STYLALGIA-GLOSSOPHARYNGEAL NEURALGIA : OUTCOME OF MANAGEMENT

Address for Correspondence: Dr. Shedge Swapna A, Assistant Professor, Department of Anatomy, KIMSDU, Karad, Maharashtra, 415110, India. Mobile(91) 9850816966 E-Mail: swapna.shedge@gmail.com Introduction: Elongated styloid may pose either Classical Eagle’s or Stylocarotid syndrome leading to oro-facial pain. However, in patients of oro-facial pain, the investigation about the elongation of styloid process (SP) is not made routinely. Consequently, SP elongation is usually over looked as possible cause of symptom referral. Materials and Methods: In our study the various presenting symptoms were throat pain, ipsilateral otalgia and foreign body sensation in throat. Digital palpation of styloid process and accentuation of pain in tonsillar fossa, positive lignocaine test along with radiological demonstration of the elongation of styloid process confirm the diagnosis. Total of 30 patients were treated surgically by transoral Styloidectomy for oro-facial pain. All resected tonsils were subjected to histopathological examination. This is a prospective study conducted at the Krishna Hospital, Karad, Maharashtra, India. Results: Twenty eight (93%) of 30 cases of oro-facial pain became asymptomatic after surgery. 1 had considerable improvement to the extent that the subject did not require any analgesics subsequently..21 (70 %) out of 30 resected tonsils revealed fibrous variety. There were no serious surgical complications. Conclusion: Tonsillo-styloidectomy is the treatment of choice for Eagle’s syndrome with a high success rate. Usefulness of medical (non surgical) treatment remains doubtful.


INTRODUCTION
ossification of stylohyoid ligament may produce cluster of symptoms in few giving rise to ''Eagle's syndrome'' also known as Stylohyoid syndrome, which is characterized by craniofacial or cervical pain [1][2][3].
In 1937 Eagle primarily described two syndromes: Classic Styloid syndrome: It occurs mainly after tonsillectomy and is charactesrised by isolated pharyngalgia in the tonsillar fossa.Its symptoms include dysphagia odynophagia, a sensation of increased salivation, and a sensation of foreign in the pharynx.

Stylocarotid syndrome:
The "second form" of the syndrome ("stylocarotid syndrome") is characterized by the compression of the internal or external carotid artery (with their peri-vascular sympathetic fibers) by a laterally or medially deviated SP. 10 It is related to a pain along the distribution of the artery, which is provoked and exacerbated by rotation and compression of the neck.It's not correlated with tonsillectomy.In case of impingement of the internal carotid artery, patients often refer supraorbital pain and parietal headache.In case of external carotid artery irritation, the pain radiates to the infraorbital region.(57th) Eagle defined the length of a normal styloid process less than 25mm [1-3].
The styloid process may vary from 5 to 50 mm in length and the stylohyoid ligament may ossify from its rigin at the styloid process to its attachment at the hyoid bone.
Elongated SP is seen in about 4% of general population, while only 4% of these patients remain symptomatic; the true incidence is 0.16% with a female predominance of 3:1 [4,5].
Eagle's syndrome can be treated conservatively or surgically or both.
Conservative treatment: Transpharyngeal injection of steroids and lidocaine, nonsteroidal anti-inflammatory drugs, antidepressant diazepam transpharyngeal manipulation with manual fracturing of the SP [6].However failing this attempt, surgery remains a viable alternative.
The transoral approach involving resection of the SP is relatively easy to perform and leaves no external scar.Both the operation and recovery times of this procedure are short.However, the rare disadvantages of the transoral approach are possible deep cervical infection, poor visualization of the surgical field and possible temporary edema at the operative site [10].
Aims & objectives: To determine the incidence of elongated styloid process among symptomatic patients visiting ENT out patient.
To assess the effectiveness of management of Symptomatic elongated styloid process (Eagle's syndrome).
A prospective time bound study of probable etiology in cases of stylalgia was carried out from December 2014 to December 2016 in a tertiary care hospital .Total of 30 cases were studied based on the clinical presentation, radiological findings and histopathology of all resected tonsils.

Inclusion criterions:
All cases irrespective of their age and gender presenting with typical symptom of throat pain, accompanied unilateral ear ache, cervico-facial pain on swallowing and or head turning movements, and not responding to initial conservative medical treatment were included in the study.Also the symptomatic cases with clinically palpable styloid, positive lignocaine test and elongated (>25mm) styloid process on radiological imaging were included.
Exclusion criterions: All cases presenting with typical symptom and having history of tonsillectomy, pregnancy, on breast feeding and diabetes irrespective of its control were excluded in this study.
In all cases subjective symptom of pain was assessed by using visual analog scale (VAS).Severity of pain experienced by an individual was recorded in the form of numbers ranging from 0-10 where 0=no pain and 10=worst imaginable pain.Depending on the range of analog scores

MATERIALS AND METHODS
the results were further grouped into three as mild=1-3, moderate=4-6 and severe=7-10.All patients were treated with tonsillectomy and transoral styloidectomy.In all cases the resected tonsillar tissues were subjected to histopathological examination.Pain was assessed by Questionnaire method using Visual Analogue scale.
Each patient was asked to describe the level of pain experienced by them in the form of numbers ranging from 1-10 or by using Visual analogue scale.patients were male and 21,182 patients were females during the study period.A total of 30 cases of ES were studied.The overall incidence of ES in patients visiting ENT opd was found to be 0.65% Sex distribution and ratio: Study group consisted of 9(30%) males and 21(70%) females with M: F ratio being 1:2.33.
Mean length of the left and right SP in two sexes: Mean length of the left and right SP in males was 32.4±5.5 and 32.2±7.1mmwhile in females it was 32.5±8.0mm and 31.6±7.0mm.No significant difference was found in mean length of SP among male and female on both sides.

RESULTS
Incidence: A total of 45,570 patients visited ENT opd during the study period, among them 24,390   Highly significant difference in average length of SP among different age groups on both sides.Among 30 patients 15(50%) had U/L ESP(L=7,R=8) and 15(50%) had B/L ESP.50% of patients presented with moderate pain and 33% patients were having mild pain while remaining 16% had severe pain according to VAS.Frequency distribution of number of patients with pain according to VAS on first visit among both the sexes shows more number of females suffering from moderate to severe pain.
Assessment of pain on 1 st follow-up 3 patients suffering from moderate pain on1 st visit were found to have mild pain after 3 weeks of medical treatment, where as there was no change in pain category for other patients after medical treatment.4% of general population an elongated SP occurs, while only about 4% of these patients are symptomatic; thus the true incidence is 0.16% with a female predominance of 3:1 [15,16].Studies performed by anatomists Keur et al., Milner et al (1996) [17], have proven that 2% to 4% of the overall population have either an elongated or a calcified SP, but only 0.04%of them are symptomatic .Baddour HM 2004 [18] reported 0.04-0.08% incidence.
Our study goes in favour with study done by Sikanjic and Vlak et al.(2008) [19], during their 2008 study on 448 X-rays, 102 of which presented with Eagle's syndrome.Of the 102 patients with Eagle's syndrome, 66(64%) were females.Y.K. Maru and Kusum Patidar (2003) [20] in their clinical experience of 332 cases of ES included 140(42%) males and 192(57%) females.As to the incidence in the overall population, Grossman & Tarsitano(1977) [21] reported that the syndrome usually affects adults, with no difference between sexes.However, Neville et al. [22] observed that the syndrome affects mostly women in their 20s and 30s.
In the present study the average length of right SP was 31.8±6.9mm while average length of left SP was 32±7.3 mm respectively.There was no statistical difference between the lengths of the two sides.
In the present study 15 (50%) of subjects were having B/L ESP which comprised of 5 (33%) male and 10(66%) females.Among remaining 15(50%) patients 8 (53.4%) [1 male (12.5%) and 7 female (87.In the present study only 3(10%) patients out of 30(100%) were benefitted to some extent by medical treatment but was not acceptable to the patients.In a similar study by Sanjeev Mohanty et al.(2009) [27] on 28 patients of ES, 17 were females and 39 were male.All these patients underwent a trial of the drug carbamazepine, taken orally at a dose of 200 mg TDS for 3 weeks, but without any relief in symptoms.
All patients underwent tonsillo-styloidectomy by trans-oral approach.A total of 35 SP were removed.In 10 patients B/L tonsillo-styloidectomy was done, while in case U/L cases the symptomatic ESP was removed .There was no intra-operative or postoperative complication.

CONCLUSION
The present study has laid to the conclusion that: ES is a rare, definitive, often misdiagnosed clinical entity with elongated SP as the underlying etiology.The analysis of clinical symptoms allows not only to diagnose the syndrome, but also to foresee a possible disturbance of the SP or the SHL.But the basics in pathogenesis are not yet clearly understood, so also are the factors that encourage calcification at SHL. Radiological analysis is the basic method for the localization of the stylohyoid complex disturbance and the diagnostics of its nature.Medical treatment did not seem effective, and we feel that every patient with an enlarged, misdirected and fractured symptomatic SP must be offered surgical treatment preferably in the form of intraoral complete excision of SP.An excision of SP by the intraoral route under general anesthesia is easy and most appropriate answer to the nagging, disturbing pain syndromes in the head and neck which appears to be due to enlarged SP.Fibrous tonsillitis could be considered as one of the other etiological factors in Eagle Syndrome.

International
Journal of Anatomy and Research, Int J Anat Res 2017, Vol 5(2.3):3952-57.ISSN 2321-4287 DOI: https://dx.doi.org/10.16965/ijar.2017.227yoid ligament and the lesser cornua of the hyoid bone, forms the stylohyoid apparatus .The word Styloideidos is derived from Greek-stylos i.e. 'pillar' and eidos i.e. 'like' meaning pillarlike process.An abnormally elongated styloid process or Embryologically origin of styloid process is from Reichert cartilage of the second branchial arch.It arises from the inferior surface of the temporal bone at the junction of its petrous and tympanic bones.Styloid process with the styloh-Shedge Swapna A, Havle Abhay D et al.STYLALGIA -GLOSSOPHARYNGEAL NEURALGIA: OUTCOME OF MANAGEMENT.

Table 1 :
Distribution of study group.

Table 2 :
Mean length of SP in different age groups.

Table 4 :
Assessment of pain on all visit.

Table 4 :
Comparison of sex ratio in Eagle syndrome.