Medical Therapy
Medical management includes the following:
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Analgesics
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Anticonvulsants
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Antidepressant
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Local infiltration with steroids or long-acting local anesthetic agents [12]
Surgical Therapy
The two traditional surgical approaches to styloidectomy (removal of the elongated portion of the styloid process) are the intraoral approach (or transpharyngeal) and the extraoral approach.
Eagle introduced and preferentially used the intraoral transpharyngeal approach. Manual fracture of the styloid process was also proposed. [33] This technique should be avoided because it often does not relieve the symptoms and needlessly endangers important surrounding structures.
Preoperative Details
See Indications.
Intraoperative Details
Intraoral approach
The surgeon locates the styloid process by digital palpation of the tonsillar fossa. After the incision and the identification of the styloid process, it is necessary to split the muscles, to elevate the mucoperiosteum, and, finally, to fracture and excise the styloid process. If the pharyngeal tonsil is present, performing tonsillectomy first during the same operation is necessary.
The advantages of the intraoral approach are that the method is safe, simple, less time consuming, and an external scar is avoided. The disadvantages are possible infection of deep neck spaces, risk of injury to major vessels, and poor visualization. Intraoral resection of the styloid process is a safe technique, but it is not recommended with bilateral intervention at the same surgery, because of possible great discomfort postoperatively. [32, 34]
A study by Torres et al of a modified, tonsil-sparing transoral approach to removal of an elongated styloid process, as performed in 11 patients with Eagle syndrome involving the carotid artery, found that 10 of the patients experienced complete symptom relief and functional improvement. No intraoperative or postoperative complications were reported in any of the cases. [35]
A study by Fitzpatrick et al indicated that in patients with Eagle syndrome, transoral robotic styloidectomy leads to symptom improvement similar to that derived through traditional transoral and transcervical techniques, while being associated with reductions in length of hospital stay, blood loss, and operative time. [36]
Extraoral approach
The external approach starts with a cervical incision at the upper two thirds of the anterior margin of the sternocleidomastoid muscle to the hyoid bone. After identification and incision of the platysma muscle and the superficial cervical fascia, the parotid fascia is reflected anteriorly and the carotid sheath and the sternocleidomastoid posteriorly in order to reach the posterior belly of the digastric muscle and the vascular-nervous bundle of the neck. The styloid process can now be palpated. Aponeurotic and muscular insertions are separated from the styloid process. Styloidectomy is then performed. Ceylan et al reported a 93.4% of success after external resection. [32, 37]
A study by Heim et al suggested that Eagle syndrome can be safely and effectively treated with a cervical approach, with a survey of four patients who underwent the procedure finding them to be asymptomatic at mean 53.75-month follow-up. No visible scarring or hypoesthesia in the involved area was reported by the patients. [38]
A retrospective study by Jalisi et al indicated that either transoral or transcervical styloidectomy represents an effective treatment for long-standing Eagle syndrome, with the report, in which each approach was used on three patients, finding complete symptom resolution in all six cases. [39]
A retrospective cohort study by Chen et al indicated that an elongated styloid process can also be addressed using an endoscope-assisted styloidectomy carried out through a retroauricular incision. Complete symptom relief was found in 107 of 133 patients (80.5%), with partial symptom relief achieved in 20 patients (15%). [40]
Postoperative Details
For the intraoral approach, patients usually start to take oral soft foods after 4-6 hours, and they are discharged 8-24 hours after surgery. For external approach, patients are usually discharged 36 hours after surgery.
All patients take oral antibiotics and analgesics for 1 week. [32]
Follow-up
Patients are followed up for at least 1 year (12-20 months) and are examined every 3 months during the first year. [32]
Complications
The main surgical complications associated with styloidectomy are as follows:
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Injury to main neurovascular structures
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Hemorrhage
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Temporary alterations of speech and swallowing
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Injury of the facial nerve
Outcome and Prognosis
The overall success rate for treatment (medical or surgical) is about 80%.
The failure of treatment may be associated with the presence of other causes involved in the pathogenesis of the problem (multifactorial etiology).
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Radiographs of the vertebral spine: a-p and lateral view. Neither distinct malposition nor major degenerative changes of the cervical spine are recognizable. The ligamenta stylohyoidea on both sides is largely ossified. The patient's medical condition might be ascribed to a kerato-stylohyoidal syndrome.
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CT scan: calcification of the stylohyoid ligament.
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Three-dimensional reconstruction CT scan.
