False positive of ES?

If only 4-7% (?) of the population has calcified stylohyoid ligaments (or elongation of the styloid process—but for this purpose I’m more curious about the calcified ligaments), but only another 4-7% (?) have pain (aka Eagle Syndrome), it seems possible that many times people may end up having pain and if they happened to have awareness that their ligaments are calcified, they might assume it’s ES. So my question is this:

Have any of you found out via a scan (dental scan, etc) that your ligaments were calcified, but didn’t have any symptoms so didn’t think much of it.

But then, when at some point you had pain, then assumed it was ES? Or even was diagnosed with ES?

And then, has anyone had the pain or symptoms clear up only to realize it wasn’t ES?

Has anyone had surgery for ES only to find out it was never the issue?

My concern, is that say you find out your submandibular gland was inflamed and it was causing a lot of pain. In the meantime you were diagnosed with ES after presenting it to the doctor. Then your pain diminished greatly once the submandibular gland was treated, but you still have an ES diagnosis. Would you still get the surgery? Or would you wait to see if all the pain goes away?

If so many have calcifications but no symptoms, and only a small amount of people have symptoms from the calcifications, isn’t it likely to have false positives?

Hi SRR- let me try to take a stab at some of this. I’m not quite as experienced as many others here but I’m certain they can elaborate on what I am able to contribute.

ES is defined as having elongated styloid processes (generally speaking, average length is about 2.5cm). You can be asymptomatic and still have ES and obviously do nothing about it since you have no symptoms. But even with normal lengths you can be presented with symptoms due to curvature and thickness of the styloid and also calcification of the stylohyoid ligament. It’s a vicious little game.

The gold standard for diagnosing ES is via CT although some have seen elongated styloids on a panoramic dental X-ray. I’d have to believe that if found on a panoramic that a CT should follow just to be accurate in a diagnosis.

It is very possible that symptoms can wane and wander. Mine had been constant all day every up until right after I was diagnosed then they completely went away for about a month before returning. I’ve read many folks have “flare ups” which I assume means that there are no symptoms or that they’re manageable until that flare occurs and things get worse.

I haven’t read about submandibular pain being a direct symptom of ES (but someone else here can clarify). I suppose it’s not out of the question since ES can contribute to some really odd symptoms that you’d never believe were related. Mostly what Ive read about is post-op when the submandibular gland gets irritated from surgery causing first bite syndrome- when it is hypersensitive upon the first couple bites of a meal and sends a pain in that area, then settles right down. This in time goes away in most cases.

I hope this helps get the ball rolling to get you answers your looking for :blush:


I think the simple answer is yes. It is possible to have false positives given the complicated nature of ES. There is no blood test to diagnose ES but rather more on symptoms combined with imaging support. The shear number of symptoms that comes with ES can indeed mimic other diseases and vice versa so one has to be really careful and rule out any other mimicking pathologies before considering ES. A good ENT would do that first. Also, you can have both, ES and other mimicking condition so in this case it is even harder to tell which one is producing the symptoms.

One important thing to note is that it is never about ligament calcification or the length of the Styloid process but whether the Styloid + ligament is compressing/irritating nerves or blood vessels. For example, my Styloids are normal in sizes. The one on the left is roughly 1.8 cm but because it is compressing my Jugular Vein, I have the diagnoses of ES (Vascular variant). Millions of people have Styloids with the same length as mine and are perfectly fine because it is not angled downward, towards their Jugular Vein. Similarly, you can have long Styloid with calcified ligament, if it never messes with your cranial nerves or blood vessels, you do not feel any symptoms (asymptomatic). The Styloid itself is part of a normal human anatomy and calcification is part of our biology both of these are not pathogenic. Only when they invade other tissues’ spaces or compress them is when we have an issue. For the lack of better analogy, this is similar to cancer in a way, if cancer was not spreading and invading other major organs, it would never have been a disease to begin with. It is basic fact of biology that cells grow, divide, repair and die. After all from embryonic stage to now, that is what our cells were doing to get us where we are now. The problem is cancer cells keep dividing uncontrollably and invade organs and tissues depriving them of blood and nutrients and eventually lead to the death of that particular organ. Similarly, elongated, calcified ligaments put you at greater risk of ES for that fact that they are growing in crowded space of cranial nerves and major blood vessels that supply the brain so even if they do not presently cause issue, you might be a whiplash or fall or dental work or sudden violent neck movement away from having them contact each other to trigger ES. Sorry for the long ramble but nothing in biology is easy neither is ES.


I’ve been diagnosed with ES due to calcified ligaments and the pain, and have a surgery scheduled for about a week. However, once I solved my submandibular inflammation with warm moist washcloth every night and lemon drops, I’ve been very close to pain free for over a week now. I’m really concerned about getting a surgery if I’m not having bad symptoms. However, I’m wondering if I postpone my surgery it will flare up again, and then I’d need to wait to get surgery.

My calcified ligaments were discovered in 2014 and I had no issues until this year after having Covid (falling and hitting my head) and then two weeks later food poisoning. And then a few weeks later at the gym I started having an intense pain under my left jaw, which I now think may have been my submandibular gland.

Did you end up getting a surgery? And is a month without pain the longest you went? Did you have to take it easy, or did you do your normal things?

Thank you for this great info. My dentist found my calcified ligaments back in 2014. I didn’t have any issues until this year. Around Christmas of last year I fell and hit my left side of my forehead. Then two weeks later I had food poisoning. Then two weeks later at the gym I had my first pains. Which I am confused now as to if they were from an infection in my submandibular gland. I’ve done different tests. Recently I went to a surgeon who is familiar with ES and since I presented thinking it was that, from my pain and imaging he agreed. But now with my surgery less than a week away and I’m not having much pain for about 9 days, I’m wondering if I should postpone my surgery. The doctor even said he noticed that my submandibular gland is no longer inflamed.

@SRR You are welcome and I feel your dilemma since surgery is less than a week away. I would say investigate this thoroughly and see if you can postpone it. I have also quickly looked into how calcified ligament can interact with the submandibular gland I came across an interesting study (see the source study below) where the calcified ligament displaced the submandibular gland although the patients did not feel to pursue surgery here since the symptoms were intermittent. So yes, the calcified ligament can indeed interact with submandibular gland but whether it warrants surgery is patient & symptom dependent.

Source Study : stylohyoid


SRR ~ In my opinion, the fall where you hit your head then the subsequent episode w/ food poisoning could have sufficiently “shaken up” things in your neck to cause the onset of ES symptoms. However, I agree w/ @KoolDude, if your symptoms are sufficiently reduced at the moment, & stay that way for the next few days, even during workouts, it would be worthwhile cancelling your surgery for the time being. I suspect your submandibular gland was only contributing to what are most likely true ES symptoms, but it would be great if it was the total cause & surgery isn’t in your future.


@SRR - what I’ve come to understand is that symptoms are commonly triggered be an event…such as a bad cold, a fall, even painting when you have your neck stretched in odd angles. There never seems to be a consistent reason for symptoms to show.

My pain was more classic vs vascular and had been constant. Relentlessly there day in/day out with ear fullness, lateral neck pain right where the styloid was and the back 1/3 of my tongue and throat burned all day. I believe my SP was irritating my Glossopharyngeal nerve.

Nothing worked. Prior to finally getting diagnosed, I’d tried it all from every therapy to gimmicky solutions. I ultimately met with two ES specialists in my area to obtain as much confidence as I could that surgery was the right decision. It was after one ENT tried to feel for the styloid that my symptoms randomly disappeared for a month or so. He must’ve moved something around just enough to give relief.

I did have surgery on the left side on 5/4 and noticed some improvements right away. I’m very early I’m recovery and where nerves take many weeks/months to heal but I feel I’m on a positive track.

I hope this helps some. I understand your concerns with a surgery and not wanting to pursue if it isn’t necessary. I was in that same place after having been misdiagnosed early on and having a surgery that didn’t resolve my pain. With that heavy on my mind when considering ES surgery, I knew I did everything I could and as others stated, at some point you have to do what you can to rule out where your pain comes from. This was the next logical step for me and I’m feeling more and more confident as I heal that it was the right choice for me.

I’d hate to mislead you but I tend to concur with Jules and KoolDude to postpone if your symptoms aren’t uncomfortable at the time. But truly spend some time exploring and getting answers so that you’re well-informed and can be comfortable with surgery at a later date if you find it’s necessary.


Oh, poor you, that is a dilemma! I did have an inflamed submandibular salivary gland too, it started around the same time as my ES symptoms ramped up, but when that was sorted I was still left with jaw pain & neck pain & got diagnosed with ES after this was investigated…have you looked at the common symptoms & possible explanations section in the Newbies Guide? There might be some other ones that you’ve not connected to ES which might help you decide. If you are still pain-free though it might be an idea to postpone surgery if you can like the others suggest, it’s not without risk, so to have it done unnecessarily would be a shame! Praying that you make the right decision! :pray:


Thank you for your input on this. I haven’t tried to workout again since the beginning of April due to the pain. However, in the last 9 days or so my pain has been very minimal for the most part—but still there. I think the sharp pains (the worst ones for me) were from the submandibular (the doctor thought maybe that too) gland inflammation. And since I’ve been treating that with a warm moist washcloth every night multiple times and I had lemon candies, I think it fixed it in a way. However, the doctor also thought I may have three things going on:

  1. Ligaments calcified
  2. Submandibular gland was inflamed
  3. Tonsil may be coming back some (I’ve had a sore throat for weeks and I can see my tonsils—especially on the left were the pain is—are red and inflamed like I have tonsillitis. The doctor can’t feel any bones or anything in my tonsil area.

So, I’ve been babying myself for months to try to not have intense pain. But now that the gland seems to have calmed down, my tonsils I’ve been having menthol lozenges, I haven’t been in much pain.

I do still feel a dull pressure under my left jaw area a lot.

My surgery is set for 6/13. If I reschedule, I doubt I’ll be able to get in for another month at least. And my concern is if I test working out and it ends up hurting super badly and causing more pain again (like I’ve had in months last) then I’ll be stuck waiting again for a surgery. That’s if I postpone this one.

The pain started in Feb. and became consistent in April. So overall I’ve been having the pains for about 4 months. I’m unsure how long is safe to wait and test it out more. And I’m unsure how much pain is worth getting the surgery. I want to be able to work out (I can still walk fine now that gland isn’t as upset especially) and do all my normal things.

Thanks so much.

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Thanks so much for this info. I for sure think it’s possible when I passed out (with Covid) and hit my left forehead, that I may have done something that messed with my ligament. OR it’s possible I’ve had issues with my submandibular gland (I’ve read Covid can get in there) and that I mistakenly attributed it to ES due to my calcified ligaments and other symptoms matching up.

I wonder, if symptoms can show up, after years of having calcified ligaments, couldn’t they also go away?

For your throat burning, were your tonsils inflamed as well, or was your throat red? Or was it more of a feeling (due to the nerve) without any obvious redness?

I’m so glad your surgery went well and that you’re seeing improvements. My surgery would also be on my left side, however I have bilateral calcifications. The doctor said my styloid processes look normal.

Thank you. I’m trying to rule things out. I just don’t want to end up causing more nerve damage if it is indeed from my ligament. About how long from first symptoms did you wait to have surgery?

My symptoms at the moment are tolerable for sure. But in the past I’ve had days were I feel almost normal, but then all of the sudden it will start hurting really badly. But I still think that could’ve been from my submandibular gland. However, I do think if I try to work out again, I might start having pains again.

I may look into rescheduling with my doctor for another month out (if that’s possible). I’m just worried about trying to work out etc and ending up in bad pain, only to need to wait a month again to get surgery.

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Thanks, Jules. Interesting you also had an inflamed submandibular gland. How much of your submandibular gland pain do you think made up the overall pain you were having? And how long was your gland inflamed?

Yes, I have looked at the newbies guide (just did), thank you. I’ve been researching ES for months now on and off.

I’m not pain-free, but so much better than I was. I still feel a dull pressure under my left jaw, near the lymph nodes. And sometimes I feel a pressure when I swallow. However, my tonsil on my left is also irritated as I can see it’s red and swollen. And the doctor could not feel anything (ligament or process) back there. So I am wondering if maybe once I clear up what’s going on in my tonsils (chronic infection maybe after having Covid?) my pain will be almost gone? It’s just so hard to know.

I think I may try to reschedule my surgery for another month out. I’ve already waited a month to get to it, and haven’t been pain-free, but do feel a lot better. I would for sure not like to have the surgery unless I need it, given the risks. Plus, if I get this left ligament removed, I’ve heard the right may start acting up more. Which I have noticed in the past month symptoms starting on my right a little (nothing bad), which could be from the reactive lymph nodes (found on ultrasound recently) or my glands.

Thank you for the prayers!

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Wow! This is so helpful! Thank you for this info. That’s very interesting. Nothing really showed up for my submandibular gland on my CT with contrast (soft tissue) in March, nor in my ultrasound this month of the neck. But my doctor did say my submandibular gland was inflamed in May. Then I started treating that with warm compresses in the evenings and having lemon candies and my dry mouth went away, the pain reduced greatly, and I felt a lot better. Then this month for another check up, my doctor said my gland was back to normal feeling. And ironically, now I only have a minor pressure in that region now and still sore tonsils.

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@SRR - I just read your bio and shame on me, I didn’t know you’re new here and never properly welcomed you! So welcome and know you’ve got a huge resource for information and experiences. While no one is a medical expert nor can they make choices for you, they will provide you with tons of support that will help you make a good choice for yourself! I personally couldn’t have asked for a better group to help me navigate this!

That said, I’ve scoured this forum and read often that symptoms can and do come and go but they’ll never go away permanently on their own if they’re attributed to ES. Surgery is the only cure. This is a very small area and a lot of things are going on here. 6 of your 12 cranial nerves run through this area as well as vascular structures, muscles, ligaments and bones. There’s very little room so where calcification occurs, to me it feels like it’s a 50/50 shot of whether one has symptoms or not. If you’re symptomatic, chances are good it will only get worse as that calcification continues.

I’m glad you asked about my burning. I wish like mad I would’ve had something that would’ve been visible to guide me into a direction of what was wrong. I had not a single visible sign. No redness, no sore tonsils (which I still have as often folks who had tonsil removal are diagnosed with ES) and no visible inflammation of any kind. Which further hindered trying to figure out the source. I really thought I was crazy!

I began having symptoms March of ‘20 right after CV19 exploded with no rhyme or reason. I’d spent every day of every month m I had, obsessively trying to figure it all out.

Fall of ‘21 I was trying dry needling. After several appts my PT started to quiz me about ES because of where my pain was but fully disclosing he knew very little about it. I had begun seeing a pain mgmt doc at this time, went online to review his notes which referenced “pain in the styloid process area”. I immediately messaged him and he said he was sending my 2020 CT scan back to radiology for review. 2 days later it came back stating “definitely longer than normal”. Sadly, this is such an unknown diagnosis that I’d hit a wall on who could help me. Clearly, no one to that point knew enough about it to help. Still today when I share my diagnosis I get looked at quizzically.

October-ish ‘21 I joined this forum, began asking questions and getting a ton of support. I met with the two specialists on the list here in my area and both felt ES was a likely diagnosis. The ENT ordered a 2nd Maxillofacial CT to specifically look at my styloids. He guessed them at 3.5 (L) and 3.1 (R -thus far asymptomatic). He also agreed that the vascular surgeon I’d already met with would be a wise choice to do my surgery. I appreciated his transparency.

Due to CV19 and is wake, it took me 7 mos to schedule my surgery then it was a mere 2 week countdown. But MN was a huge hot spot for CV19 at that time. My styloid process was removed to the skull base and the ligament was removed. There’s pretty much a null chance of this ever coming back. My styloid upon removal was 4cm so a bit longer than the CT guesstimate, which is typical. I still have some symptoms- mostly a level of burning still but as I’ve been very gently reminded of here during my panics about recovery, nerve irritation could’ve been occurring long before symptoms became visible (thank you KoolDude) and it takes a very long time to heal. I’ll get there, I’m confident!

And I’m confident you’ll make all the right decisions along your path to assure yourself in what the nexts steps are! Lots of folks here that are ready and willing to answer questions and help you along! :blush:


SRR - As @Tjmhawk01 said, ES symptoms often come & go but as the nerves get more & more irritated, some symptoms may come & stay. I’m suspicious about your tonsils & the redness. I agree that the pain & swelling could be a throw back to COVID19, but, there is also a possibility, even in the absence of your doctor being able to feel a bone there, that the calcified ligaments/elongated styloids are irritating nerves that could be causing the pain & redness. Just more food for thought.

I totally understand your fear of heading back to the gym. I had to quit going as well when my ES symptoms ramped up. It wasn’t till about 4-6 weeks post op that I was finally able to return to that level of exercise.

I’m praying for you to have wisdom as you make your decision about whether or not to postpone surgery. :hugs:

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Thank you for this info. I’ve heard from some people that say their only regret is not having the surgery sooner. It would make sense that I’d the nerve gets more irritated over time, that it would be harder for it to go back to normal. And the longer you wait to remove the ligament (in my case) the longer it will remain irritated.

I did do a test yesterday with trying to swim. I haven’t used my arms like that in months (one of my triggers seems to be using my left arm as it seems to trigger pain under my left jaw area.). Well overall during the swim I felt pretty good, surprisingly. But yesterday evening I started having a dull ache type pain around where I think my ligament meets my hyoid bone (allegedly where it’s most calcified).

Question: with ES pain on swallowing, where do people usually feel the pain? In the tonsil region, under the jaw like a pressure, etc?

That’s so encouraging you were able to go back to the gym after 4-6weeks! Is that even without having the 2nd side done? Also, are you able to do full exercise now, with weights etc? Without sharp pains etc?

In addition to my last response, I’ll say one reason I ask about the sore throat is because a lot of my current symptoms mimic strep throat. But it would have to be chronic strep. I had Covid in late Dec. and I haven’t had the sore throat the whole time. But over the last 1-2 months it’s been every day. It hurts to swallow in back left tonsil. And also it hurts under my jaw area like a pressure maybe? Which I thought could be my lymph node which did show up as reactive on a recent ultrasound. I think I’m just trying to make sure I’m not having something else before I go get the surgery in a week. I’m quite anxious and confused. Unsure if I should post pone. But then again, if it will possibly give me relief after surgery and I can get on with my life, it makes me want to do the surgery sooner. However, my pain levels have been much more manageable since the submandibular gland stuff cleared up. But as you’ve noted, the ligament could be messing with the nerve.

I think the gland was inflamed for a couple of months before I realised what it was, but once the blockage cleared I didn’t get that sharp pain after eating. I did have aching all along my jaw still though, & toothache which I learnt later was trigeminal nerve pain.
If you do reschedule, I know it’s not nice to be in pain but if you’re only having to wait a month it’s not so bad, worth it to make sure you’re making the right decision, lots of us have had to wait ages for our surgeries…I’d give it a go upping the exercise a bit & see what happens…


Per another response I wrote.

I will say, your symptoms with the gland and then the pressure still after sounds similar to what I have. I think with rescheduling I’m worried about it getting a lot worse if I start pushing it and then me causing more nerve damage, if that’s happening. Yesterday while eating dinner my whole lower left teeth felt sensitive. It was a new and strange.

These are from my dental cone scan this year. I don’t have photos from my ct soft tissue, and when the surgeon looked the ct over with me, it wasn’t 3d, so I couldn’t see how my styloid processes were. He said they were normal. However, is it normal to not get measurements from a doctor? Or the 3d imaging I see many have?

The plan is to remove my left stylohyoid ligament only. He didn’t think the styloid process needed to be shortened. And he doesn’t remove from skull base, due to the risks.Then in the future if my right side ligament becomes more symptomatic I can have the right side removed.