Unexpected bony structure in tonsillar fossa during tonsillectomy

Vojnosanit Pregl 2017; 74(4): 371–373. VOJNOSANITETSKI PREGLED Page 371 UDC: 616.21-089 DOI: 10.2298/VSP151008193C CASE REPORT Unexpected bony structure in tonsillar fossa during tonsillectomy Neočekivana koštana struktura u tonzilarnoj jami tokom tonzilektomije Ljiljana Čvorović*†, Milan B. Jovanović*‡, Dragoslava Djerić*†, Nenad Arsović*† † Faculty of Medicine, University of Belgrade, Belgrade, Serbia; *Clinic for Otorhinolaringology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia; ‡Clinical Hospital Center “Zemun”, Belgrade, Serbia Abstract Apstrakt Introduction. The elongated styloid process is a very rare clinical entity. In most cases it is asymptomatic, but also could cause Eagle’s syndrome. We presented a rare case of the anatomic variation of styloid process and its clinical implication. Case report. In the left tonsillar fossa an unexpected bony structure was found during the routine tonsillectomy on a 16-year-old female patient. Computed tomography showed the elongated styloid process. No further treatment was necessary because it was asymptomatic in the follow-up period. Conclusion. The elongated styloid process is a very rare condition, but physicians should be aware of it and keep it in mind in order to make the diagnosis in patients with suggestive symptoms. Uvod. Produžen stiloidni nastavak je veoma redak klinički entitet. U većini slučajeva je asimptomatski, ali može uzrokovati Eagle-ov sindrom. Prikazali smo anatomske varijacije i kliničku prezentaciju stiloidnog nastavka, kao i indikacije za lečenje bolesnika sa tim sindromom. Prikaz bolesnika. Tokom rutinske tonzilektomije kod 16-godišnje bolesnice nađena je neočekivana koštana struktura u levoj tonzilarnoj jami. Načinjena je kompjuterizovana tomografija i nađen je produženi stiloidni nastavak. U periodu praćenja bolesnica nije imala simptome produženog stiloidnog nastavka, pa dalje lečenje nije bilo potrebno. Zaključak. Produženi stiloidni nastavak veoma je redak entitet. Radi pravilne dijagnoze i mogućeg daljeg lečenja bolesnika sa tim sindromom, lekari moraju biti upoznati sa njegovom kliničkom prezentacijom i simptomatologijom koju daje. Key words: temporomandibular joint disorders; ossification, heterotopic; diagnostic techniques and procedures; tonsillectomy. Ključne reči: temporomandibularni zglob, poremećaji; osifikacija, heterotopična; dijagnostičke tehnike i procedure; tonzilektomija. Introduction An elongated styloid process is an extremely rare clinical entity. It could cause Eagle’s syndrome with vague symptomatology 1, facial pain or be silent and incidentally find during tonsillectomy 2, but also could cause a sudden death 3. Data from literature show that 0.04–0.08% of population suffer from this disease and only 0.16% patients are actually symptomatic 4. We presented a rare case with unexpected bony structure in the left tonsillar fossa without characteristic symptoms for elongated styloid process, found during the routine tonsillectomy. styloid process. After removal of the left tonsil, a straight hard mass about 2 cm (intraoperatively) was seen in lateromedial direction (Figure 1). Normally, the styloid process of normal length are not palpable in the tonsillar fossa, and if it is possible, it is elongated styloid. After the operation, computed tomography (CT) scan was done showing one-sided elongated styloid process (Figure 2). It was an unexpected finding during tonsillectomy because the patient was symptom-free, so no further treatment was necessary. Unusual, asymptomatic, hard mass in tonsillar fossa only need further imaging and precise information for patient. The Ethic Committee of the Clinical Hospital Center “Zemun”, Faculty of Medicine, University of Belgrade approved this case report. Case report A 16-year-old female patient underwent tonsillectomy under general anesthesia due to chronical tonsillitis. The patient did not suffer any characteristic symptoms for elongated Disscusion The stylohyoid components are derived embryologically from the first and second branchial arches. The styloid process Correspondence to: Ljiljana Čvorović, Clinic for Otorhinolaringology and Maxillofacial Surgery, Clinical Center of Serbia, Pasterova 2, 11 000 Belgrade, Serbia. E-mail: Page 372 VOJNOSANITETSKI PREGLED Vol. 74, No 4 Fig. 1 – After removal of the left tonsil, a hard mass about 2 cm long was pointed into tonsillar fossa intraoperatively. SP – soft palate; U – uvula; PPW – posterior pharyngeal wall; PPA – palatopharyngeal arch; PGA – palatoglossal arch; TF – tonsillar fossa; ESP – elongated styloid process. Fig. 2 – Computed tomography (CT) scan (coronal view) shows the left-sided elongated styloid process. develops from the tympanohyal and stylohyal segments and is usually connected in adolescents 5. The stylohyoid ligament starts from the tip of the styloid process to the hyoid bone. The stylomandibular ligament extends from the styloid process to the angle of the mandible. There are three muscles: the stylopharyngeus, stylohyoid and styloglossus and innervation comes from IX, VII, XII cranial nerves, respectively. The internal jugular vein and XI, XII, X, IX cranial nerves are located medial to the styloid process. The glossopharyngeal nerve has close relation with the styloid process. It passes from the jugular foramen, medial to the styloid process, where it curves around the posterior border of the stylohyoid muscle. This anatomic relationship is important due to explanation of glossopharyngeal neuralgia in cases with the elongated or fractured styloid process. The usual length of the styloid process in an adult is approximately 2.5 cm and could not be detected in tonsillar fossa after tonsillectomy. An elongated styloid is defined as greater than 3 cm3. The longest symptomatic elongated styloid process was around 6.3 cm and underwent surgery 6. Nevertheless, the length as a single parameter is not a risk factor but its combination with direction and curvature is important for severity of symptoms 7. The males had greater styloid process lengths than the females 8. The elongated styloid process rarely occurs in childhood or adolescence 9. Nevertheless, in this study the presented patient was 16 years old. Although the elongated styloid process is usually bilateral 10, in the presented patient was unilateral. Nevertheless, bilateral cases do not always involve bilateral symptoms. Etiology of the elongation is a poorly understood process and there are three theories for explaining the development of elongated styloid process. The first theory is the hyperplasic reaction of the styloid ligament stimulated by pharyngeal trauma that caused ossification of the ligament. According the second theory there is a metaplastic reaction of styloid ligament, also due to traumatic stimulus, which re- sults in ossification. The third theory is that the styloid process and the styloid ligament are anatomic variations 11. Eagle’s syndrome is cha (...truncated)