sindrome de Eagle

Minimal effect
Fig. 4 Diagnostic imaging for Eagle’s syndrome. A 57-year-old man
was diagnosed with bilateral carotid occlusion after an evaluation for
acute myocardial infarction and a history of carotid-type Eagle’s syn-
drome. Sagittal, two-dimensional CT angiogram (right side, a) and
three-dimensional CT reconstruction (left side, b) demonstrate bilateral
elongated styloid processes. The occluded area was readily apparent in
the three-dimensional reconstruction (b, arrow). This configuration
suggests that the elongated styloid processes may have caused the
vascular occlusion. A styloid process, B carotid artery. [Used with
permission from Barrow Neurological Institute]
1122 Acta Neurochir (2012) 154:1119–1126
that head rotation or jaw opening could compress the glosso-
pharyngeal nerve between a fixed styloid process and a prom-
inent lateral process of atlas.
Diagnosis
Given the variation in the clinical presentation of classic-type
Eagle’s syndrome, the differential diagnosis is broad and
includes glossopharyngeal neuralgia [76, 78, 79], occipital
neuralgia [54], sphenopalatine neuralgia, temporomandibular
disorders [17, 26, 43], dental infection, tonsillitis [2, 27],
mastoiditis [19, 60], and migraine [33, 50, 54]. For the carotid
type, vasculopathy and cardiac pathology should be consid-
ered [4, 14, 15, 24, 63, 92]. Careful recording of the history of
the present illness and review of systems is crucial to the
diagnosis. In particular, the clinician should be suspicious of
a history of face and neck pain exacerbated by neck flexion,
extension, and contralateral rotation. Should suspicion for
Eagle’s syndrome be raised during history-taking, palpation
of the ipsilateral tonsillar pillar during physical examination is
appropriate [5, 32]. After administering a local anesthetic, the
clinician can attempt to palpate the anterior pillar region with
the index finger [62, 82]. Under physiologic conditions, the
styloid process cannot be palpated at this site. When elongat-
ed, however, palpation is not only possible but often recreates
the particular neuralgia.
After the clinical examination, the optimal imaging modal-
ity for styloid process pathology is spiral CT of the neck and
skull base. With three-dimensional reconstruction, the length
and angulation of the styloid process with respect to the neck
vessels can be calculated (Fig. 4) [7, 12, 36, 74]. In dynamic
(flexion-extension) studies, the compressive impact of the
styloid process and styloid chain on the carotid artery and
jugular vein can be evaluated [1, 57]. Given obscuration of the
styloid process by coplanar bone and poor sensitivity for
calcification in the styloid chain, simple radiography is a
second-line option [56, 65].
Treatment
Noninvasive management is first-line for the neuropathic se-
quelae of Eagle’s syndrome. Oral agents, including gabapentin,
amitriptyline, valproate, carbamazepime, and image-guided cor-
ticosteroid injections can provide temporary relief [28, 74].
Surgical interventions are considered only after noninvasive
therapies have failed. The two most common approaches de-
scribed in the literature are intraoral resection of the styloid
process and external resection of the styloid process. Each has
its own risk-benefit profile [9, 18, 53].
Oral surgeons and otolaryngologists most often perform
the intraoral approach. Through an oral corridor, an incision
is made anterior to the tonsillar fossa and the tip of the
styloid process is exposed via blunt dissection. This dissec-
tion proceeds as proximally as possible along the styloid
process, ultimately leading to removal of the process at its
base [35]. Complete exposure and thus complete excision of
the styloid process are often not possible with this approach,
although the excised component is almost always sufficient
to relieve symptoms. The intraoral approach is favored for
its cosmesis by avoiding any external incision and for its
potential for shorter operative times [6, 29]. Nevertheless,
exposure of the retropharyngeal spaces to intraoral contents
does elevate the infection risk [11]. Further considerations
include poor carotid artery access in case of intraoperative
injury, airway edema, and trismus. Given the elevated risk
of airway edema, bilateral operations must be staged [13].
In the external approach, an oblique incision is made in
the skin crease halfway between the angle of the mandible
and the tip of the mastoid process (Fig. 5). Dissection begins
with opening of the superficial fascia and posterolateral
retraction of the sternocleidomastoid muscle. With ongoing
blunt dissection, superior retraction of the parotid gland,
inferior retraction of the posterior belly of the digastric
muscle, and identification and preservation of the facial vein
can be achieved. The elongated styloid process is identified
and detached from the stylohyoid ligament distally. Muscu-
lar attachments are removed via subperiosteal dissection.
The styloid process is then removed completely in a piece-
meal fashion [10, 11, 53, 83]. The operating surgeon must
take care to expose and then to avoid the mandibular branch
of the facial nerve in the superficial fascia as well as external
carotid artery branches within the deep fascia. The most
common postoperative complication of the external ap-
proach is weakness of the mandibular branch of the facial
Fig. 5 External approach for right styloidectomy. Intraoperative illus-
tration of the incision line (middle) marked between the mastoid
process (lower mark) and the angle of the mandible (upper mark).
[Used with permission from Barrow Neurological Institute]
Acta Neurochir (2012) 154:1119–1126 1123
nerve, which is usually transient [47]. The primary advan-
tage of this approach is the minimal generation of airway
edema, and the consequent ability to perform bilateral sty-
loidectomy in the same sitting. Minimally invasive external
approaches involving styloid chain transection and resection
of the lesser cornu of the hyoid bone have been used with
the aid of stereotactic navigation [87]. These approaches are
rare, and there is not yet a consensus about their utility.
Acknowledgments The authors thank Mauro Ferriera, MD, who
performed and photographed the cadaveric dissections while complet-
ing a fellowship at Barrow Neurological Institute.
Conflicts of interest None.
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