Introduction and CT Reading Question

Hello! I joined yesterday, and I have been reading so much my brain is tired, and I am hoping that someone might be able to offer some help looking at the CT angio I had today. I think that I can tell what I am seeing, but I could also be looking at a stylus instead of a styloid :slight_smile:.

To introduce myself, I am Jennifer, and I live in Tempe, AZ. I am a teacher at Arizona State. I have a 20-year-old daughter who will return to college in a few weeks, and then it will be me and the cat. My symptoms started suddenly at about 9p on 6/20. I remember pretty much precisely. It started with pain near my right external carotid/ jugular about halfway up my neck. I had a big job interview the next day (all day), so I pushed through the pain. The pain continued to get worse over time. My entire right neck was in pain, with my carotid or jugular visibly throbbing. A headache wrapped up behind my head, over the top, and pierced through my right eye. I ended up in an ER on 6/25, and they did a CT angiogram there. They had no findings other than a (known) thyroid nodule and a hypoplastic left ACA at the A1 segment. They gave me muscle relaxers and said I pulled something.

Later that week, I was still in pain, so I contacted my migraine specialist (neurologist). She got me in on 7/3. She didn’t know what was wrong and ordered another CT angiogram (more specific to the neck) and physical therapy. PT wouldn’t take me without knowing what was wrong. While I waited for the subsequent CT, I started poking around and realized that touching my tonsil recreated the pain. I got into an ENT who immediately said he suspected Eagle’s syndrome, but he doesn’t treat it. He gave me a note to give the CT people.

So that’s where I am at. I had the CT today and asked for the CD. I have been looking through images for about 4 hours. I downloaded the free trial of RadiAnt, but I am still unsure what I am looking at. I attached a few images for some feedback if you can. If I need different angles or views, let me know. I also uploaded a quick video of the 3D render

I have a referral to the “main” neurology practice and an appointment there on 8/11. I don’t mind waiting if I have to, but I suspect that if it is Eagle’s, I need to look elsewhere for treatment.

Thanks for reading!


Hi @Sonoran_Sunset,

I would like to take a closer look at your CTA. Do you mind uploading it to DicomLibrary That site will anonymize your CTA and allow me and the other members to look at the scan in greater detail. Then post the anonymized link here.

This is what I could see in the video and the pictures posted. This is just my opinion.

Styloids have some calcification and only the right styloid slightly touches the IJV, which is common. So probably not the typical case of Eagle’s with a lot of calcification along the styloid ligament.

There is a large reduction of clarity on the left IJV and carotid artery at C2. This may be because there is a lot of scatter coming from your molars that have metallic fillings or implants. If not it could be a possible site of impingement.

The other thing I saw is the right greater horn of your hyoid bone has trapped the carotid artery on the right side. We saw this recently with another member that posted on the forum. Opinions on my scans and images please - #5 by KoolDude


Hi, & welcome to the site! I’m not knowledgeable enough with anatomy to comment on your CTs, but just wonder if you do suspect ES then whether it’s worth getting a referral in to one of the doctors on our list in the mean time if you don’t feel the current medical practice would be able to help? There’s 3 with ES experience in AZ…


I’m in @Jules camp, @Sonoran_Sunset, but I did notice the left IJV & ICA look very constricted at the point, @GCD noted. The greater horns of your hyoid also look a bit close to your spine but that could just be imaging angle, however, it could also explain what GCD noted as the right greater hyoid horn entrapping your ICA on that side.
Your styloids look thick to me even if they aren’t super long, & the right side seems more angled inward than on the left which could also account for worse symptoms on that side.

The pain you described could definitely be caused by impingement of either your ICA or IJV or both. Sometimes these problems occur only when the head is in a certain position. Have you noticed your symptoms getting worse w/ a particular head position?

Thank you, @GCD. That is very helpful. When I was looking at that second scan, I thought the point you marked as the greater horn of the hyoid was the start of the styloid. I haven’t had any symptoms on my left side. I was diagnosed with a bulging disc at T1 years ago and always had some pain there. I also failed to mention that I have a dural veinous malformation of some kind near my right ear. They thought it was a dural AVM and went in to seal it but found it was just veins. They said it wasn’t anything to be concerned about (it causes me to hear my heartbeat in my right ear).

Here is the full CT angio

I don’t know if you also need the download link.

Thank you again and I am going to read the other thread you linked.


Thank you @Jules. I wasn’t sure if I needed a diagnosis before I called one of those providers. I am lucky to have insurance that doesn’t require a referral, but I know some of those doctors may require one. I will start checking into it.


@Isaiah_40_31, I thought that the right styloid also looked particularly thick and somewhat curved. Neither measured over 3cm, as far as I could tell. I am not sure of a specific position that causes the pain. Turning my head to the right or pulling my right shoulder up seems to worsen it (but not always consistently). One thing that makes it better is looking straight to the sky with my mouth closed, opening my mouth and dropping my jaw, and then closing my mouth. I thought I was just stretching my sternocleidomastoid. But if this issue is more at my hyoid, that makes more sense. I have also learned that my morning headache goes away if I make sure I only sleep on my left side (not the right or on my back). Clearly, I was compressing something even further and causing a morning headache.

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One thing that stands out in my opinion after having a very quick look is that your right common carotid artery seems to have a loop which might or might not be symptomatic.

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@Sonoran_Sunset - Styloids don’t need to be long to be problematic & to produce ES symptoms. Other physical features such as thickness, angle/curve of growth, how twisted or pointed they are can also create symptoms. Unfortunately, many doctors don’t recognize the symptoms as ES unless they see elongated styloids. Many doctors won’t diagnose calcified stylohyoid ligaments (where the styloids are normal length) as ES either when they definitely can cause ES symptoms, too.

Interesting observation about which position helps to alleviate your headache. I’m sorry I can’t give any insight into that, but I’m glad you’ve found something that’s helpful.

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Sure no problem. I was able to finally download the CTA. DicomLibrary was very slow today and my downloads kept expiring.

The second axial image where I pointed out the greater horn of the hyoid is actually the superior cornu of the thyroid cartilage trapping the carotid artery (CA). Which may explain the pain getting worse when turning to the right.

I made a short video showing you the location. I use my mouse to outline the thyroid cartilage. Also look at the opposite side to see how the CA should be on the outer portion of the thyroid cartilage.

I’m not saying this is you, but I did find a case study of patient suffering from this issue. However the full article must be purchased. A lot of times college students have access to these medical journals through the university, so maybe your daughter can help you.

Also if you can get the CTA from the hospital it would be helpful to compare. It may show the CA in a different position popping off the thyroid cartilage. That’s if the scan goes that far down.

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That is incredibly helpful. I drove the 30 minutes to get a copy of the hospital CTA and am waiting for them to give it to me.

My symptoms are much worse today (hands going numb unless I turn my head the right way, difficulty swallowing). I may end up at the ER again. I am deciding which ER to go to if it is needed. I can go to a hospital where all three of the surgeons on the list have privileges, but it isn’t a great ER. If this isn’t Eagles, maybe going to the hospital where my endocrinologist has privileges is better. She has already suggested taking out my thyroid because of a nodule. I doubt this is in her area, though.

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Omg, please go to the ER if the problems persist or get worse.

It’s probably a roll of the, dice if you went to the hospital with the recommended surgeons, if one of them would help you since you are not currently under their care. Probably worth a shot though if you have to go.

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I’d speculate you might have problems with the neck stability, or a herniated disc, or some blood flow problems. These might explain numbness in arms. Honestly, Eagle’s syndrome may cause pain in shoulders, due to the effect on accessory nerve, but numbness in the hands/arms might more likely be something else, neurologically related. Especially hands. It suggests that brachial plexus might be affected, or spinal cord, or nerve rootlets/roots around C5-T1


@GCD - FYI - your video for @Sonoran_Sunset showed up blank on my computer. I’m not sure if others are having an issue viewing it.

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@Sonoran_Sunset - I’d head to the ER that offers better care. If part/all of your problem is thyroid cartilage, starting w/ your endocrinologist might be best.

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@GCD - I loaded my MRV onto Dicom Library last week & it took 10-12 hrs. It was ridiculously slow.

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If things get worse, I will go to the closer one that I prefer. I think I may have just been having an anxiety attack making it worse.

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Yes. That disc at T1 is likely. I do get this occasionally when my body’s overall inflammation levels are high. The difficulty swallowing is not something I ever have.

I am printing out images and saving everything. I really appreciate it. I did get the hospital CT and I even tried to download an use 3D slicer, but I couldn’t figure it out. Here are the links in case you have time to look:

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Try Radiant Viewer (windows) or OsiriX (mac). Much more friendlier software than Slicer 3D

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