neurological and vascular symptoms such as headaches, syncope, and other related symptoms. Type I (the classic type) was described as an elongation of the styloid process itself, while type II (the carotid type) was linked to an ossification of the stylohyoid ligament[7] Materials and Methods A retrospective study done in the department of otorhinolaryngology from March 2019 to May2025. Patients who presented to the hospital with the complaints of chronic neck pain, painful swallowing and pain associated with neck movements, foreign body sensation in the throat were examined to rule out any inflammatory and infectious causes of pain. Patients with clinically palpable styloid process or tenderness over tonsillar fossa or anterior pillar were then advised for an orthopantomogram to confirm the diagnosis, and all of these 45 patients revealed an elongated styloid process. Under general anaesthesia, Intra oral tonsillo-styloidectomy was performed. A meticulous dissection of the surrounding soft tissues was undertaken, with careful elevation of the periosteum. The styloid process was identified, fractured at its attachment to the skull base, and removed in entirety. Post operatively patients were given antibiotics for7 days along with analgesics and advised regular follow up at 1, 2 and 3 months postoperatively. Results Out of 45 patients, 42 were female and 3 were male (Figure1). The most common presentation was during 3rd and 4th decade of life with mean age of presentation was from3rd to 4th decade (give single number for mean value) of life. 34 patients had chronic neck pain along with referred otalgia, 6 patients had pain while swallowing, 3 patients had pain associated with neck movements and 2 patients had foreign body sensation in the throat (Figure 2). Orthopantomogram revealed an average elongation of styloid process of 3.5–4.5cm. Out of 45 patients 28 patients had bilateral elongated styloid process and 17 patients had unilateral elongation (Figure3). Average length of the removed styloid process ranged from0.6–3.5 cm. Post operatively all patients showed significant improvement in relief of pain. Most patients were followed up till 6 months postoperatively and remained free of symptoms. Figure 1: International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 578 Figure 2: Figure 3: Figure 4: International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 579 Figure 5: Figure 6: International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 580 Figure 7: Figure 8: International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 581 Figure 9: Figure 10: Discussion Eagle syndrome is a rare clinical condition caused by elongation of the styloid process or calcification of the stylohyoid ligament, leading to compression or irritation of adjacent anatomical structures. The styloid process is the point of attachment for the bundle of Riolan, that is, the stylopharyngeus muscle, styloglossus muscle, and stylohyoid muscle as well as for the stylomandibular and stylohyoid ligaments. Numerous important anatomical neck structures are located in the direct vicinity of the SP, including IX to XII cranial nerves, internal carotid artery, external carotid artery, and internal jugular vein[8]. Previous epidemiological studies on Eagle’s syndrome reveal that it is more common in females above the age of 30 and right-side predominated, although the elongation of SP has been observed bilaterally, symptoms are usually experienced on 1 side only. The presenting symptoms include dull, aching pain on either side of the teeth, throat, difficulty in swallowing, foreign body sensation in the throat, pain in the facial region, and recurrent headache and vertigo[8,9] In our analysis, females were more involved than males with a ratio of 14.1. Radiographic examination showed elongated styloid process in both sides in 28 patients (62%) and on one side in 17 patients (38%). Among unilateral cases (17 out of45; 6 were on right side and 11 were on left side). The main complaints included toothache, foreign body sensation of pharynx, odynophagia, syncope with turning of the head-neck, and pain of anterolateral neck. The exact pathogenesis of Eagle's syndrome remains unclear. There are many different etiologies that have been proposed to explain Eagle's syndrome, such as congenital elongation due to persistence of cartilaginous precursors, posttraumatic scarring, and hyperplasia related to previous tonsillectomy. It is widely accepted that Eagle's syndrome is associated with elongation of the styloid process International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Nayak et al. International Journal of Current Pharmaceutical Review and Research 582 and/or aberrant ossification of the stylohyoid apparatus. Thus, Eagle's syndrome is also nominated and known as elongated styloid process or styloid process syndrome[8,9] Several theories had been established for its pathophysiology which includes: Direct compression of the nerves, pseudo arthrosis or ossification or calcification of stylohyoid ligament[10] Conservative management with analgesics, anti-convulsants, antidepressants and local injection of steroids can be tried as first line of treatment and might help in alleviating symptoms in some patients [11,12]. Eagle’s syndrome could be controlled by conservative methods of medical management, such as nonsteroidal anti-inflammatory drugs, anticonvulsants and antidepressants, however, this mode is usually inefficient[13,14] The literature searched tend to support that surgical intervention should be the first choice which would result in more definitive treatment and long-lasting symptomatic relief[15,16] Surgically, styloid process can be tackled intraorally and by cervical approach. Intra-oral approach is preferred because it is less invasive and also for cosmetic reasons. However, cervical approach may be necessary in cases with limited access (due to reduced mouth opening, atlantoaxial joint instability which makes positioning difficult, very long styloid process or suspicion of malignancy). Conclusion Eagle’s syndrome is not a rare condition but is often under-diagnosed or overlooked. Therefore, all cases of chronic neck or throat pain should be thoroughly evaluated with a detailed history, comprehensive clinical examination, and appropriate radiological investigations. Accurate diagnosis relies on a combination of detailed clinical evaluation, physical examination—particularly digital palpation of the tonsillar fossa—and confirmatory radiological imaging. When conservative management is unsuccessful, surgical intervention remains the most effective option, helping to significantly reduce patient morbidity. An accurate diagnosis and timely intervention of Eagle’s syndrome is of great importance to relieve physical pain and ameliorate psychological diseases to help them regain normal daily life and work. References 1. Oluseisi AD. Tramatic eagle syndrome: Does neck trauma result in complete ossification in partially ossified stylohyoid ligament. Int J Otorhinolarynogol. 2006;4:2. [Google Scholar]. 2. Eagle's syndrome (elongated styloid process)L Balbuena Jr et al. South Med J. 1997 Mar. ;90(3):331-4.doi: 10.1097/00007611199703000-00014. 3. Ferreira PC, Mendanha M, Frada T, Carvalho J, Silva A, Amarante J. Eagle syndrome. Journal of Craniofacial Surgery. 2014 Jan 1;25(1):e84-6. 4. Czako L, Hirjak D, Simko K, et al. 3D navigation in surgery of Eagle syndrome. BLL 2019;120:494–7. 5. Dou G, Zhang Y, Zong C, et al. Application of surgical navigation in styloidectomy for treating Eagle’s syndrome. Ther Clin Risk Manag 2016;12:575. 6. Eagle WW. Symptomatic elongated styloid process; report of two cases of styloid processcarotid artery syndrome with operation. Arch Otolaryngol 1949;49:490–503. 7. Heim N, Warwas FB, Singer L, Kramer FJ, Bourauel C, Götz W. Differences in the osseous ultrastructure in 2 differing Etiologies of Eagle syndrome. A micro-CT study. J Craniofac Surg. 2023;34(5):e453– e458.https://doi.org/10.1097/ SCS.0000000000009296 8. Badhey A, Jategaonkar A, Anglin Kovacs AJ, et al. Eagle syndrome: a comprehensive review. Clin Neurol Neurosurg. 2017;159:34– 8. 9. Searle E, Searle A. An overview of Eagle’s syndrome. Br J Pain. 2021;15:388–92. 10. Mishra A, Dabholkar J, Lodha MSJ, Sharma A, Mhashal S (2015)Stylalgia: a missed diagnosis. Otolaryngologia Polska 69(2):34– 37. 11. Taheri A, Firouzi-Marani S, Khoshbin M (2014) Nonsurgical treatment of stylohyoid (eagle) syndrome: a case report. J Korean Assoc Oral Maxillofac Surg 40:246–249. 12. Chandra A, Sharma A, Yathish SK, Kapoor R (2014) Clinical investigation of stylalgia-our experience of conservative management. Am J Adv Med Sci 2(4):38–41. 13. Dey A, Mukherji S. Eagle’s syndrome: a diagnostic challenge and surgical dilemma. J Maxillofac Oral Surg. 2022;21:692–6. 14. Eagle WW. The symptoms, diagnosis and treatment of the elongated styloid process. Am Surg. 1962;28:1–5. 15. 15.De Ravin E, Frost AS, Mady LJ, et al. Transcervical styloidectomy for Eagle syndrome. Head Neck. 2022;44:1492–5. 16. Bargiel J, Gontarz M, Marecik T, et al. Minimally invasive cervical styloidectomy in stylohyoid syndrome (Eagle Syndrome). J Clin Med. 2023;12:6763.