Could thick but normal length styloids be the cause of Eagle's symptoms?

[nmnrtk]

In early 2020, I started hearing some buzzing after driving, and a few days later I had the onset of a left side tinnitus, which can be modelled by pressing in the soft zone just below the left temporal - stronger tinnitus.

Next year, I had an episode of vertigo. For two weeks I could barely do any movement without feeling disoriented. I had to lay in the sofa in a certain angle to make it calm down. It took a long time to subside. Cleared for BPPV. ONT doctors - even some specialists in vertigo - asked for head MRI, but eventually nothing remarkable was found.

Then for the next two years, same previous issues, but with anxiety as well. Forgetfullness, depersonalization, incapacity to hold the train of thought, unable to sit for a long time, ocular migraines with aura, ocular scintillation, occipital pain, feet feeling cold but warm to the touch of the hands, the perception that the floor is sloped (when it’s just plain), dry eyes (especially the right one), visual snow, chest pressure, eye floaters, neck just feels weak and tense SCM, even sometimes clearing the throat triggers a bit of disorientation.

Even today, when I turn my neck to look up I start again to have some sensation of losing the balance. Another one is sometimes there’s a loud spike in tinnitus, but as soon as I move the neck around, that spike diminishes considerably.

I feel sometimes slight pain in a spot, like some pointy object being pressed into the left ear.

When sleeping, it’s very common to wake up feeling hand/arm numbness.

I also have (almost always) stinging in the eye, like you’ve just touched your eyes with a soapy finger. I think the basal tears are not being produced or are very weak. One curious thing is: when the eyes are very dry, if I get down to grab something from the floor, bending the back, I can get a tear to be produced immediately.

The only medication that helps is clonazepam. It calms a bit the tinnitus and the back pain.

Finally I found an “Eagle’s-aware” TMJ specialist. He ordered a CT scan of the face and we found out the styloids are within the acceptable length (28 mm and 30 mm), but they look very thick, and it’s this thickening that could be doing IJV or nerve compression. The doctor did not comment anything on calcifications.

Because the doctor ordered the exam without contrast, we can’t see any IJV impingement. I have a brain angio-MRI done, but the radiologist can’t merge it with the head CT that I have.

[Jules]

Wow, they are really thick! I would think that they could well be thick enough to cause symptoms, and many of your symptoms are seen with ES… You cant see for sure with your imaging how much of a gap there is between the styloids and the C1 processes, as this is where the IJVs often get pinched, but given their thickness & they’re pretty angled, it could possibly be enough to compress the IJV where it exits the skull base. Fatigue, brain fog, off-balance feeling, disorientation/ depersonalisation are all common with IJV compression. I never felt the floor was sloped, but did feel closer to the floor than I was, like I was really short, & that’s been mentioned before as an intracranial hypertension symptom, so it sounds like you could have IJV compression which is increasing head pressure…As the vagus nerve exits there as well, you could have irritation/ compression of this nerve too, which can cause BP issues or heart arrythmias, and anxiety..
If you’ve not looked at the common symptoms info page, it’s worth reading, you might find some more!
ES Information: Common Symptoms And Possible Explanations For Them - Welcome / Newbies Guide to Eagle Syndrome - Living with Eagle
Dry eyes are common- possibly from the trigeminal nerve which I think supplies the lacrimal glands, which produce the oily part of tears.
Your hyoid bone processes look fairly chunky too, but you don’t mention any throat or swallowing issues? Your thyroid cartilage looks fairly calcified also, but doesn’t sound like that’s causing you symptoms either? Some people’s are naturally like that & they’re not symptomatic…
It’s certainly worth trying to get a CT with contrast done- if you can get this timed to show the arteries and veins this would be good to get the full picture. Some radiologists can do this dynamically, so if your symptoms are worse in one position you could ask about that, but not many places do this.
If you’re able to do this, & it does show IJV compression by the styloids, then you would need to find a doctor who is able to remove the styloids as close to the base of the skull as possible for surgery. We only have one doctor on our list- Dr Carlos Nabuco, Dr. Carlos Nabuco - IPFace Medical Team - Portuguese Institute of Face | Lisbon
We have been given his name as treating a friend of a member, none of our members have seen him, so don’t know anything about him…

[nmnrtk]

@Jules

Your hyoid bone processes look fairly chunky too, but you don’t mention any throat or swallowing issues?

Thank you so much for your response. I actually have some symptoms while eating. It’s like the muscles under/back of the tongue get tired if masticating for a few seconds, though this doesn’t happen all the time.

Also there’s another puzzling thing: both eyes blink naturally, but the right eye one takes more time to do the movement, even when I put artificial tears.

And in this same eye, sometimes the upper eyelid twitches. Only the right eye. Could be unrelated but still worth mentioning.

[Jules]

The facial nerve is commonly affected with ES, & that can cause some facial paralysis, so either droopy eyelids or lip, so it could be related!

[Isaiah_40_31]

@nmnrtk - Agreed! Your styloids are probably the thickest I’ve ever seen + as @Jules noted, they’re pretty angled, more upward than we usually see.

If you do have IJV compression (which seems likely based on your symptoms) & Dr. Nabuco either denies that you have ES or isn’t experienced w/ IJV decompression surgery, Dr. Kamran Aghayev in Turkey is quite experienced with that surgery & has helped a number of our members. If you can afford to travel, he would be a good resource for you. He does phone or video consults, too, so you wouldn’t need to see him in person to get his opinion.

•Dr. Kamran Aghayev - https://kamranaghayev.com

[nmnrtk]

I have now the CTA, but the report is confounding. This time another different radiologist measures the styloids as having both 25mm instead of 30mm and 28mm.

And it seems that the CTA on the sagittal plane is only from a single point of view. So they on the report only one styloid (says right on the report but it’s my left anatomical side) being tangential to the external carotid and the posterior auricular artery (who knew… that’s my side with the worst most life debilitating tinnitus). I haven’t been able to visit the doctor yet for evaluation. They mention normal permeability of the cervical arteries, right-side being dominant.

[JGont]

Hello @nmnrtk, I just wanted to encourage you to keep on trying to get an evaluation. My styloids are also thick and in the normal variation. Dr. Hepworth in Denver took a look at my normal CT scan/report (which did not note any issues) and was able to determine a few things wrong that nobody else could.

We have a lot of the same symptoms and I am also early in the process of diagnosing all the issues. Hope you find the right person to help, and the symptoms alleviate a bit.

All the same:

• Tinnitus worse when pressing on muscle groups and changes with neck position. Clonazepam also helps with my tinnitus (but does not eliminate it).
• Forgetfullness
• Depersonalization
• Incapacity to hold train of thought
• Ocular migraines
• Dry eyes
• Visual snow
• Chest pressure
• Eye floaters
• Tight SCM and neck muscles
• Stinging eyes

You are not alone, keep on trucking!

[Isaiah_40_31]

@nmnrtk

I have now the CTA, but the report is confounding. This time another different radiologist measures the styloids as having both 25mm instead of 30mm and 28mm.

Going back to the title of this post, even though your styloids aren’t exceptionally long, they’re very thick & steeply angled. Without your styloids being elongated, those two features are enough to be causing the symptoms you’re having.

Even though your recent radiology report noted that the styloid is tangential to the ECA & PAA, your head was in a neutral position during the scan. Because of the thickness of your styloids, when your head is turned to the left or right, that could change such that your styloid(s) actually come in contact w/ the ECA & possibly the PAA & even the IJV(s).

I annotated your axial image which doesn’t show compression of the IJVs or ICAs but it does show how thick your styloids are at the level of C1. Often we just see small, round, white circles. In my non-medical opinion, I think your styloids could be causing some vascular compression, even though it didn’t show up in the recent CTA you had.