Indo American Journal of Pharmaceutical Research, 2014ISSN NO: 2231-6876 BILATERAL ELONGATED STYLOID PROCESS: A CASE REPORT Simmi Soni1, Mohd Nazeer1, K Rattaiah2, KV Pavana Kumari2, D Ranzeetha2, Shaik Haseena1, Tumu Ramakranthi 1, JV Sireesha1 1 Dr. V.R.K. Women's Medical College Teaching Hospital & Research Centre, Aziznagar, R.R. District 500075, Telangana, India. Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India. 2 ARTICLE INFO Article history Received 27/11/2014 Available online 24/12/2014 Keywords Elongated Styloid Process, Stylohyoid Chain, Eagle Syndrome, Temporal Bone. ABSTRACT An abnormally elongated styloid process may be the cause of undiagnosed cervico-facial pain and remains a diagnostic challenge. We report an unusual case of bilaterally elongated styloid process in a macerated adult skull. The probable etiology and symptomatology of the present case have been discussed, in view of available literature in this paper. The present report emphasizes the need of routine investigations for the possibility of elongated styloid process as a part of differential diagnosis in cases of unexplained throat and ear pains. Copy right © 2014 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. www.iajpr.com Page Please cite this article in press as Dr Simmi Soni et al. Bilateral Elongated Styloid Process: A Case Report. Indo American Journal of Pharm Research.2014:4(12). 5783 Corresponding author Dr Simmi Soni, Associate professor, Department of Anatomy, Dr V.R.K. Women's Medical College Teaching Hospital & Research Centre, Aziznagar, R.R. District – 500075, Telangana, India.
[email protected], 0800888206 Vol 4, Issue 12, 2014. Dr Simmi Soni et al. ISSN NO: 2231-6876 INTRODUCTION Styloid process (SP) is a cylindrical bony projection arising from the tympanic part of temporal bone, immediately anterior to stylomastoid foramen [1]. Its apex is clinically important as it is located between the carotid arteries [2] and is connected to lesser cornuae of hyoid bone by stylohyoid ligament. The significant cranial nerves like facial, glossopharyngeal, vagus and accessory nerves run in close proximity to SP. The SP, stylohyoid ligament and lesser cornuae of hyoid bone constitute the stylohyoid chain which develops from the cartilaginous elements of Reichert’s cartilage, derived from second pharyngeal arch [1]. The SP varies in size and morphology and could be long enough to cause compression of adjacent vital structures [3]. This paper documents a case of bilaterally elongated Styloid Process (ESP) in a dry adult skull. Case Report During an inspection of the osteological collection of Anatomy department of Katuri Medical College, we came across a dry skull with abnormally elongated styloid processes. (Figure 1) The lengths of the SP were measured from the base of the skull to the tip using a digital calliper. The SP measured 5.0 cm on left side and 4.8 cm on right side. Both left and right SP revealed a thickening in the middle. (Figure 1) The thickening observed could possibly represent the site of the union between the apex of the SP and the ossified part of the stylohyoid ligament. Page 5784 Figure 1: showing bilateral elongated styloid process (*). RSP: right styloid process, LSP: left styloid process, ZA: zygomatic arch, MT: maxillary tuberosity, TP: tympanic plate, MP: mastoid process, FM: foramen magnum. www.iajpr.com Vol 4, Issue 12, 2014. Dr Simmi Soni et al. ISSN NO: 2231-6876 Discussion The normal length of SP ranges from 0.5-2.5 cm and a length more than 2.5 cm was considered elongated [4]. However, other studies accepted 3.0 cm as elongated [5,6]. Whereas, Jung et al stressed that a length more than 4.0 cm should be considered abnormal [7]. Though the threshold for elongation is highly variable and range from 2.5-4.0 cm, many authors considered 3.0 cm as the threshold for elongation [2]. In the present study, we report a case of bilaterally elongated SP of 4.8 cm and 5.0 cm on right and left side respectively, which exceeds the normal range. (Figure 1) The incidence of ESP seems to range from 4% to 18% [8,9], probably due to varied thresholds accepted for elongation, methodology applied for estimating the length, anatomic/ surgical/ or radiologic specimens investigated and ethnic variabilities [3]. The affected subjects are usually elderly, afflicting females more frequently than males [8,10]. Three types of variations were observed; Type 1: continuous ESP, from long to completely ossified structure connecting the SP to lesser cornuae of hyoid bone, Type 2: pseudo-articulated segments of bones in the stylohyoid fibrous matrix, Type 3: segmented non continuous elements of stylohyoid chain [11]. The present case seems to be the type 1 variation proposed by Langlis et al in 1986. The variations are in majority cases, bilateral and symmetrical as observed in the present case [8]. The etiology of abnormally ESP is stilled under discussion; the suggested hypotheses are hereditary, embryology, metaplasia, trauma and ageing [12]. Hardy et al observed co-existence of ESP and vertebral and laryngeal calcifications with foramen arcuate [8]. He argued for a genetic origin of these variations. Several authors have associated ESP with other conditions like: cervical osteophyte and cervical spondylosis [13]. Kim et al (2012) reported a case of severely ossified stylohyoid ligament complex in twins with same pattern of presentation which probably implies that there might be a genetic factor associated with SP elongation [14]. Significant correlation was found between the length of SP and serum calcium concentration levels [15]. Meanwhile significant differences were reported in the morphology of stylohyoid chain between Londoner’s and Chinese depicting the ethnic variability [16]. A wide variety of symptoms have been attributed to ESP, including no specific cervical pain, throat pain radiating to ear & orbit, dysphagia, odynophagia, increased salivation, foreign bodies sensation and cerebro-vascular symptoms induced by positional changes [12]. A constellation of associated symptoms is termed as Eagle’s syndrome, which derived its name from Watt Weems Eagle, an American Otolaryngologist who first described the clinical sequelaes associated with ESP [4]. The symptoms are nonspecific and can be confused with a wide variety of disorders such as gastro intestinal malignancies, salivary gland diseases, neuralgia, temporo-mandibular joint dysfunctions, dental malocclusion and hyoid bursitis [9]. The symptomatology has various origins. The cranial nerves such as glossopharyngeal, vagus, mandibular or chorda tympani can be directly stimulated by the ESP and induce pain. The other symptoms including inflammation of tendons, pharyngeal mucosa excitation, impact of carotid bulbs and dizziness are attributed to involvement of carotid arteries [3, 6]. The present case of abnormally long styloid process could have caused variety of symptoms and psycotraumatic stress to the person but might have been overlooked during clinical examinations. CONCLUSION The clinical symptoms associated with ESP can be mistaken with those attributed to a wide variety of cervicofacial neuralgia, oral, dental or temporomandibular disease. Hence, the probability of ESP should be considered in the differential diagnosis, when patients present with symptoms of cervicofacial pain. The present report highlights the need of including the possibility of ESP as a routine part of differential diagnosis especially in cases of unexplained throat and ear pains. Competing Interests The authors declare no conflict of interest. www.iajpr.com Page REFERENCES 1. Standrings S, Ellis H, Healy JC, Johnson D, Williams A, Collins P, Wigly C. Grays anatomy. 39 th ed. London: Elsevier Churchill Livingstone; 2005.p.1306. 2. Anbiaee N, Javadzadeh A, Elongated styloid process: is it a pathologic condition? Indian J Dent Res. 2011, 22 (5), 673-677. 3. Paraskevas GK, Raikos A, Lazos LM, Kitsoulis P, Unilateral elongated styloid process: a case report, Cases J. 2009, 2, 91359137. 4. Eagle WW, The symptoms, diagnosis, and treatment of elongated styloid process, Am Surgery. 1962, 28, 1-5. 5. Skrzat J, Mroz I, Walocha J, Zawilinski J, Jaworek JK, Bilateral ossification of the stylohyoid ligament, Folia Morphol. 2007, 66 (3), 203-206. 6. Murtagh R, Caracciolo J, Fernandez G, CT Findings associated with Eagle syndrome, AJNR. 2001, 22, 1401-1402. 7. Jung T, Tschernitschek H, Hippen H, Schneider B, Borchers L, Elongated styloid process: when is it really elongated? Dentomaxillofac Radiol. 2004, 33(2),119-124. 8. Hardy H, Guichard B, Eliezer M, Choussy O, Péron JM, Trost O, Unilateral complete articulated ossification of the stylohyoid apparatus: case report and review of the literature, Surg Radiol Anat. 2014, 36(9), 941-945. 5785 ACKNOWLEDGEMENTS The work was supported by all the faculty and staff of Department of Anatomy, Katuri Medical College. We wish to thank Dr. B Muralidhar, HOD Anatomy, for his valuable consideration. Vol 4, Issue 12, 2014. 11. 12. 13. 14. 15. 16. Bozkir MG, Boga H, Dere F, The evaluation of elongated styloid process in panoramic radiographs in edentulous patients, Tr J Medical Science. 1999, 29, 481–485. Kar IB, Mishra N, Raut S, Singh AK, Facial pain due to elongated styloid process, Contemporary Clinical Dentistry. 2013, 4(2), 248-250. Langlais RP, miles DA, Van Dis ML, Elongated and mineralized styholyoid ligament complex: A proposed classification and report of a case of Eagle’s syndrome, Oral Surg Oral Med Oral Pathol. 1986, 61, 527-532. Bouzaïdi K, Daghfous A, Fourati E, Kechaou I, Jabnoun F, Chtioui I, Eagle's syndrome, Acta Radiol Short Rep. 2013,2 (5), 2047981613495676. Zeliha U, Sebnem O, Gorkem E, Asim A, Patel B, Elongated Styloid Process and Cervical Spondylosis, Clinical Medicine: Case Reports. 2008, I, 57-64. Kim JE, Min JH, Park HR, Choi BR, Choi JW, Huh KH, Severe calcified stylohyoid complex in twins: a case report, Imaging Sci Dent. 2012, 42 (2), 95-97. Okabe S, Morimoto Y, Ansai T, Yamada K, Tanaka T, Awano S, Clinical significance and variation of the advanced calcified stylohyoid complex detected by panoramic radiographs among 80-year-old subjects, Dentomaxillofac Radiol. 2006, 35, 191-199. MacDonald-Jankowski DS, Calcification of the stylohyoid complex in Londoners and Hong Kong Chinese, Dentomaxillofac Radiol. 2001, 30, 35-39. 54878478451141164 5786 10. ISSN NO: 2231-6876 Page 9. Dr Simmi Soni et al. www.iajpr.com