Found an old panoramic xray that i want to share with my neurologist

[Toaster_coffee]

Thanks for accepting me here. I’m very grateful to have this community to help.

I’m 40, 5’2 (not too sure if that relevant but maybe?) and been struggling for over 20 years!

Id like to start by listing off my issues and symptoms:

For as long as i can remember, i’ve always grinded my teeth. Ive been given mouth guards which I chew through. Cant have botox as my local hospital doesn’t offer this on the NHS now and i cant afford to pay private for it. I get a lot of jaw pain and it often feels quite loose and unstable in the mornings… like it could pop out of place!

My jaw locked a few times last year. Very scary and extremely painful! Took 12 months to see a Maxilliofacial Surgeon. I told him quite a few dentists have told me i have TMJ. Lots of clicking and unpleasant jaw sensations. He examined my orally and also around my neck and jaw. Said my TMJ wasnt as bad as it seems and to try a different night guard. One worn between the front teeth. Again (as with the Botox) completely out of my price range so thats been shelved for now. I am gutted as i feel a guard at the front of my teeth would help.

He discharged me back to my dentist. I mentioned ES to him and he dismissed it very quickly and said its very unlikely i had it. This was a very quick 10 mins exam/consultation with no follow up imaging. Pretty disappointing as id waited a long time to see him.

I wanted to ad my TMJ history as i have read that ES and TMJ seem to have a lot of crossover symptoms.

For over a year ive also had let sided shoulder, arm and hand/finger complaints. My left shoulder often feels quite tight. My GP said it was rotator cuff injury yet i had actually injured it. I also don’t perform an repetitive movements that could aggravate it. I left the GP a little confused but was told to follow up with some at home exercises and come back if it didn’t resolve. I was then finally referred to physio (yet to get an appointment).

My left arm often goes numb, especially upon waking in the morning. I dont sleep in a way to cause that so unsure why its happening. My left hand and fingers often get pins and needles and feel weak.

Im currently under a vascular surgeon (for issues unrelated to ES) and expressed my concern for thoracic outlet syndrome given my arm and should complaints. He performed some tests in his office. Arms above head, felt for cervical ribs, checked arm pulses etc and said unlikely TOS.

Fast forward to now. All of what i’ve mentioned above are still going on. I have good and bad days.

I finally saw my GP (again!) who referred me to neurology for awful headaches along with neck and behind the ear pain. Always left sided. My neck is so tight on the left that my range of motion is poor. If i try to fully look over my left shoulder it feels like something will snap in the back of my neck.

My neurologist suspected migraines from my symptoms. Even tho i felt i didn’t present with the typical migraine symptoms. I don’t get nausea, i don’t have an aversion to light. I literally just have pain left sided from my neck, around to the back of my left ear (where the bony part is in the skull) all the way over the left side of my head. Its awful.

Thankfully my MRI has come back as normal so nothing terrifying there. Still no further with my answers.

My neurologist wants to try some occipital nerve injections in hope to relieve my headaches. I’ve not followed up with him yet since my MRI.

Other symptoms i have:

Thumping and whooshing in my left ear. Often when i lay down on that side. I can feel and hear my heart beating.

Tinnitus which can get quite extreme and often muffles to very brief hearing loss, im talking a few seconds. I can only describe it as my hearing just fading out. Silent, then it fades back in. Very loud noises cause this such as police sirens etc.

When i swallow i get a weird sensation in my throat. The only happens if my head is turned or tilted in a certain way. Its not painful but i can sometimes feel clicking or catching in my throat.

I have noticed on a few occasions i will get a tingly electric sensation in my left cheek. Like pinpricks lightly stabbing my skin. It goes away as quick as it comes. Lasts no longer than 5 mins.

So after finding out about ES i managed to obtain an old panoramic dental xray from 2015.

I would love to know what you all think of the image. I can see both styloids. They ‘look’ slightly elongated, angled and pretty sharp. Compared to other images of ES mine doesn’t seem extreme. But maybe its enough to cause some of the issues ive been having for such a long time?

Im going to send this to the neuros secretary with a write up of these symptoms. Im hoping he can order a CT as the next step.

Sorry for some reason i cant upload an image… please bare with

[Jules]

Hi & welcome to the site!
So frustrating for you that you’ve had symptoms for ages with no answers or help! Sadly that’s not unusual here
Firstly the site blocks people from uploading images until they’ve posted a bit- I’ve altered that for you so you should be able to upload your x-ray image now. (It’s not the best way to see the styloids, & we’re not doctors but can hopefully see if there’s anything worth pursuing!)
Your symptoms do sound like common ES ones- the weird sensation in your throat & clicking etc is mentioned alot, also pain and stiffness trying to turn your head. It does sound like you have nerve irritation and pain; the facial & trigeminal nerves are often affected which can give pain, electric shocks, tingling or numbness all around the ear, jaw, teeth, cheek, up the side of the head etc. The occipital nerve can also cause pain, and the accessory nerve to the shoulder often causes arm/ shoulder pain or weakness. I would’ve suggested getting checked for TOS but good that’s been ruled out. It could be that when you’re laying you do trap that nerve maybe with your neck position, or it could be the styloids. But it might be an idea to see if your Neuro (or your GP if you’ve got to wait a while for your Neuro appt.) would prescribe you nerve pain medication to try- like Amitriptyline, Gabapentin or Carbamazepine.
Tinnitus is very common, as also are hearing problems- either losing hearing or over sensitive hearing. The whooshing sounds like pulsatile tinnitus, which can be a symptom of a compressed jugular vein.
Ideally a CT would be best to check the styloids, & one with contrast would hopefully show any jugular compression. (Although if you only get the pulsatile tinnitus when you’re laying on that side, a CT with contrast done in that position would show it best, but not sure if you can get that done on the NHS! Good if your neuro will order one for you…
Hopefully if you can get a diagnosis then you can get a referral to maybe Mr Hughes in London or Mr Axon at Addenbrooks, although NHS waiting times are really bad atm!
Best wishes, Jules

[Toaster_coffee]

Thank you for the in-depth reply. I’m very grateful!! I’ve updated my post with a photo

I have head and cervical MRI but understand these don’t show styloids.

What are your thoughts on trying the occipital nerve injections? Can this relieve ES symptoms at all? I’m a little apprehensive for now as not sure it would work and don’t want to start doing these things unnecessarily…

Can styloid compress the jugular vein? I do have some MRI imaging which looks like narrowing on the left side but this wasn’t mentioned on the report

I’ve yet to follow up with neuro since my MRI so hoping we can discuss when I see him.

[Jules]

You can see the styloids on both sides of your jaw; they’re not that long, but as you say they are pretty angled & pointy at the end, like little needles, which can cause symptoms. It’s not always the length but the angle too… Obviously the scan only shows the bottom part of the styloids; sometimes they can be much thicker at the skull base which can also cause compression.
The styloids can compress the jugular veins, yes; the Internal Jugular Vein exits the base of the skull from the jugular foramen, which is close to where the styloids are, so if they’re wide or angled they can put pressure on the IJVs. The IJVs can also get squashed between the styloids and the C1 vertebra processes, if those processes are long. We can’t see that from your image, but you might be able to get an idea if they’re long from a cervical MRI…
I don’t know about the occipital nerve blocks; you could have a look through the past discussions using the search function about whether others have had that done, or maybe someone will comment.
If you get pain in the area of this nerve then maybe it could be worth a try:

I did use to get pain with this nerve, but I think my pain was more because of muscle tension in this area compressing the nerve. I had a prolapsed disc C5-C6 which was causing pain in the area and my muscles were locked tight, I had physio & the exercises I was given really helped…So not sure if it might be something similar for you?

[Toaster_coffee]

With this type of X-ray, is it typical to actually see the styloids? Or are they only usually visible if they are elongated?

Is there anywhere that shows a ‘normal’ panoramic dental X-ray? I’ve dug around online and can only seem to find ES images

Sorry for all then questions, I’m sure I’ll have many more!

[Isaiah_40_31]

@Toaster_coffee - with the type of x-ray you posted, the styloids are typically not visible if they are normal length. So, yes, yours are likely a bit elongated. It’s also possible that they are longer now than they were in 2015 since they often continue to grow once the elongation process starts. As @Jules noted, an updated CT scan with or without contrast could be very helpful in getting you a diagnosis. Contrast does allow the soft tissues to be seen & w/o only the bones/calcified areas are visible.

[Toaster_coffee]

Thank you so much. I didn’t know they kept growing! Yikes.

I’ve sent the X-ray over to my neurologist so I should hear back soon

[Jules]

They don’t always keep growing; some people naturally have long styloids, but others if they’ve had neck trauma or a tonsillectomy get inflammation in the area which can cause them to keep growing…I agree with @Isaiah_40_31 that being able to see them on a panoramic x-ray means it’s more than likely that they’re elongated.

You can see the styloids clearer on this image, & they’re a bit thicker than yours, but not as angled or as long…

In this one they’re barely visible…

[Toaster_coffee]

Thank you. I’ve also got another X-ray from 2011! Slightly more to seen in this one

[Isaiah_40_31]

Good sleuthing! It doesn’t look like they’re much different in length in the 2015 x-ray, but that means they’ve been a bit long for awhile.

[Jules]

Maybe a little longer than in 2011, not massively though? The angle & pointy end are more visible…

[Mcwelly]

Good morning all, not posted for a while but wanted to add that I had a GON block which sadly, has had no benefit whatsoever. My throat symptoms are back etc etc. however, unofficially I’ve been told my neck MRI shows a significant problem at C1-2. Remember the mri and ct I had done privately in November didn’t mention C1-2 nor the styloids. I’m losing faith in the reading of scans.

Who can you turn to interpret these scans or get them looked at again?

Good luck with the nhs waits. At least I’m back in the system and the pain consultant is very good, it’s a shame the nerve block didn’t work for me but hey, worth a try!!

[Jules]

I’m so sorry that the nerve block hasn’t helped at all, that’s rough…some members have used online radiologists to get scans properly checked, there’s also Kjetil Larsen, who I think is a radiologist & has helped with diagnosis for lots of people, I don’t know how much it would cost, but he does spot things others miss:
Home - MSK Neurology
I hope that your pain consultant can come up with something else for you

[Isaiah_40_31]

I’m also sorry for the struggle you’ve had getting pain controlled & getting your scans read accurately. At this point, the referral @Jules gave you for Kjetil Larsen is probably the best one for getting a more thorough look at your scans. If you contact him, please let us know how he does for you.

[PatientD]

Hello, I am sorry about your difficulties. You are right to be concerned about imaging reports. Mine have often missed vital facts too. One exception to that for me was Mr Timothy at Nuffield Leeds who first diagnosed my problems with JV compression & did my C1/C2 fusion. If you have C1/C2 issues he may help. But sadly he is private only now so not nHS. I did read about a consultant at Queens Sq on instability. If can find his name & if NHS will send on. May be worth seeing instability physio in meantime in London or Leeds? Take care. D