Bilaterally Elongated Styloid Process – A Case Report

Case Report Bilaterally Elongated Styloid Process – A Case Report Anatomy Section ID: IJARS/2014/9667:2005 Rajan Kumar Singla, Bhagya Shree, Ravi Kant Sharma ABSTRACT The styloid process is a long cylindrical process arising from the temporal bone. It is usually 20-30 mm long. If it is more than 30 mm long, it is said to be elongated styloid process. It may be due to ossification of stylohyoid ligament and may be unilateral or bilateral. The material for the present study comprised of a skull prepared in the Department of Anatomy, Govt. Medical College, Amritsar after routine undergraduate dissection. The styloid processes in the said skull were elongated on both the sides, the length being 76 mm on right and 71 mm on left side. These were fused with the hyoid bone at site of lesser cornua. A knowledge of such variation may be of interest not only for anatomist but also for physicians and surgeons. An elongated styloid process may be responsible for different sets of clinical features like cervicofacial pain or feeling of foreign body in pharynx. These may be attributed to compression of some neural or vascular structure by it. Keywords: Styloid process, Skull, Stylohyoid ligament Introduction Styloid process of temporal bone is a long, cylindrical, bony projection attached to the base of the skull and extends downwards, forwards and slightly medially. It gives attachment to the muscles and ligaments which have a role in mastication and swallowing [1]. One of these ligaments, the stylohyoid ligament passes downwards and forwards from its extremity to the lesser horns of the hyoid bone [2]. Usually the styloid process is 20- 30 mm long [3]. If it is > 30 mm long, it is said to be elongated styloid process. It may be due to ossification of stylohyoid ligament and may be unilateral or bilateral [1]. Elongation of styloid process and or ossification of stylohyoid ligament may result in styloid stylohyoid syndrome which is also known as Eagle syndrome, elongated styloid process syndrome, styloid process- carotid artery syndrome, stylohyoid syndrome or styloid process neuralgia [4]. According to Kim et al [5] the elongation was Ist described in 1652 by an Italian surgeon Marchetti and Eagle [6] coined the term styalgia to describe the pain associated with elongation of styloid process. He primarily described the two types of syndrome associated with elongated styloid process in 4% of population and stressed that not all cases of elongation are symptomatic [7]. The classic styloid syndrome is usually seen after tonsillectomy as pharyngodynia localised in the tonsillar fossa, sometimes with dysphagia, odynophagia, hypersalivation, foreign body sensation and more rarely by temporary voice changes, all of which presumably occur when tightened tonsillectomy scar tissue moves across the tip of the elongated styloid process during functional movements. The stylo-carotid syndromes (Carotidynia and Ernst syndrome) are due to compression of the internal and /or the external carotid arteries and especially their perivascular sympathetic fibers, resulting in a persistent pain radiating to the carotid territory, as headache, chronic neck pain, pain upon turning the head and pain radiating to the eye. Ear pain and vertigo are other possible complaints. Patients with any of these clinical manifestations may thus present to dental, otorhinolaryngology, [Table/Fig-1]: Bilaterally elongated styloid process [Table/Fig-2]: Fusion of styloid process with hyoid bone at site of lesser cornua [Table/Fig-3]: Medial extent of tips of two styloid processes 6 International Journal of Anatomy, Radiology and Surgery, 2014 Sep, Vol-3(3): 6-9 http://ijars.jcdr.net Rajan Kumar Singla et al., Bilaterally Elongated Styloid Process – A Case Report [Table/Fig-4]: Measurement of angle on medial side between long axis of right styloid process and base of skull [Table/Fig-5]: Measurement of angle on medial side between long axis of left styloid process and base of skull [Table/Fig-6]: Measurement of angle on anterior side between long axis of styloid process and base of skull Types Nomenclature Radiographic Appearances I Elongated Uninterrupted integrity of styloid image (>25- 28mm) II Pseudo-Articulated Styloid process is joined to the mineralised stylomandibular or stylohyoid ligament by a single pseudo articulation, usually located superior to inferior border of the mandible. III Segmented Short or long continuous portions of the styloid process or uninterrupted segments of mineralized ligament. [Table/Fig-8]: Morphological Characteristics of Styloid Process [Table/Fig-7]: Radiograph of the two styloid processes Patterns Radiographic Appearances ophthalmology or neurosurgery department with a plethora of complaints [8]. Calcified Outline Thin radiopaque cortex and a central lucency that constitutes most of the process Earlier many reports on elongated styloid process have been published but such long and thick styloid process and that too on both the sides is rarest of the rare anomalies, so is being reported in this article. Partially Calcified Thicker radioopaque outline with almost complete opacification as well as small and occasionally discontinuous radiolucent core. Nodular Complex Knobby or scalloped outline which may be partially calcified with varying degree of central radiolucency. Case Report During the routine preparation of skulls in the department of anatomy we came across a skull which had enormously elongated styloid process with ossified stylohyoid ligament on both the sides [Table/Fig-1]. On right side, its total length from lower margin of tympanic plate upto tip of styloid process was 76 mm. At base its anteroposterior diameter was 8 mm and transeverse diameter was 6 mm. At a distance of 36 mm from base there was a swollen area of length 8 mm, AP diameter 12 mm and transverse diameter 7 mm. Then its diameters decreased towards tip and the minimum diameters just before its tip were 4 mm X 2 mm. At the tip the styloid process again dilated to the diameters 6 mm X 4 mm. It has been described in the report that the first swelling at the distance of 36 mm from the base could be the site of fusion between actual styloid process and stylohyoid ligament since the stylohyoid ligament is ossified in this specimen, it could not be seen as a ligament. Thus the proximal 36 mm represented the actual styloid process and distal part represented the ossified stylohyoid ligament. The apical dilatation represented the International Journal of Anatomy, Radiology and Surgery, 2014 Sep, Vol-3(3): 6-9 Completely Calcified Totally radiopaque with no evidence of radiolucent interior. [Table/Fig-9]: Patterns of Calcifications site of fusion between stylohyoid ligament and lesser horn of hyoid bone. This has been shown in the [Table/Fig-2], where the distal end of ossified stylohyoid ligament thus fused with the hyoid bone at the site of lesser horn. On the left side, the total (...truncated)