Hyoid, Reconstructed CT, Digastric

Wondering if anyone can comment on any of this. I just looked at my appt notes.

My surgeon at the post-op appt said the small cut he made in the belly of the posterior digastric muscle should help with swallowing (I asked him to do it as I knew it reduces tension on nerves and muscles). I had been having pain in the area of the digastric; it’s totally gone now.

Then I asked him about throat spasming. It was an issue before my surgery and right after it was bad. Now it seems to have quelled. I asked if it could be related to the positioning of the hyoid. He said that a scan would’ve shown improper positioning. He also said that it’s possible that when the ligament was attached, it was pulling it in a funny position.

I had read that measuring the cornu / horns of the hyoid in relation to the carotid, could tell us something. I highly doubt that any radiologist does this. Plus, I didn’t get a soft tissue CT. I think if I still have unresolved spasming or styloid issues on the other side, I’ll see if I can get a soft tissue CT with attention to styloid and hyoid.

Has anyone heard of this scan?:

CT Scan of the Neck with 3D Reconstruction: This specialized CT scan provides detailed images of the styloid process, its length, angulation, and relationship to adjacent anatomical structures, such as blood vessels and nerves. The 3D reconstruction aspect is particularly useful as it allows for a more comprehensive view of the styloid process and its potential impingement or compression on surrounding tissues, which is crucial in the diagnosis of Eagle’s Syndrome.

Finally, some of what the Dr was saying about the pain I was having near my parotid was that it activated the sympathetic chain nearby.

The sympathetic chain runs alongside the vertebral column, and it’s not directly associated with the carotid artery. However, sympathetic nerves do innervate blood vessels, including those in the neck region, including the carotid arteries, regulating their diameter and blood flow. These nerves travel in close proximity to the carotid arteries.


This is a good description of what a dynamic CT with contrast can show if the radiologist reading the scan has the instructions to note the things you’ve mentioned. Without specific notation, most radiologists will note styloid length or just that they’re elongated. Some may note stylohyoid ligament calcification. If there is obvious ICA or IJV compression that may be noted, but isn’t always.

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As everyone knows, I’m a big advocate of having the catheter venogram done to get the entire picture. If you didn’t get it prior to surgery, see if you can get it now. Not every radiologist is competent enough and there’s only a few that these surgeons trust to do it right. Patsalides is doing mine next week!! I would advocate for yourself!! Best of luck!!!


For some of us like myself, the procedure isn’t an option, sadly. It’s dangerous for me to have contrast, no doc will do it based on prior anaphylactic reaction. Puts a crimp in many folks ability to see things. Just have to rely on symptoms and view of styloid bone.

Keep us posted on what yours shows. Does it measure the pressure in the blood vessels? Or just take pics?


@Thans - It’s an ultrasound (no contrast required) that measures the blood flow velocities. Venograms look for “kinks in the hose”. That’s another option if done by a vascular doctor who knows the specific requirements/protocol of the surgeon for whom the test is being done.

Is he going to do pressure gradient readings too? Across the whole vein down to the final confluence?

Hi, I’m confused. Isn’t this right?:

A catheter venogram or angiogram is typically performed using X-rays and contrast dye to visualize veins. It involves the insertion of a catheter into a vein, often in the leg, groin or arm area. Contrast dye is then injected through the catheter, and X-ray images are taken to visualize the veins and identify any abnormalities, blockages, or blood flow issues.

Ultrasound is more commonly used for non-invasive imaging of veins, such as in Doppler ultrasound studies. This technique doesn’t involve the insertion of a catheter and is useful for assessing blood flow, detecting clots, and evaluating the structure of veins from outside the body.


Yes, you are right. Catheter venogram/venography/angiogram/angiography is when the catheter is inserted through an incision into the vein or artery (usually through one of the “big” blood vessels in the groin, but can be done through the arm too, or in some exceptional cases directly through the neck). Then the catheter is navigated though the vascular system until it reaches the destination point and the iodine-based contrast fluid is injected, after which the sequence of x-rays (called fluoroscopy) is performed to record a motion picture of the flow.


Dynamic CT scan is a bit different thing.

There’s no contrast, that I’m aware of. Dr. Patsalides is very conservative. He was very stern with me regarding any upcoming surgeries and the potential outcomes. Many surgeons look to this procedure prior to doing surgery.

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I believe so! He told me the pressure gradients are more important in the brain than in the neck. I am looking at possible stenting in the brain I know based on what Hepworth had informed me. I’m following back up with Constantino beginning of February. My gut is telling me, I may need more serious surgeries done the road.


But then what are they going to do with that catheter?

Usually the catheter is used to deliver the contrast at some specific point and then the flow of the contrast is observed via fluoroscopy (“animated” x-ray pictures.)

I’ve heard of some very advanced methods where they can use a very tiny camera attached to the catheter and film everything via visual method, but I guess that’s not something used in the regular venograms? (One of the tools is https://www.venamed.ca/ but I think there have been many attempts to create “chip on tip” investigation tools.)


What is the order of importance of these tests?

My surgeon was leaning towards doing an ultrasound and dynamic CT venography as they were less invasive compared to the catheter venography.

I’m guessing that if the former two tests reveal strong evidence of jugular vein compression, that a catheter venography may not be necessary.

I don’t know how much I should insist that the catheter venography be done prior to surgery, especially if the other two tests provide unambiguous evidence of jugular vein compression.


I’d say even static CT scan with contrast/CTA most likely would be completely sufficient to tell whether the jugular veins are affected or not by the styloid processed and/or C1 lateral masses and/or something else (e.g. some muscular compression), it depends on the radiologist reading and interpreting the scan.

Doppler ultrasound scan might be helpful too, especially to evaluate the impact of neck/head movements, but that’s something, I suppose, only very diligent and trained ultrasound technicians can properly perform (I’ve heard Dr Hepworth trusts only a few places to perform this type of imaging.)

Dynamic CTV scan in this context is perhaps about taking a few CT scans with the head in multiple positions.

Is the catheter venography absolutely necessary before the surgery? It’s a good question. It might uncover additional places in the venous system (e.g. vena cava) where the compression may be present, or it might be just a useless additional (and huge, by the way) exposure to radiation and show nothing that wasn’t already shown by the CT angiogram/venogram. Also, catheter based procedures have additional significant risks of accidentally causing a stroke.

In my case, the single CTA scan with contrast had showed everything that was needed for the Eagle’s syndrome surgery, and catheter angiography was unnecessary but local doctors insisted on it, as our medical system didn’t want to accept anything that is related to compressed jugular veins.

Ultrasound is harmless in the vast majority of cases (there are some potential risks, but they are negligible, compared to even the regular CT scan), so you might want to start with that one, but without a CTA/CTV it will be hard to know the real “big picture”.


Thank you for the detailed answer.

In my case, the problem is that the static CTV does not in fact show clear evidence of jugular vein compression. But I do have very long styloids (4.8cm) and compatible symptoms.

It is my guess that the longer the styloid, the more likely it is that it will move at its inferior end, and so the more likely it is that the structures in the carotid sheath (jugular vein and nerves) are obstructed positionally. So in my case, hopefully more strong evidence is revealed with provocative manoeuvers done during ultrasound.

One doctor I spoke to was skeptical that my long styloids were the issue at all. In his opinion, it is only the angle of the styloid and the space between styloid and C1 that matters, and that the length really does not matter if it is not obviously compressing the jugular vein on a CT scan, even if the styloids are very long like in my case.

Somehow I am skeptical of that. Can long styloids be so easily dismissed?


The whole Eagle’s syndrome, IJV compression realm is a bit controversial and unreliable for a very simple reason… There are too many variables, variations, and the area is very dynamic (the neck has quite a significant range of motion.)

It’s not as easy and consistently observed as, let’s say, a broken bone, or bleeding, or appendicitis, or cancer that all we know in most cases lead to very serious problems if left untreated.

Eagle’s syndrome, elongated styloids… Sometimes they may cause arterial dissection possibly leading to stroke, but that’s also not always the case, so I suspect that’s why all these conditions are under-explored and there aren’t universal recommendations on the treatment like for heart attack or cancer.


Yes. I’m sure Dr. Patsilides isn’t doing a Doppler ultrasound (you can get that at any radiologist lab). He’s inserting a catheter and using contrast of some sort (online search says iodine).

More of my thoughts on scans: I’m a case in point of scans not showing much but the problematic bone on the non-contrast CT. Scans are unable to show movement. I had arterial issue, but MRA angiogram with gadolinium didn’t show the carotid impingement, it looked clean. My styloids were so fat and bent, it’s really all the surgeon needed to see. It’s such a tight space in there to begin with. All symptoms matched up with nerve impingement and then vascular at the end.

As much as I wanted proof of issue, I had it if I listened to my body. I wasn’t happy to hear it, but now know Dr Annino was right- I didn’t need to waste time with more testing.

Since my strangulation attacks started happening pretty recently, I’m going to assume that it wouldn’t have been impaired enough for the catheter to detect changes in my neck. Maybe slight pressure issue in my head. Not sure about that.

It’s such a nuanced condition, pretty hard to capture. Harder for folks either too unwell for invasive catheter, or too allergic to iodine contrast.

I had hardly slept in 24 years, from inflammation creating jerking every time I entered sleep state. I had become reactive to a great many things. In my case, it was about the timing. I’m still waiting to hear back from my October 12th Dr. Costantino appointment where he said he’d call in scans for me. My follow-up calls went unanswered. Time was of the essence for me, as was surgeon skill. Had I gone with Drs. Pashkover or that local oral surgeon, I highly doubt I’d be doing as well as I am. I KNOW that my digastric wouldn’t have been transected, inflamed lymph node removed, fascia cut strategically (something I recently learned) etc etc.


This study shows that a more vertical styloid is more likely to cause symptoms.

But what I found interesting was that:

the mean distance between styloid and C1 is smaller in healthy people, counter intuitively and unexpectedly.

But the sample size is small. Also I think we know from patients on this forum that symptom relief is achieved with surgery despite the styloids not being very vertical, if the styloid is very long.

Frustratingly, the study seems to have failed to document the length of the styloids of the patients.


Really interesting findings!
For the record, mine were vertical. Totally. Just with a few mm space between the spikes and the C1 in supine position (and military, straight neck back then.)


It’s absolutely delicate surgery. I learned it hard way, as I needed a revision after the first attempt by a local surgeon…