Help me make a decision please!

Hi there,

I have been sick since Feb/21 and got diagnosed in Aug/23. My symptoms are head pressure, facial pain/pressure, and brain fog.

I have left IJV compression between styloid and C1 as well as narrowing of both transverse sinuses. I have two surgeons offering surgery - doctor A (Cognetti) wants to preform just a styloidectomy and doctor B (Cosantino) wants to do a C1 shave/styloidectomy. I’m from Canada and would be paying completely out of pocket so obviously Cognetti is much more accessible (he can do the surgery April 5, and can also will likely be much cheaper than Cosantino who has not been able to provide a quote/date). Once I am done with eagles surgery, my doctor in Toronto will stent my transverse sinuses.

My preference is Cosantino because of his knowledge of vascular eagles/outflow obstruction, but as mentioned it will be much more expensive and probably a longer wait.

I am looking for some guidance and advice… am I severely decreasing my chances of symptom relief by going with Cognetti/only a styloid removal?

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This is a great question. The answer depends on what the dominant cause of your IJV compression is i.e. is it coming more from the styloid or more from the transverse process of C1? Sometimes it’s impossible to tell until the surgeon can visually see the structures during surgery. Other times it’s fairly obvious on a CT scan. If the styloid is the major player in the compression then cutting the styloid back beyond it’s point of contact w/ the IJV will often allow the IJV to decompress on its own. However, if C1 is more to blame, cutting the styloid back will reduce the pressure on the IJV but often not enough for it to reopen w/o help i.e. C1 shave or moving the IJV away from C1. There have also been a couple of cases of IJV compression caused by the accessory nerve, in which case space needs to be created between the nerve & the IJV so the IJV can expand.

My gut says to keep after Dr. Costantino’s ofc until you get a cost estimate & if you can afford to see him, a surgery date. If his price is too high, seeing Dr. Cognetti is certainly worthwhile as a styloidectomy could allow IJV decompression.

I’m sorry I couldn’t provide a solid answer, but I’ve given you some food for thought.

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I agree with @Isaiah_40_31 that as it looks as if the C1 is involved with the compression then it might be better to consider Dr C…it’s a difficult decision though, I hope that you’re able to afford the surgery with him :hugs:

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