Thank you again for the warm welcome and for all the helpful information already shared here. I hope it’s okay if I attach a few anonymized screenshots from my exam, just to give some context to my questions.
I have confirmed mixed TOS arterial and neurogenic with dynamic vascular compression.
My CTA was done for TOS not specifically for Eagle syndrome.
The report shows bilateral costoclavicular compression during provocation, including complete left subclavian artery occlusion over 1 cm and short right subclavian subocclusion.
It also mentions subclavian vein narrowing during provocation, estimated at about 60% on the left and less than 50% on the right.
My GP mentioned Eagle syndrome as something to consider because some symptoms don’t seem clearly explained by TOS: nocturnal dizziness/vertigo, choking or breathing discomfort at night, deep ear,neck,occipital pressure, pressure behind the eyes, extreme fatigue, and vagal/autonomic-type symptoms.
What caught my attention is not that my styloids look very long.
On 3D they do not look dramatically elongated to me.
It is more the apparent proximity to the upper cervical vessels on MPR/2D views with my amateur measurements around 1.6–2.0 mm in some areas, plus a possibly narrow styloid-C1 space.
I know screenshots and self-measurements are not diagnostic. I’m not asking for a diagnosis, just trying to understand whether this kind of close styloid tovessel or styloid-C1 anatomy has been relevant for others with vascular Eagle/IJV compression, especially with positional or nocturnal symptoms.
Did anyone here have symptoms despite styloids that were not extremely long? Did you need venous phase or dynamic imaging to clarify things?
Welcome @Emoprince! I have to say, your styloids look very thick and seem to be angled inward. You have a lot of the symptoms that many of us have shared here.
My symptomatic side is shorter, just at 3mm according to my radiology report but its angle and thickness are what is causing my symptoms.
@Emoprince - Welcome to our forum! I totally agree w/ what @lsheep said & noted the same things about the angle of your styloids & how thick they appear. They could definitely be contributing to the non-TOS symptoms you have.
It looks like your imaging only looked at your carotid arteries as your internal jugular veins aren’t visible. Did your have a CTA or a CT w/ contrast in general? Do you have any pictures that show your IJVs?
Your right styloid looks to be quite far from the transverse process on the right side, but the thickness of the styloid at it’s attachment on the skull base is plenty thick enough to cause IJV compression above C1, in my opinion (not a doctor). I think the same is true for your left styloid.
We have had members who had IJV compression caused only by their styloids & others who had it mostly being caused by the TPs of C1, though in most cases, the styloids were also involved to some degree. Because your IJVs don’t show up in your imaging, it’s hard to say for sure how they’re being impacted. Your internal carotid appears to be very close to C1 on the left. Your head position during sleep could cause that styloid to be contacting the ICA which would cause dizziness & vertigo. Since the vagus nerve is inside the carotid sheath w/ the ICA & IJV, it’s possible it’s also getting poked & irritated which could contribute to your choking & breathing discomfort.
Pressure behind your eyes can either be from the facial nerve or from IJV compression, but extreme fatigue alongside vagal/autonomic symptoms point more to IJV compression than that of the carotids.
I agree that your styloids look longer than ‘average’, and also thick at the top- I’m sorry I’m not great with tech so can’t label them, but on the very first image you’ve posted they look much wider than we normally see from these axial images.
Also your hyoid bone processes to long quite long, it might be worth reading up on hyoid bone syndrome too (there’s some research papers posted on here & we’ve had some discussions about it), choking can be caused by this, & if yours only happens at night maybe it’s a positional thing? Just a thought & maybe another rabbit hole for you to go down!
Also your neck looks pretty straight in the images, this means it’s lost it’s natural lordotic curve, called military neck, & this can make ES & often IJV compression worse.
There’s some info & exercises which can help restore your neck’s curve in here: List of my favourite resources on YouTube to learn anatomy - General - Living with Eagle
I do think it’s worth you looking into ES as well as TOS based on those images though, I’m sorry!
In this image, which I didn’t label, you can see good space between your cervical spine & your ICA but in the one above the cervical spine looks to be in contact w/ your ICA. It may just be the angle of the picture but in reality if this is happening, it could cause some vascular symptoms like dizziness & a sense of not getting enough oxygen.
In this final picture you can see your ICA looks to be in contact w/ the TP of C3 so a similar situation as on the left whereas in the picture above this one there is good space.. Again, it may have to do w/ head position but it doesn’t look normal to me.
Thank you so much for the welcome! I’m really glad I found this community and I genuinely appreciate the time everyone has taken to respond to me.
I’m sorry to hear you’re symptomatic too that can’t be easy to live with day to day.
Your point about the angle and thickness is really interesting to me because I had been mostly focused on the length. It’s a new angle I hadn’t considered and something I’ll definitely bring up at my next appointment!
Thank you so much for this, it’s incredibly helpful!
To answer your question my imaging was an angio MRA focused on the arteries specifically because it was ordered to investigate my arterial TOS. So that explains why the jugular veins aren’t visible. I don’t have any images that specifically show the IJVs which is something I’ll ask about going forward.
The connection you’re making between the IJV compression and the fatigue, the pressure behind the eyes and the autonomic symptoms is really eye opening for me.
Those are exactly the symptoms I struggle to explain to my doctors and having a potential mechanism behind them is something I can actually bring to my next consultation.
The sleep position and carotid contact also makes a lot of sense for the nighttime choking. I hadn’t connected those two things before.
Thank you again for taking the time to go through all of this!
Thank you and please don’t worry about the labeling your observations are just as valuable!
The hyoid syndrome is something I hadn’t explored yet and given that I have pain right at that bone on palpation plus a constant throat sensation, it actually feels very relevant.
Another rabbit hole to add to the collection! My browser history is really something at this point!
I’ll definitely bring it up with my ENT.
On the military neck, I can see it on the images too. I’ll mention it to my physio, though I’ve been advised to be careful with cervical exercises for now given what’s going on with my vessels. But useful to have it on the radar.
And yes the overlap between ES and TOS is exactly what I’m trying to get my medical team to look at together. Thank you for the resource link too, I’ll check it out!
You came back even after being tired that means a lot!
What you flagged fits really well with the dizziness and the sense of not getting enough oxygen that I deal with regularly so having a potential structural explanation for those is genuinely helpful.
I’ll make sure these observations make it to my vascular surgeon and ENT. Thank you again!
The images come from the DICOM files provided by my radiologist which I open in a program called OsiriX Lite. It lets you generate those 3D surface renderings yourself which has been incredibly useful for visualizing everything.
I have to be honest though I’m not entirely sure what the exact process behind the 3D rendering is it just works! Have you ever tried OsiriX before?
Thank you so much for sharing those tutorials! I actually tried it with OsiriX and it’s been really eye opening!
And honestly what I’m seeing on the right side is pretty striking, the structures look incredibly close to the vessels there. I’ll definitely be bringing these images to my next appointments!
@Emoprince - The vessels most often irritated by the greater horns of the hyoid are the common carotid artery, the internal & external carotids & sometimes the carotid sinus (at the carotid bifurcation) can get poked which can affect heart rhythm. That could also explain your night time symptoms.
I have documented hyoid pain on palpation that radiates to the shoulders and neck and looking at my CT scan, the hyoid doesn’t appear straight it seems tilted, with the left side sitting higher than the right.
The carotid sinus connection is particularly relevant for me! I have ECG recordings showing ectopic beats that correlate precisely with my symptomatic episodes.
I went to the ER last night with a full symptom cluster including pre syncopal episodes, right sided paresthesias, ear fullness… Everything came back normal at rest, which makes sense given the dynamic positional nature of this type of compression.
I’m glad that your testing came back normal then, certainly lots to discuss with your doctors… Some doctors are still skeptical, even when the scans show blood vessel compression, you could always take a research paper or two with you to show them, although that doesn’t always work! Are they very approachable?
I can see that your hyoid bone is a bit crooked in the picture you posted last. That can certainly impact what the greater horns contact especially if they’re elongated. I also believe the hyoid’s position can be fixed by surgery though it would take someone who’s very experienced w/ Hyoid Bone surgeries.
