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Review Article

Eagle syndrome: A review of current diagnostic criteria

and evaluation strategies
Vishlesh Arora, Arvind Shetti, Vaishali Keluskar
Department of Oral Medicine and Radiology, Institute of Dental Sciences, Belgaum, Karnataka, India

ABSTRACT
The mineralized and elongated styloid process and Eagle’s syndrome are similar processes of elongation in which mineralization of
the stylohyoid ligament leads to styloid process of the temporal bone. The mineralized and elongated styloid process and Eagle’s
syndrome differ significantly in terms of the symptoms displayed and the treatment modalities that are sought. The mineralized and
elongated styloid process refers to unilateral or bilateral elongation of the styloid process that does not result in any significant pain,
discomfort, or limitation of neck movement. It often remains asymptomatic until it is discovered on extraoral radiographs. Eagle’s
syndrome refers to pain and discomfort in the cervicofacial region resulting specifically from the elongated styloid process. Surgical
shortening may be the only treatment that will alleviate the patient’s symptoms.This article reviews the entire process of elongation
pertaining to the styloid process and discusses the associated syndromes, including current knowledge of the theories of elongation,
diagnostic criteria and treatment strategies.

Key words: Eagle’s syndrome, elongation and styloid process

INTRODUCTION process, although it has been reported as starting at the

The styloid process of the temporal bone lies anterior to the
stylomastoid foramen. It is attached by cartilaginous tissue.
The process normally measures 25 mm in length, although
it varies in length from person to person and even from side
to side of the same person.[1-3]
lower end of the stylohyoid ligament, at the lesser cornu of
the hyoid bone, and, less commonly, in the mid-portion.[4]
Subjects with elongated styloid processes at least 40 mm
long had the highest incidence of discomfort on swallowing.
The majority of patient with styloids less than 30 mm were
symptom-free.

Although researchers agree that elongation is common,
symptoms associated with elongation are uncommon
unless the calcification has progressed through the stylohyal
complex to in duce symptoms. Diagnosis is a clinical
challenge for general dentists when the symptoms appear,
as symptoms may emerge in a variety of manifestations.
Common symptoms include foreign body sensation in the
throat, dysphagia, and intermittent facial pain related to the
mineralized and elongated styloid process (MESP). Various
studies have reported incidence of the MESP ranging from
1.4-30%.
Elongation usually results from ossification within the
stylohyoid ligament. The ossification usually occurs in the
upper end of the ligament and is in keeping with the styloid
Correspondence Dr. Vishlesh Arora, Department of Oral Medicine and
Correspondence:
Radiology, Institute of Dental Sciences, Belgaum, Karnataka, India.
E-mail: vishlesharora@gmail.com
ANATOMIC AND EMBRYOLOGICAL CONSIDERATIONS
The styloid process normally projects down, forward and
slightly medially. The tip of the process is situated between
the internal and external carotid arteries. It lies posterior
to the tonsillar fossa and lateral to the pharyngeal wall;
muscular and ligamentous structures are attached at various
locations on the process. Three muscles are attached to the
process, the stylopharyngeus (arising from the base and
innervated by the glossopharyngeal nerve), the stylohyoid
(attached to the middle portion and innervated by the facial
nerve), and the styloglossus (originating from the extremity
of the process and innervated by hypoglossal nerve).
The two ligaments in relation to the process are the
stylomandibular and the stylohyoid. The stylomandibular
ligament is inserted at the apex of the process and attaches
at the angle of the mandible. The stylohyoid ligament

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Arora, et al.: Eagle syndrome
inserts to the apex of the process and attaches at its far
end to the lesser cornu of the hyoid bone. The stylohyoid
chain consists of the styloid process, the lesser cornu of
the hyoid bone, and its connecting ligament (usually the
stylohyoid ligament). The chain is derived from the sec-
ond branchial or hyoid arch known as Reichert’s cartilage.
In many mammals, this cartilage gives rise to a series of
four bony parts: the tympanohyal, stylohyal, epihyal and
ceratohyal.[5] In humans, it is believed that the tympanohyal
fuses with the stylohyal and the petrous part of the temporal
bone to form the styloid process. Normally, the epihyal
cartilage degenerates but its fibrous sheath remains; this
sheath is the stylohyoid ligament.[6] The ceratohyal or
hypohyal cartilage persists and becomes the lesser cornu
of the hyoid bone.[7] Variation in the ossification and fusion
of these various parts can result in marked variation in the
chain’s appearance.
In 1964, Lengele and Dhem proposed the developmental
theory about the elongated styloid process, based on the
morphogenesis of Reichert’s cartilage.[8] To establish the
mechanisms involved in the morphogenesis of the so-called
elongated styloid process, a comparative microradiographic
and histological study was performed on 19 long and short
processes. Some morphological differences between short
and long processes were noticed. Numerous partially calci-
fied cartilaginous islets were observed within the trabecular
bone of very long styloid processes or covering their tip.
Although calcified fibrous tissue or calcified fibrocartilage
sometimes contributed to the thickening of an enlarged
styloid process, the authors reported that the growth of
the process did not seem to result from calcification or
ossification of the stylohyoid ligament. Mechanical stresses
stretch the second branchial arch during fetal development
and the morphogenesis of the styloid process may induce a
variable involvement from the different parts of Reichert’s
cartilage. Lengele and Dhem concluded that the elongated
styloid process should he congenital; however, they agreed
that further growth still was possible through the car-
tilaginous cap of the tip of the styloid process.[8]
CLINICAL FEATURES AND EXAMINATION
According to studies performed on the elongated styloid
process between 1964 and 1986, symptomatic patients
usually were over the age of 40.[9,10] There was no sex
predilection in the majority of the studies. When pain and
discomfort upon swallowing, foreign body sensation in the
throat, or a limitation of mandibular movements appear to
be associated with the radiographically detectable MESP,
the condition known as Eagle’s syndrome (also known as
elongated styloid process syndrome) is diagnosed.
2 Journal of Indian Academy of Oral Medicine and Radiology / January - March 2008 / Volume 20 / Issue 1
An extensive review concerning the association between
cervicopharyngeal pain and stylohyoid ossification placed
patients in three broad categories based on their symptoms
(the stylohyoid, pseudostylohyoid, or Eagle’s syndromes).[11]
The same study reported that Eagle’s syndrome typically
involves patients with a recent history of neck trauma or
surgical procedures (for example, a tonsillectomy) who
show radiographic evidence of an elongated styloid process.
Clinical palpation of such elongation or calcification usually
can be performed chairside. Patients may complain of
sensation of a foreign body in the throat, pain on swal-
lowing, or neurologic pain in the head and neck region; they
also may have significant pain in the temporomandibular
joint (TMJ) region, radiating to the sub-auricular and
submandibular regions. The term stylohyoid syndrome
applies to patients of any age, although most usually are
older than 40 at the time of diagnosis; while these patients
may not have significant symptoms, the ossification can
be demonstrated on routine extraoral radiographs.[12] Such
ossification also may be palpable clinically.
Pseudostylohyoid syndrome is reserved for patients older
than 40 who have no history of trauma and no radiographic
or clinical evidence of stylohyoid chain ossification. These
patients have symptoms identical to those of stylohyoid
syndrome patients but do not have radiographic or clinical
findings of ossification within the ligament. It is proposed
that these people have tendonitis at the junction of the
stylohyoid ligament and the lesser horn of the hyoid bone
resulting from the degenerative and inflammatory changes
in the tendinous portions of the stylohyoid insertion.[4]
Langlais et al. reported on a subgroup of patients with
constant parietal headaches; these patients were theorized
as having a “stylo-carotid syndrome.”[4] The differential
diagnosis depends on the symptoms. The most common
inclusions are glossopharyngeal neuralgia, sphenopalatine
neuralgia (also known as Sluder’s syndrome), histamine
cephalgia (cluster headaches), migraine headaches,
carotidynia, myofascial pain dysfunction, impacted third
molars, and other conditions associated with dysphagia,
otalgia and tinnitus.[4]
The effects of hyperflexion/hyperex tension (that is,
whiplash) injuries are exacerbated by the presence of this
unexpected calcified structure. Researchers have correlated
the ligamentous ossification of the stylohyal complex
and osteophytes of the cervical spine, concluding that
a significant correlation exists between cervical diffuse
idiopathic skeletal hyperostosis (DISH) and various styloid
process-stylohyoid ligament complex abnormalities.[13]
The examination of the styloid region can be performed by
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Arora, et al.: Eagle syndrome
seating the patient in a chair with firm back support. The
palpation of the styloid region of the neck can be conducted
bimanually and digitally by standing behind the patient.
An intraoral examination method includes visualizing the
tonsillar area with a tongue blade or a mouth mirror and
digital palpation of the area. Patients whose referred pain is
in the tonsillar area will be able to respond to the palpatory
stimulus.
RADIOGRAPHIC FEATURES AND CLASSIFICATION
Elongation and mineralization of the stylohyoid ligament
complex can be observed readily on panoramic radiographs
[Figure 1]. However, because the panoramic radiographs
are obtained primarily for the visualization of teeth and
associated bony structures within the jaws, observing the
mineralized stylohyoid complex within the pantomograms is
inconsistent and often distorted. This is due to the fact that
the styloid process frequently lies outside of the panoramic
focal trough depending on the patient positioning. The
images become distorted due to the unreliable magnification
within the posterior focal trough of the panoramic machines.
Lateral skull view, reverse Towne view [Figure 2] and
posterior-anterior views of the skull also demonstrate the
Figure 1: Panoramic radiograph showing the mineralized, elongated
and pseudoarticulated styloid process bilaterally, with a calcified outline
pattern. Orange arrow represent pseudo-articulation
Figure 2: A reverse Towne view of the skull, demonstrating the calci-
fied styloid processes bilaterally and showing pseudoarticulation on
the left side (orange arrow)
Journal of Indian Academy of Oral Medicine and Radiology / January - March 2008 / Volume 20 / Issue 1
unilateral or bilateral presence and elongation of the styloid
process. The mineralized stylohyoid ligament is easy to
recognize when it extends below the mandibular border or
when its attachment to the mandibular cornu of the hyoid
bone can be seen on the radiographs.
Radiographic features alone are not enough to distinguish
the symptomatic from the asymptomatic elongated styloid
processes. When the posteroanterior radiographs show
extreme medial deviation, the carotid artery subtype may
be considered.[4] Langlais et al. proposed a radiographic
classification of the elongated and mineralized stylohyoid
ligament complex22. Their classification included three types
of abnormal radiographic appearances and four patterns of
calcification/mineralization (Figure 3) (see Tables 1 and 2).
DIAGNOSIS AND MANAGEMENT
An elongated styloid process may be one cause of
aggravated maxillofacial or craniocervical pain. Diagnosis
requires a thorough clinical examination of the head and
neck and should be confirmed radiographically. Panoramic
radiographs or bilateral lateral oblique radiographs should
be taken for patients who are examined in a dental office
setting for oropharyngeal discomfort, chronic cervi-
cofacial pains, or chronic headaches. Radiographically, the
mineralized styloid process falls under any of the aforemen-
tioned types of elongation or the patterns of mineralization.
The outcomes of treatment have no bearing on the type of
Table 1: The three types of elongation
Characteristics
Elongated Characterized by uninterrupted elongation (>25-
28 mm)
Pseudoarticulated Less frequent than elongation; the styloid
process is joined to the mineralized
stylomandibular or stylohyoid ligament by a
single pseudo-articulation, usually located
superior to the inferior border of the mandible
Segmented Consists of short or long noncontinuous portions
of the styloid process or interrupted segments of
mineralized ligament
Table 2: Patterns of calcification
Characteristics
CalciÞed outline Reminiscent of the radiographic appearance
of a long bone with a thin radiopaque cortex
and a central lucency that constitutes most
of the process
Partially calciÞed Thicker radiopaque outline, with almost
complete opaciÞcation as well as a small
and occasionally discontinuous radiolucent
core
Nodular complex This pattern has a scalloped outline and
may be partially or completely calciÞed with
varying degrees of central lucency
Completely calciÞed This pattern is totally radiopaque with no
evidence of a radiolucent inner core
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Arora, et al.: Eagle syndrome

Figure 3: A representation of the various types of elongation commonly observed in the stylohyoid complex. Bottom:
The patterns of mineralization that are commonly observed in the stylohyoid complex

elongation or pattern of mineralization. The classification is
designed to help dentists understand the variation among
the different elongation patterns and may even offer clues
as to the etiology of the elongation.
Eagle’s syndrome can be a secondary cause of
glossopharyngeal neuralgia. Glossopharyngeal neuralgia
may be a life-threatening condition as a result of associated
cardiovascular complications. Even when life-threatening
complications are absent, glossopharyngeal neuralgia can
be a severely debilitating disease, leading to depression,
suicidal tendencies, fear of swallowing, weight loss and
malnutrition. Due to the elongated styloid process, Eagle’s
syndrome is considered an important etiological factor for
precipitation of secondary glossopharyngeal neuralgia.[11]
A stylectomy is effective for Eagle’s syndrome and should
be considered before embarking on any neurosurgical
procedure.
Surgical shortening is the universally accepted treatment for
confirmed elongation of the styloid process. Multidisciplinary
management yields optimal results; some studies have
recommended an intraoral approach (that is, trans-tonsillar
fossa excision). Other authors have preferred an extraoral
cervical approach, believing that surgical visualization was
optimal and the risk of deep cervical infection was minimal.
Trans-tonsillar fossa excisions is a simple technique that does
not result in greater morbidity than a routine tonsillectomy,
although the trans-tonsillar approach has been criticized for
inadequate surgical shortening of the styloid process due to
poor visualization of the surgical field. Dentists must weigh
the advantages and disadvantages of each technique and
select the procedure that is appropriate for the patient.
Cases in which a MESP alone is present do not require any
immediate treatment, although patients should be warned
about the elongation of the styloid process.

The effects of hyperfiexion/hyperextension/whiplash injuries SUMMARY

can be exacerbated by the presence of the calcified styloid.
Additional symptoms may include neck or throat pain
radiating to the ipsilateral ear. Diagnosis usually can be made
by physical examination. Digital palpation of the styloid
process in the tonsillar fossa exacerbates the pain. This
diagnosis should be considered if symptoms can be .relieved
by injecting an anesthetic solution in to the tonsillar fossa.
Although the elongated styloid process is not an entirely new
entity, studies of symptomatology and diagnostic strategies
involving different population groups have produced new
information about the various types of elongation, patterns
of calcification, and symptomatology. When evaluating
the chronic orofacial or cervicofacial pain, elongation of

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Arora, et al.: Eagle syndrome
the styloid process should always be considered. Proper
selective radiographic techniques and examination of
the tonsillar and cervical areas may reveal elongation or
mineralization in the stylohyoid complex, which may be
the cause of the elongated styloid process. The styloid
elongation should be included in the list of differential
diagnoses for evaluating headaches, tonsillar discomfort,
pain referred to the jaw region, difficulty in swallowing and
the inability to move the jaw from side to side during lateral
excursions. Symptomatic cases of stylohyoid elongations
should be referred to as Eagle’s syndrome. When complex
patterns of stylohyoid chain mineralization appear on plain
radiographs and tomograms with no signs of disabling
symptoms, mineralized and elongated styloid process may
be the more appropriate diagnosis.
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1. Worth HM. Principles and practice of oral radiologic interpretation.
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3. Eagle WW. Elongated styloid process: Symptoms and treatment. Arch
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4. Langlais RP, Langlmd OE, Nortje CJ. Diagnostic imaging of the jaws.
Philadelphia: Lea and Febiger; 1995. p. 617-23.
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Philadelphia: W.B. Sansders; 1985. p. 13-7.
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9. Gossman JR Jr, Tarsitano JJ. The styloidstylohyoid syndrome. J Oral
Surg 1977;35:55-60.
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11. Soh KB. The glossopharyngeal nerve, glossopharyngeal neuralgia
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Source of Support: Nil, Conflict of Interest: Nil
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