Paratonsilar Approach to Styloid Process in Eagle's Syndrome—A Retrospective Analysis

Abstract

Eagle's syndrome, defined by Eagle in 1949, is characterised by morphological abnormality/ossification of the styloid process. Traditionally styloid process is approached after tonsillectomy or through an invasive external cervical approach. In the present study we propose a novel Paratonsillar approach for elongated styloid process in eagle's syndrome. The study was retrospective analysis of the medical records of patients who underwent styloid process excision through paratonsillar approach over 2 years period. The present study included 26 patients who underwent paratonsillar styloid process excision. Elongated styloid process was mostly prevalent in the middle age group 30–50 years constituting 73% of patients included in our study. 65% patients had symptomatic elongated on the right side and 35% had on left side. In 62% patients the procedure was over in 15–30 min. There was no documented post operative complication. Paratonsillar approach for styloid process excision is a safe, minimally invasive, day care procedure with almost no postoperative complications.

Introduction

Eagle's syndrome, defined by Eagle in 1949, is characterised by morphological abnormality/ossification of the styloid process. The incidence is 4–8 per 10,000 people [1]. Eagle and others stated that a normal styloid process is about 25–29 mm in length and any length beyond is elongated [2]. Mineralisation or calcification of the styloid complex can cause this elongated styloid process and is seen in 2–28% of the general population [3]. Only 4–10% of all subjects with an elongated styloid process are symptomatic [4]. Traditionally styloid process is approached after tonsillectomy or through an invasive external cervical approach. Though described in textbook, Literature review lacks data regarding the proposed paratonsillar approach for the elongated styloid process, in fact there is only one study which describes the same approach. In the present study we propose a novel paratonsillar approach for elongated styloid process excision in eagle's syndrome.

Methods

The present study was based on retrospective analysis of the medical records of 26 patients who underwent paratonsillar styloid process excision at Aarupadai veedu medical college, Pondicherry and at Shree Krishna Hospital, Karamsad over the past 2 years (December 2017–December 2019). Detailed proforma including clinical history, surgical procedure, time taken for the surgery, intraoperative and postoperative complications was noted for all the patients who underwent paratonsillar styloid process excision.

Surgical Procedure

The surgical procedure was performed under aseptic precautions and general anaesthesia with oral or nasal intubation with patient positioned in supine Rose's position and surgeon seated at the head end of the patient. Using Boyle davis mouth gag adequate mouth opening obtained. Mouth gag is then stabilized with Draffin bipod. Infiltration with lignocaine with adrenaline (1:2,00,000) performed in the anterior tonsillar pillar region. A vertical incision of 2–3 cm made in the anterior tonsillar pillar. The tip of the elongated styloid process identified by deep digital palpation and exposed by blunt dissection. The periosteum incised on the tip of the elongated styloid process. The styloid process was stripped free of the surrounding tissue and attached ligaments by using ring curette. The styloid process could be easily exposed upto the base, near the skull base. The free and naked styloid process broken with stout artery forceps. After removing the elongated styloid process the mucosa was primarily closed with absorbable inverted sutures (Figs. 1, 2, 3).

Fig. 1.

Paratonsillar exposure of styloid process

Fig. 2.

Post excision

Fig. 3.

Excised styloid process

Results

The present study included 26 patients who presented with symptoms suggestive of elongated styloid process (Vague cervical pain, foreign body sensation in the throat) and palpable styloid process who underwent paratonsillar styloid process excision.

Age Distribution

Elongated styloid process was mostly prevalent in the middle age group 30–50 years, constituting 73% of patients included in our study probably due to the fact that the aetiology of the eagle's syndrome is calcification of stylohyoid ligament which happens in older age group (Fig. 4).

Fig. 4.

Age distribution of patients with elongated styloid process

Side of elongated styloid process 65% patients had symptomatic elongated on the right side and 35% had on left side. One patient had radiologically elongated styloid on both sides but was having palpable and symptomatic elongated styloid process only on right side hence right side styloid excision was performed.

Length of elongated styloid process In 31% patients length of elongated styloid process was in the range of 41–50 mm. One patient had a visibly elongated styloid process which was 73 mm (Fig. 5).

Fig. 5.

Length of elongated styloid process

Duration of surgery Duration of the procedure was noted from the incision time to closure time performed by single surgeon to avoid bias. In 62% patients the procedure was over in 15–30 min. In one patient the procedure took a little longer as styloid process was lost on palpation intraoperatively, which was identified and excised in toto (Table 1).

Table 1.

Duration of surgery

Duration	Number of patients	Percentage
15–30 min	16	62
31–45 min	9	35
46–60 min	1	3
Total	26	100

Intra operative complications Among the 26 patients operated, in one patient the palpation of styloid was lost intraoperatively probably due to inadvertent fracture of the styloid during palpation. The identification of the fractured styloid was little cumbersome and should be avoided.

Post operative complications All the 26 patients had an uneventful post operative period with minimal pain and discomfort.

Discussion

Elongated styloid process is often under-diagnosed in a busy Otorhinolaryngology outpatient department as the presenting complaints and symptoms suggestive are varied. Patients with eagle syndrome present with a plethora of symptoms ranging from vague cervical pain, globus sensation, referred otalgia, facial pain, odynophagia,painful mouth opening and chewing. Morbidity associated with eagle's syndrome can be eliminated by performing the proposed minimal invasive techinique for styloid process excision.

Most of the patients included in the present study were in the age group between 30 and 50 years. This is in comparison to the study performed by scheller et al. [5] in which the mean age group was 49.8 ± 16.1 years. In our study right sided elongated styloid process was common. One patient had bilateral elongated styloid process wherein left side was asymptomatic. Length of the symptomatic elongated process was in the range of 30–50 mm. Severity of symptom does not seem to have relationship with the length of styloid process, no such correlation could be established.

Mean operation time in the study performed by scheller et al. [5] was 29.4 ± 7.9 min which is comparable to our study where in 62% patients the procedure was completed in 15–30 min. During the intraoperative period we experienced inadvertent fracture of styloid in one patient due to which the procedure took longer and cumbersome to dissect out the fractured styloid. In the postoperative period all the patients had minimal pain and discomfort. Paratonsillar approach for styloid process is done following the elongated styloid process itself, hence complications associated with the procedure is negligible as far as we stay in the vincity of the styloid process, ensuring minimal dissection and deviation from elongated styloid process.

Conclusion

Eagle's syndrome is mostly treated conservatively due to the anatomical position of styloid process in the vicinity of major vessels and cranial nerves. Paratonsillar approach for styloid process excision is a safe, minimally invasive, day care procedure with almost no postoperative complications. We the authors of this article recommend the use of the proposed approach for styloid process excision in routine practice.

Funding

Self.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflict of interest.

Ethical Approval

Approved by Institutional ethics committee.

Human and Animal Rights

This particular study is a retrospective analysis of data available in medical records.

Informed Consent

Informed consent was waived by the institutional ethical committee as this particular study is a retrospective analysis of data available in medical records.