Introduction: Eagle syndrome can affect many patients of any age, anywhere from 25 to 80 years old. The most common symptoms are ear and anterior superior neck pain underneath the angle of the jaw, tinnitus, some throat symptoms, and dizziness. There are two approaches that can be done for surgery, with our preference being for the intraoral approach.
The pathophysiology is that the stylohyoid ligament becomes calcified and can cause pressure on blood vessels and nerves, causing variable symptoms. It is frequently undiagnosed causing patients to visit several physicians before correctly identifying the problem.
A CT scan of the neck with or without contrast, can help identify the problem.
Case presentation: A 39-year-old female with a history of ear and upper neck pain at the angle of the jaw. CT imaging showed calcification of the stylohyoid ligament. Surgery was recommended and a trans-oral approach was used.
Methods: General anesthesia with muscle relaxation was used. A crow Davis or Dingman tractor was used to retract the endotracheal tube to allow exposure of the Oropharynx. Betadine was used to help sterilize the oropharynx. Palpation on each side is done to localize the calcified ligament and if present, the surgery is much easier to do. A 2.5 cm vertical incision is made in the anterior tonsillar pillar, being careful not to go too high on the soft palate because it can paralyze the soft palate causing significant reflux into the nasopharynx and nose, with speech and swallowing problems.
The tonsil capsule and the medial pterygoid muscle are identified, and the dissection is between the two. The calcified ligament is usually about 2.5 cm deep to that area. It is in or under the fat pad in the prevertebral area. It may be difficult to find, and it is helpful if your finger is passed through the incision to palpate deeper to feel the bony process.
The stylohyoid muscle and fat must be cleaned off the bone as high and low as can be dissected ideally using a combination of the monopolar and bipolar cautery. It is important to be careful in this area with the monopolar cautery because of the proximity to the internal carotid artery and jugular vein. Also, the vagus nerve can be injured.
A Kerrison rongeur is used to fracture the bone superiorly. The ligament is connected at the inferior part which can be divided with the cautery.
It is important to obtain good hemostasis using the bipolar cautery and saline irrigation. The wound is closed by sewing the tonsil capsule to the medial pterygoid muscle after which the mucosal incision is sewed. Preferably, vicryl sutures are used so that it will last approximately four weeks.
Bupivacaine 0.5% can be injected around the surgical site to decrease postop pain.
The surgery is done as an outpatient basis and the patient is given pain medication and antibiotics for significant throat pain lasting 7 to 10 days postop.
Conclusion: The removal of the calcified Stylohyoid ligament via an intraoral approach, can be simple or very complicated, and must be done carefully by an experienced surgeon to avoid major complications.
Most patients benefit significantly with relief of their symptoms and are very grateful. This case illustrates the surgical procedure that was easy to perform, but they are not all that easy.
Siddharth Patel, MD
James Y Suen, MD
Conflicts of Interest: None
Funding: This research received no external funding
Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA