Sunday, June 5, 2011
The myth of carotidynia
Thursday, June 2, 2011
Styloid-carotid artery syndrome
A 42-year-old commercial pilot was placed on medical leave because of frequent episodes of syncope that occurred when he turned his head to the extreme right lateral position. The patient's partner said that these syncopal episodes were accompanied by jerky movements that resembled seizure activity. The patient would regain consciousness as soon as his head became realigned in the midline. As his symptoms increased in severity and frequency, he began to experience transient episodes of blindness in his right eye.
The patient was seen by a neurologist, who ordered computed tomography (CT) and magnetic resonance imaging (MRI) of the nead and neck with contrast; the MRI demonstrated no abnormalities. Magnetic resonance arteriography and magnetic resonance venography showed that the circle of Willis was patent, as were the internal and external jugular veins bilaterally. However, computed tomographic (CT) angiography demonstrated that the styloid processes were elongated and the stylohyoid ligaments were calcified bilaterally. In addition, the lumen of the right carotid artery appeared to be narrowed by 50% as a result of its tortuous course around the calcified ligament.
The patient was taken to the operating room for surgical resection. Intraoperative neurophysiologic monitoring detected no signs of abnormal brain activity. He successfully underwent a transcervical resection of approximately 5 cm of the elongated right styloid process and calcified ligament without complication. His postoperative course was uneventful, and his syncope resolved.
In 1937, Eagle and Durham described 2 cases of post-tonsillectomy pharyngeal pain that had been caused by an elongated styloid process; this condition is now known as Eagle's syndrome. (1) In 2002, Prasad et al described their experience with 58 cases of Eagle's syndrome over a 10-year period. (2) All of their patients had presented with a chief complaint of pain, and their diagnosis was based on palpation of the tonsillar fossa, a panoramic x-ray, and a positive lidocaine infiltration test. All of these patients underwent resection via a transoral approach. The longest styloid process excised measured 3 cm.
In 2000, Bafaqeeh subclassified Eagle's syndrome into two types: its classic form and an entity he called styloid-carotid artery syndrome. (3) Our patient's presentation, diagnosis, and treatment more closely resembled styloid-carotid artery syndrome than classic Eagle's syndrome. On presentation, his primary symptoms were syncope and associated neurologic manifestations, including blindness, that had been caused by not only an elongated styloid process but by a calcified stylohyoid ligament, as well. On axial CT, the extent of calcification of the stylohyoid ligament was not well appreciated, nor was its close association with the carotid artery. However, the association was clearly demonstrated on the sagittal reconstruction of the CT angiography. In view of the extent of the calcification and its proximity to the carotid artery, a transcervical approach was favored over the transoral approach.
Special recommendations for the diagnosis and management of patients with styloid-carotid artery syndrome include sagittal CT angiography with reconstruction when clinical suspicion is high, intraoperative neurophysiologic monitoring, and a transcervical approach to resection.
What Is Eagle Syndrome?
Eagle syndrome (ES) is a clinical condition in which there is abnormal ossification of the stylohyoid apparatus, consisting of the styloid process, the attached stylohyoid ligament, and the lesser cornu of the hyoid bone. Anatomically, the styloid process arises from the temporal bone and passes downwards, forwards, and medially. Embryologically, it is derived from the Reichert's cartilaginous component of the second branchial arch. Ossification of the styloid process and the stylohyoid ligament leads to an increase in the thickness and length of the styloid process, which then presses on the adjacent structures like the internal jugular vein, carotid artery, facial nerve, vagal nerve, glossopharyngeal nerve, and hypoglossal nerve, resulting in various pressure symptoms. The styloid process normally measures 2.5-3 cm in length; when the length exceeds 3 cm, it is said to be elongated.
The cause of this elongation of the styloid process is not well understood. It can be idiopathic, congenital (due to the persistence of cartilaginous elements of precursors of the styloid process), or acquired (due to the proliferation of osseous tissue at the insertion of the stylohyoid ligament).
The symptoms that patients complain of have varied pathophysiological explanations; for example, symptoms may be due to: 1) fracture of the styloid process leading to granulation tissue proliferation, which results in pressure on surrounding structures; 2) compression of adjacent nerves, eg, the glossopharyngeal, the lower branch of the trigeminal, or the chorda tympani; 3) degenerative and inflammatory changes at the tendinous portion of the stylohyoidinsertion, which is known as insertion tendonitis; 4) irritation of the pharyngeal mucosa due to direct compression, or post-tonsillectomy scarring involving the cranial nerves V, VII, IX, and X; and 5) impingement of the carotid vessels with irritation of the sympathetic nerves in the arterial sheath.
There are two types of ES as described originally by Eagle: first is the classic styloid process syndrome due to fibrous tissue causing distortion of the cranial nerve endings in the tonsillar bed after tonsil removal; and a second type due to compression of the sympathetic chain in the carotid sheath.
ES can be diagnosed radiologically and by physical examination. The elongated styloid process can be felt in the tonsillar fossa, and palpation can lead to an increase in symptoms. This elongation can be confirmed radiologically using conventional radiographs or CT scan. 3DCT helps in surgical planning and allows the physician to better explain the lesion and the surgical details to patient. It also helps to obtain measurements in three dimensions, along the plane of the styloid process being measured; in contrast there is underestimation of the length of the styloid process with two-dimensional cross-sectional imaging, where even in the coronal plane, the images are usually not parallel to the styloid process.
ES can be treated by surgical and nonsurgical means. Nonsurgical treatments involve reassurance to the patient, analgesics, and steroid injections. Surgical treatment can be performed using one of two approaches: transpharyngeal or extraoral. The latter is thought to be superior because it is less likely to cause deep space infection of the neck.
Figure Bilateral hypertrophied styloid processes as shown with three-dimensional CT scan
The cause of this elongation of the styloid process is not well understood. It can be idiopathic, congenital (due to the persistence of cartilaginous elements of precursors of the styloid process), or acquired (due to the proliferation of osseous tissue at the insertion of the stylohyoid ligament).
The symptoms that patients complain of have varied pathophysiological explanations; for example, symptoms may be due to: 1) fracture of the styloid process leading to granulation tissue proliferation, which results in pressure on surrounding structures; 2) compression of adjacent nerves, eg, the glossopharyngeal, the lower branch of the trigeminal, or the chorda tympani; 3) degenerative and inflammatory changes at the tendinous portion of the stylohyoidinsertion, which is known as insertion tendonitis; 4) irritation of the pharyngeal mucosa due to direct compression, or post-tonsillectomy scarring involving the cranial nerves V, VII, IX, and X; and 5) impingement of the carotid vessels with irritation of the sympathetic nerves in the arterial sheath.
There are two types of ES as described originally by Eagle: first is the classic styloid process syndrome due to fibrous tissue causing distortion of the cranial nerve endings in the tonsillar bed after tonsil removal; and a second type due to compression of the sympathetic chain in the carotid sheath.
ES can be diagnosed radiologically and by physical examination. The elongated styloid process can be felt in the tonsillar fossa, and palpation can lead to an increase in symptoms. This elongation can be confirmed radiologically using conventional radiographs or CT scan. 3DCT helps in surgical planning and allows the physician to better explain the lesion and the surgical details to patient. It also helps to obtain measurements in three dimensions, along the plane of the styloid process being measured; in contrast there is underestimation of the length of the styloid process with two-dimensional cross-sectional imaging, where even in the coronal plane, the images are usually not parallel to the styloid process.
ES can be treated by surgical and nonsurgical means. Nonsurgical treatments involve reassurance to the patient, analgesics, and steroid injections. Surgical treatment can be performed using one of two approaches: transpharyngeal or extraoral. The latter is thought to be superior because it is less likely to cause deep space infection of the neck.
Figure Bilateral hypertrophied styloid processes as shown with three-dimensional CT scan
Tuesday, May 31, 2011
A Pain in the neck!
Hyoid Bone Syndrome
The hyoid bone has been identified with a specific, although not well recognized,
trauma at the greater cornu of the hyoid bone with the pain radiating to other sites.
to resection of the greater cornu. The pain usually radiates from the greater cornu
of the hyoid bone to the throat, mandible, mandibular molar teeth, zygomatic arch,
condyle, face, ear, and temple superiorly; anteriorly to the neck, clavicle, upper half
of the breast, shoulder, arm, and over the shoulder to the scapula of the back
inferiorly on the same side.
The condition is not well known in medicine and dentistry for at least two reasons: (1) the diffuse and seemingly unrelated radiation of symptoms and (2) the apparent absence of histopathologic evidence of injury.
In my wanderings across the internet, I came across a paper called "Hyoid Syndrome:
The condition is not well known in medicine and dentistry for at least two reasons: (1) the diffuse and seemingly unrelated radiation of symptoms and (2) the apparent absence of histopathologic evidence of injury.
In my wanderings across the internet, I came across a paper called "Hyoid Syndrome:
A Pain In The Neck", which describes the symptoms as such:
* Lower facial / neck pain radiating to a variety of areas
* all patients, when asked to point to the area of most discomfort, indicated an area
overlaying the hyoid bone
* most patients described the pain as worse when swallowing
* many patients described a sensation of a foreign body
* all cases were unilateral, with a nearly 50/50 split between the left and right
side of the neck
* symptoms present for 3 months to 4 years in the sample group in the study (13 patients)
* all of these patients had had extensive diagnostics which showed nothing remarkable;
a couple had had teeth removed or sinus surgery to no avail
* in all cases, examination revealed tenderness upon palpitation of the neck in the region
of the greater cornu of the hyoid on the affected side
* palpitation of this area recreated/exacerbated symptoms
Bottom line: diagnosis is achieved by the exclusion of any physical abnormalities or infections with various imaging techniques, combined with the specific finding of tenderness over the hyoid bone.
* Lower facial / neck pain radiating to a variety of areas
* all patients, when asked to point to the area of most discomfort, indicated an area
overlaying the hyoid bone
* most patients described the pain as worse when swallowing
* many patients described a sensation of a foreign body
* all cases were unilateral, with a nearly 50/50 split between the left and right
side of the neck
* symptoms present for 3 months to 4 years in the sample group in the study (13 patients)
* all of these patients had had extensive diagnostics which showed nothing remarkable;
a couple had had teeth removed or sinus surgery to no avail
* in all cases, examination revealed tenderness upon palpitation of the neck in the region
of the greater cornu of the hyoid on the affected side
* palpitation of this area recreated/exacerbated symptoms
Bottom line: diagnosis is achieved by the exclusion of any physical abnormalities or infections with various imaging techniques, combined with the specific finding of tenderness over the hyoid bone.
Did you know?
Hyoid bone
The hyoid bone (lingual bone) (Latin os hyoideum) is a horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage. At rest, it lies at the level of the base of the mandible in the front and the third cervical vertebra behind.
Unlike other bones, the hyoid is only distantly articulated to other bones by muscles or ligaments. The hyoid is anchored by muscles from the anterior, posterior, and inferior directions and aids in tongue movement and swallowing. The hyoid bone provides attachment to the muscles of the floor of the mouth and the tongue above, the larynx below, and the epiglottis and pharynx behind.
Its name is derived from the Greek word hyoeides meaning "shaped like the letter upsilon"
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