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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 66-68

Eagle syndrome or foreign body throat?


Department of Otorhinolaryngology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia

Date of Web Publication4-Jul-2019

Correspondence Address:
Michael Sze Liang Wong
Department of Otorhinolaryngology, Faculty of Medicine, University Malaya, Kuala Lumpur 50603
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_20_19

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  Abstract 

Eagle syndrome is a rare condition caused by an elongated styloid process or abnormal calcification of the stylohyoid ligament complex. Patients typically present with recurrent throat pain, neck or facial pain, sensation of foreign body in the throat, or even dysphagia. The finding of an elongated styloid process is usually incidental, with patients having no related symptoms. Only patients with symptoms are diagnosed with Eagle syndrome. This condition may be difficult to diagnose due to its rarity and the nonspecific nature of signs and symptoms. Diagnosis is mainly by clinical assessment and confirmation with radiological evidence. We present a unique case of eagle syndrome in a patient who complained of acute neck pain after eating fish.

Keywords: Eagle syndrome, swallowed fish bone, stylalgia


How to cite this article:
Wong MS, Adzreil B, Prepageran N. Eagle syndrome or foreign body throat?. Indian J Community Fam Med 2019;5:66-8

How to cite this URL:
Wong MS, Adzreil B, Prepageran N. Eagle syndrome or foreign body throat?. Indian J Community Fam Med [serial online] 2019 [cited 2019 Nov 13];5:66-8. Available from: http://www.ijcfm.org/text.asp?2019/5/1/66/262118


  Introduction Top


Eagle syndrome was first described in 1937 as “stylalgia” – a condition caused by abnormal length of the styloid process or mineralization of the stylohyoid ligament complex.[1] The stylohyoid complex consists of the styloid process, the stylohyoid ligament, and the lesser cornu of the hyoid bone. The styloid process is a cylindrical bony projection from the temporal bone. It extends downward, forward, and medially, and is immediately anterior to the stylomastoid foramen. The adjacent structures around the stylohyoid complex include the internal and external carotid artery; internal jugular vein; and the facial, glossopharyngeal, vagus, and hypoglossal nerves.

Usual complaints from patients with stylalgia are recurrent throat pain and foreign body sensation. Occasionally, a palpable hardness can be felt in the tonsillar fossa which could be indicative of this condition. The incidence of this condition is only about 4% of the general population and occurs in adults aged 30–50 years.[2]


  Case Report Top


A 43-year-old woman presented with throat pain after a fish meal. She claimed to be eating fish when she felt a sudden prickling sensation at her throat and tried to remove the bone with her fingers but was unsuccessful. She consulted a general practitioner who duly referred her to a specialist center, where a flexible nasopharyngolaryngoscopy was done with no significant findings. A computed tomography (CT) scan was done which was reported as normal. She was discharged home with reassurance.

However, her symptoms persisted, and thus she went to seek another consultation 3 weeks later and underwent an examination under anesthesia and direct laryngoscopy and esophagoscopy. There were no significant findings as well.

Post procedure, she claimed her symptoms to be still present. The doctor-in-charge promptly ordered another CT neck which showed a radiopaque foreign body in the soft tissue of the neck [Figure 1]. This led us to believe that the foreign body may have migrated from the cervical esophagus into the neck.
Figure 1: Sagittal view of computed tomography scan. Blue arrow showing the suspected foreign body

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The patient underwent neck exploration, and the suspected foreign body was found deep into the submandibular gland just above the hyoid bone [Figure 2] and [Figure 3].
Figure 2: Intraoperative findings from right transcervical approach showing the suspected foreign body in blue arrow. Yellow arrow marks the right submandibular gland

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Figure 3: Specimen of the suspected foreign body removed. It appeared to be soft with a cartilaginous feel and smooth edges

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After the operation, the patient's symptoms completely resolved.

Histopathological examination of the “foreign body” removed showed benign lamellar bony tissue with adjacent fibrous and cartilage tissues, suggestive of ligament tissue [Figure 4].
Figure 4: Histology picture of the suspected foreign body showing bone marrow (blue), bone (green), and cartilage (red)

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  Discussion Top


Classical symptoms of eagle syndrome are pain or foreign body sensation in the throat, odynophagia, and dysphagia. This is usually precipitated by tonsillectomy operation. Clinically, hardness can occasionally be palpated in the tonsillar fossa. Rarely, the styloid process causes pressure to the surrounding carotid arteries, leading to symptoms such as neck pain on head movement, buzzing in the ear, and headaches.[2]

Theories on the cause of this condition include congenital (persistence of cartilaginous elements of precursors of styloid process) or acquired (proliferation of osseous tissue of the stylohyoid complex).[3]

There are several explanations for the symptoms, based on anatomical understanding namely:

  1. Fracture of the styloid process leading to granulation tissue and pressure of the surrounding tissue
  2. Compression of adjacent nerve (glossopharyngeal, chorda tympani, and lower branch of trigeminal)
  3. Degenerative and inflammatory changes at the tendinous portion of stylohyoid insertion
  4. Irritation of pharyngeal mucosa from direct compression or post tonsillectomy scarring
  5. Impingement to carotid vessels with irritation of sympathetic nerves in the arterial sheath.


Skull X-ray with lateral and frontal view would usually suffice for diagnosis. However, with the availability of CT scan, images are clearer and easier to delineate the surrounding anatomy and would aid if surgical excision is required.[4]

In our particular case, the presenting complaint of the patient led us toward a diagnosis of foreign body ingestion. She came with a clear history of throat discomfort after eating a fish meal. Her first CT scan does not reveal any foreign body or any abnormality. Only 3 weeks after her initial presentation did a repeat CT showed a “foreign body” in her right neck.

This presentation would lead to an assumption of a migrated fish bone into the neck. However, this diagnosis was challenged when the intraoperative neck exploration showed the suspected foreign body found deep into the submandibular gland and above the hyoid bone with no inflammation surrounding it. The gross appearance and tactile sensation of the suspected foreign body as well was not suggestive of a migrated fish bone. The histopathological examination report was also suggestive of a calcified stylohyoid ligament.

These findings prompted us to reconsider our initial diagnosis. The challenge is how to explain her very suggestive and clear history of her complaint to her diagnosis. The possible explanation could be that she did swallow a fish bone, albeit a small and clinically insignificant one. The irritation might have alerted her to the foreign body sensation and made her more aware of it. Another explanation could be that the irritation of the pharyngeal mucosa due to the fish meal (fish bone) or due to her manual attempts to remove the bone might have exacerbated the symptoms on a preexisting elongated styloid process.

There have been other cases reported in which eagle syndrome was diagnosed incidentally.[2],[3],[4],[5]

Surgical management is the treatment of choice for eagle syndrome. The approach can be intraoral or transcervical. Either approach has its own advantages and limitations; hence, the choice of approach should depend on individual surgeon's experience and preference.

Medical management has also been described in the form of local injection with steroid or anesthetic agents. Other medications that can be used are analgesics, anticonvulsants, and antidepressants.[6]


  Conclusion Top


This case has been a unique experience to us in the otorhinolaryngology field in the way of its presentation. While it is good that the underlying condition has been treated for this patient, it is unfortunate that she had to suffer the discomfort for a whole month before treatment. This would be a lesson to others in the otorhinolaryngology field as well as primary caregivers to whom patients would seek treatment for similar complaints. Eagle syndrome is rare, and a high level of awareness is needed to not miss this benign but debilitating condition.

Acknowledgment

The authors would like to thank Dr. Manimalar Selvi Naicker A/P Subramaniam, MBBS, MPath, MMedStats, GradDipMedStats, for providing histopathology slides and report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Eagle WW, Durham MC. Elongated styloid process: Report of two cases. Arch Otolaryngol Head Neck Surg 1937;25:584-7.  Back to cited text no. 1
    
2.
Politi M, Toro C, Tenani G. A rare cause for cervical pain: Eagle's syndrome. Int J Dent 2009;2009:781297.  Back to cited text no. 2
    
3.
Al-Ekri A, Alsaei A. Incidental finding of an elongated styloid process during tonsillectomy procedure. Int J Otolaryngol Head Neck Surg 2015;4:236-40.  Back to cited text no. 3
    
4.
Beech T, Mcdermott A. An interesting presentation of Eagle syndrome. Internet J Otolaryngol 2005;5:1-3.  Back to cited text no. 4
    
5.
Murtagh RD, Caracciolo JT, Fernandez G. CT findings associated with Eagle syndrome. AJNR Am J Neuroradiol 2001;22:1401-2.  Back to cited text no. 5
    
6.
Taheri A, Firouzi-Marani S, Khoshbin M. Nonsurgical treatment of stylohyoid (Eagle) syndrome: A case report. J Korean Assoc Oral Maxillofac Surg 2014;40:246-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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