Indo American Journal of Pharmaceutical Research, 2014

ISSN 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.

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.

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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).

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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.
simmisoni9@gmail.com,
0800888206

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Dr Simmi Soni et al.

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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 Reicherts 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.

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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.

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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 Londoners 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 Eagles 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.

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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.

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