Met with Dr. Vitor Mendes Pereira on June 19, 2026 - Need help with pain management

[alfalfagrains]

Hi all,

Posting an update because I am feeling pretty lost right now. I am currently waiting for more diagnostic imaging and trying different pain management strategies in the meantime.

Documents from my appointment with Dr. Khan at the Ottawa TMJ and Sleep Apnea Clinic on Jan 20, 2026
TMJ Dentist Report.pdf (150.3 KB)
Panorex.pdf (54.9 KB)

From there, I got a referral from my doctor to get a CT (self advocated, of course ). I can’t figure out how to get a 3D reconstruction of my CT, but here is the report.
CT report - Feb 23, 2026.pdf (28.2 KB)

Since I lasted posted, I’ve also taper off of my sertraline prescription on April 11th, taking 1/2 doses from April 11-17, then every other day. This was because I met with a psychiatrist who suggested the sertraline could be having extrapyramidal symptoms that could cause motor issues. However, after being off it for a few months, I have not noticed any meaningful difference.

Post-CT (April 17th-June 2nd, 2026)
My appointment with the internal doctor was booked for April 19th, where I needed to discuss the results of my CT scan. He told me he had never heard of Eagle syndrome before, and asked me if I knew of any specialists. I did not know that I was supposed to bring that to the meeting, so I was referred to Ottawa’s ENT Urgent Care Clinic on April 19. I found out on May 14 that my referral was rejected on May 1 because there are no specialists for this syndrome in Ottawa. My internal doctor did not inform me of this development. I called ENT’s office and they told me that many ENTs avoid Eagle syndrome, since the risk of intervening is higher than the risk of doing nothing.

I have still not been formally diagnosed or physically examined by an ENT, but based on this forum I got my physician to refer me to Dr. Vitor Mendes Pereira for an in-person consult in Toronto.

Appointment with Dr. Pereira - June 19, 2026
I met with Dr. Pereira in person on June 19. He reviewed my symptoms and my chart. I asked him I can be diagnosed with classical or vascular Eagle Syndrome, but because my previous CT scan only covered my neck, he said he was not able to fully diagnose the issue or make firm conclusions yet. He recommended a CT venogram of my head and neck so the vascular structures and surrounding anatomy can be assessed more clearly. Depending on the CT venogram results, an angiogram may be considered afterward. These results will also help determine whether surgery is necessary, and if so, what the approach would be.

He observed that my posture, head position, neck angle, and tongue posture may be contributing to my symptoms. He explained that improving these could potentially help, because changing the angle of my head and neck might reduce irritation or compression. While I wait for the CT venogram, he recommended that I work on posture, power Pilates, core strength, and back strength.

He told me that does not perform the surgery himself because he is too busy these days, but he said he could refer me to ENTs and surgeons who may be able to do it if surgery becomes necessary. Follow-up and next steps will depend on the CT venogram results.

My pain remains severe around and under my jaw, as well as around my throat/hyoid area. I am still experiencing clicking, cracking, snapping, and popping sensations. I have always been high-functioning (still showing up to work, going to activities/doing my hobbies, and spending time with friends) but the pain is extremely frustrating and honestly very depressing on a day-to-day basis.

The most painful and tight areas are my jaw muscles, suprahyoid muscles, and SCM. Around the jaw and suprahyoid muscles, it feels like the muscles do not sit properly among each other. Sometimes it feels like something sharp is poking or interrupting the normal gliding of the surrounding muscles (probably my freaking styloid process!!). When I tuck my chin and tilt my head from left to right, I hear light snapping and popping, almost like the muscles are trying to realign themselves. I do not know how to make that go away.

The posture piece has really gotten into my head. I am now constantly thinking about whether I am sitting wrong, and I am confused about the best angle for my head to rest at. I know I have mild forward head posture, but it is not the worst I have seen. I guess the elongated styloid process could make even mild forward head posture more symptomatic. What confuses me, though, is that every person with Eagle syndrome has their styloid process growing at a different angle. So how am I supposed to know what head or neck angle is best for me?

At this point, I am getting pretty fed up with the pain. It makes me sad that this has become my default state of being. I am hoping the CT venogram will clarify what is actually causing the pain and what treatment options are appropriate.

I have been going to the gym to improve my posture somewhat regularly for the past six months, but I am going to try to focus more intentionally on strengthening my core and back, and opening up my chest. I am also going to start gabapentin soon for nerve pain management because the pain is becoming unbearable.

Sorry for the long post!!

[Jules]

I’m sorry that the Canadian system is so difficult to navigate, and is taking so long, it’s ridiculous but not much better in the UK or Australia, and alot of European countries too…
For your posture/ head position, the forward head posture can make symptoms worse, so it sounds like you’re doing the right things with correcting this. Lots of people have lost their natural curve, called military neck, & there’s info about correcting this in this discussion:
List of my favourite resources on YouTube to learn anatomy - General - Living with Eagle
Sometimes this can help with the pain, so it’s worth trying. Other members have worked out from their symptoms different head angles or jaw positions which can help the pain a bit, which probably answers your question about styloids growing at different angles & how to know what’s best for you- it’s trial and error, or there might not be any positions which helps you. I never found any difference, apart from avoiding the obvious like having my head turned for long and not laying on the more painful side. If tucking your chin down & tilting your head cause more symptoms, then best avoided as much as possible…
Hopefully the gabapentin will help, if it doesn’t then there are nerve pain meds which work for some. Lidocaine either as a gel or as patches can help if you can get this in Canada? Heat and / or ice if you haven’t tried those, but you probably have already… And acupuncture or dry needling has helped some members. Did you ever try the botox which was suggested by Dr Khan, did that help at all?

@alfalfagrains

I am hoping the CT venogram will clarify what is actually causing the pain and what treatment options are appropriate.

It’s helpful to have this to see if there’s any vascular compression, but to be honest, it’s not likely to show anything that you don’t already know, your CT report stated that you have elongated styloid processes, and it’s likely from your symptoms that these are aggravating the cranial nerves, which don’t show on a CT. It’s helpful to rule vascular compression out though. And realistically, the only ‘cure’ for ES is to have surgery, so unfortunately it sounds like it’s already necessary, it’s clearly affecting your quality of life! Any skull base surgeon should be competent enough to do the surgery, or a head and neck cancer/ vascular surgeon, but I guess healthcare systems are so stretched that ES isn’t a priority, not many doctors realise how debilitating it is…
I don’t know if there are any other doctors mentioned in Canada on Malvin Young’s site, he’s Canadian so might know of more doctors than we’ve been told about:
Eagle Syndrome – Diagnosis, Treatment & Patient Community
Is travelling to the US an option at all? Quite a few of our Canadian members have had to resort to this

[Isaiah_40_31]

@Jules has give you a very thorough reply & lots of good pointers. If you’re able to travel to the US for surgery, Dr. Cognetti in Philadelphia, PA (David M Cognetti MD | Jefferson Health), has done surgery for a number of our CA members. As far as we know, what he charges for cash paying patients is lower than most other doctors on our Doctors List. An initial consult with him is free (at last count) & can be done via telehealth. The price charged for surgery also includes a post op appointment whether in person or via telehealth.

With all the clicking you have going on, I’m wondering if your hyoid bone is also involved in causing some of your symptoms. The greater horns of the hyoid can also elongate, grow at odd angles or be very thick thus causing Hyoid Bone Syndrome which has many of the same symptoms as ES. The hyoid can also be involved with Clicking Larynx Syndrome. Those are two things you can research both on our forum using the magnifying glass icon in the upper right of this page & by Googling them. BTW, splint therapy has helped a lot w/ my TMJ issues & pain, but for some people having to sleep w/a foreign object in their mouths makes bruxism worse so it can be trial & error. My splint fits on my bottom teeth. The first one I had was on the top & it did make my symptoms worse.

Trying Gabapentin to help reduce your pain is a good plan. Keep in mind that it can take a month for nerve pain meds to build up enough to be helpful. Sometimes the dose also needs some tweaking either up or down depending on the strength of the starting dose. If it doesn’t help, there are a number of other nerve pain meds that you can try. Additionally, some of our members have benefitted from a muscle relaxant & some have take both a nerve pain med & muscle relaxant. Bear in mind that both have side effects so taking them at night can help reduce awareness of those.

I’ve annotated your pano x-ray. Your right styloid has an interesting bend in it & your left one is quite long (both are longer than normal). It’s not surprising they’re causing you trouble.

I’m glad you’re doing your best to remain active & involved with your friends, work, & the gym. It is tough to be fully mentally engaged when fighting severe pain, but the distractions those provide are beneficial.