The diagnostic workup included an imaging assessment (orthopantomography, neck CT scans or neck MRI scans). Physical examination included careful palpation of the tonsillar fossa, lateral pharyngeal wall, chewing muscles and above mandibular angle in an attempt to determine the patient’s discomfort. Patients affected by classic, symptomatic Eagle’s syndrome and surgical treated at the ENT Department of the University Hospital of Ferrara have been selected for this study. In addition, cases with carotid or jugular involvement underwent a hemodynamic study by the means of color Doppler ultrasound (CDU). A detailed medical history, clinical examination, 3D head CT scan with contrast were undertaken in all patients. Institutional review board approval was obtained for this retrospective analysis. ĭespite the heterogeneity of the symptomatology of the Eagle clinical picture, we hypothesized that the jugular variant could be characterized by a more specific clinical picture linked with the venous obstruction.Īim of the present study is to compare the jugular variant of the Eagle syndrome with the other more common presentations, from a clinical, imaging, and hemodynamic point of view.Īn extensive review of cases of symptomatic elongated styloid process who were admitted and eventually treated in our University Hospital in the last 6 years was performed. In some articles the symptoms seem similar to the classic syndrome, whereas others report unsuspected symptoms and complications such as intracranial hypertension and cerebral hemorrhage. However, few anecdotal reports are available regarding symptoms and clinical presentation of such jugular vein bone nutcracker. Often, in this anatomical situation, a significant compression of the internal jugular vein (IJV) can be observed. In addition, it has also been observed a variant of the Eagle syndrome, where an elongated styloid process is coursing adjacent to the transverse process of C1. In both syndromes, the length of the styloid process was thought to be the major causal factor. The latter is thought a consequence of an elongated styloid process impinging upon the carotid artery and associated nerve endings, causing pain and sometimes facilitating vascular complications and cerebral ischemia. The former seems facilitated by scar tissue developed after a tonsillectomy which stretches the nerve endings in this area, mainly causing pain, dysphagia and otalgia. In 1937, Eagle proposed two syndromes associated with an elongated styloid process, respectively a classic syndrome and a carotid artery syndrome. There may be a possible association of jugular impingement by an elongated styloid process with symptoms. The elongation of the styloid process may have different paths which creates compression on the surrounding anatomical structures. CT angiography with venous phase extended to the neck veins and imaging reconstruction is highly recommended as imaging technique, complemented by color-Doppler ultrasound. The group classic-carotid variant was characterized by ipsilateral pain respect to the jugular variant (p < .0003).

Headache was the more prominent symptom ( p < .009) as well as a documented peri-mesencephalic hemorrhage was the more significant comorbidity ( p < .0003). The jugular variant of the Eagle syndrome is clinically delineated by significant differences, as compared to the classic variant and carotid variants. Overall 23 patients were admitted to the Hospital for symptomatic elongation of the styloid process, 11 male and 12 females. We compared symptomatology, associated comorbidities and imaging. We reviewed all the cases of Eagle syndrome, including the jugular variant, admitted in our Hospital in the last six years. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia.

The elongation of the styloid process is historically associated with two variants of the Eagle syndrome.