HOW I DO IT

Eagle Syndrome: Teaching the Intraoral Surgical Approach

with a 30 Endoscope
Jacques E. Ledere, MD, FRCSC, FACS
ssification of the stylohyoid complex may cause
symptoms such as otalgia, dysphagia, facial and
cervical pain (Eagle syndrome).' The more symptomatic
patients require surgical excision of the styloid process,
which can be performed through an intraoral or an
external approach.^"* The proximity of the carotid artery,
the jugular vein, and cranial nerves IX, X, XI, XII and the
depth of the surgical field with limited exposure have
deterred many surgeons from using the intraoral
approach. In our training program, many residents have
experienced a lot of stress, working deep in the mouth with
an impressive list of significant anatomic structures. The
purpose of this article is to pre.sent a detailed description of
our technique of the intraoral approach with a 30'
endoscope to increase visualization and safely remove an
elongated styloid process.

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3.

Surgical Technique
Intravenous clindamycin 900 mg is administered 1 hour
before surgery and every 8 hours for three doses. Under
general anesthesia with orotracheal intubation, a tonsilk'ctomy is performed in the supine position using the
Davis mouth gag with a ring blade. A dry tonsillar bed
should be obtained before undertaking surgery on the
styloid process:
1. Digital palpation of the styloid process is required to
determine its precise location. A local anesthetic
solution of lidocaine 2% and epinephrine 1:100 000
(2 cc) is injected very superficially with a 5 cc syringe.
Injection in the carotid artery must be avoided. In the
middle third of the tonsillar fossa, a 2 cm incision is
Jacques E. Ledere: Department of Otorhinolaryngology-Head and Neck
Surgery. Laval University, Quebec City, Quebec.
Address reprint requests to: lacques E. Ledere, MD, FRCSC, FACS,
Centre hospitalier universitaire de Qubec, 2705 Bout. Laurier, Quebec
City. PQ GIV 4C2: c-mail: ieleclerc@ccapcable.com.

DOI 10.2310/7070.2008.070156
f. 2008 The Canadiati Society of Otolaryngology-Head & Ncck Surgery

4.

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done with the monopolar cautery to expose the

osseous part of the process (Figure lA). The incision
should be placed to create the shortest path between
the mucosal surface and the anterior medial plane of
the styloid process. The overlying soft tissue should be
removed by blunt dissection with a peanut on an Allis
clamp.
Once the ante ior medial plan of the styloid process
has been skelrtonized, a Freer elevator is used to
separate the lij'.aments from the rest of its circumference in the 2 cm window.
A Hurd pillar retractor is introduced laterally to the
stylohyoid complex, and a slight inward pressure is
applied to mejiali^e the structure (Figure IB). The
softer ligament at the lower end allows this movement
and is kept in continuity with the bony part. It is much
easier and sa^er to isolate the remainder of the
stylohyoid complex by retracting it as a string than
cutting it right away. If cut, the slender ossified part is
difficult to gra;p firmly with a clamp and is often lost
deep in the tcnsillar fossa during future dissection.
With the absence of a lower attachment, the structure
moves freely and becomes hard and even hazardous to
find.
Complete hemostasis is required to complete the
procedure. Tht stylohyoid complex is pulled medially
by the Hurd retractor, and blunt dissection of the
upper third and lower third of the tonsillar bed is
carried with th.' Freer elevator or a peanut on an Allis
clamp.
When the stylohyoid complex has been completely
fi-eed from the tonsillar bed, an AlHs clamp is used to
grasp its lower end near the base of the tongue. The
Hurd retractor is removed, and the ligament is cut just
below the clamp.
A 30 endoscope with a camera is used to see the
styloid process ,Figure IC) and follow its course all the
way up to the base of the skull. The Allis clamp is held
by an assistant A'hile the surgeon moves the scope near
the process to allow excellent visualization of the
operative field (Figure 2). The same techniques of

journal of Otolaryngology-Head & Neck Surgery, Vol 37, No 5 (October), 2008: pp 727-729

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Journal of Otolaryngology-Head & Neck Surgery. Volume 37, Number 5, 2008

2 cm
Figure 1. Schematic drawings of tbe
intraoral surgical approach of the
styloid process (sp). A, Incision in
the left tonsillar fos.sa. 8, Medial
retraction of the stylohyoid complex.
C, Use of a 30' endoscope to follow
the course ofthe styloid process to tbe
base of the skull. Modified by tbe
author from drawings by Mrs. Edilb
Tagrin.

endoscope

blunt gentle dissection are used to perform the rest of

the operation.
7. Two instruments are helpful to cut the upper part of
the styloid process. For the left tonsillar bed, the left
curved nasal endoscopie scissors are placed under
direct vision, so their opening end is directed medially
to avoid any damage to the deeper surrounding
structures. Sometimes it is necessary to weaken the
bone with one or two partial scissor cuts before
complete resection is possible. When the bone is really
hard and cannot be cut, another Allis clamp is put
where the surgeon wants the cut to take place. A smallamplitude rocking motion toward the midline will

Figure 2. Endoscopie view of tbe styloid process (black arrow) at the

base ofthe skull. Resected styloid process (insert).

break the bone with a satisfactoi7 result. With this

technique, a 2.0 to 3.5 cm resection of the styloid
process can be performed safely, leaving a bony stump
of less than 1 cm in the cranial base.
8. The pharyngeal mucosa is approximated by two or
three 2-0 plain catgut sutures.
In the postoperative period, the patient is asked to
avoid any strenous exercises for 3 weeks. Hydromorphone
1 to 2 mg orally every 4 hours is prescribed for about 7
days.

Advantages and Disadvantages

The choice ofthe approach is often based on the surgeon's
experience. The advantages of the intraoral transpharyngeal procedure include less surgical time, less surgical
trauma, and no cervical scar. Some authors report having
done the procedure under local anesthesia without a
tonsillectomy. I prefer to proceed under general anesthesia
after a tonsillectomy to obtain better exposure. Poor
visualization, which is the main disadvantage of this
approach, is addressed by (1) the medialization of the
stylohyoid complex away from the neurovascular structures and (2) the use of a 30 endoscope for the upper part
near the skull base. If needed, the endoscope can be used

Ledere, niraoral Surgical Approach to Eagle Syndrome

earlier in the procedure. The other drawback of this

approach is intraoperative contamination of the deep neck
.strtictures.
References
1. Eagle WW. Elongated styloid process. Report of two cases. Arch
Otolaryngol 1937^25:584-7.

2. Chase DC, Zarmen A, Bigelow WC, McCoy |M. Eagle's syndrome: a

comparison of int,a,,ral versus extraoral surgical approaches. Oral
Surg Oral Med On 1 Pathol 98662:625^9.
3. Ghouvei P. Rombi\ux C, Philips C, Hamoir M. Stylohyoid chain
ossification: choice of the surgical approach. Acta Otorhinolaryngol
Beig 1996;50:57^1
4. Strauss M, Zt)har V, Laurian N. Elongated styloid process syndrome;
intraoral versus ext.'rnal approach for styloid surgery. LarjTigoscope
1985;95:976-9.

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