Hi everyone, I have bilateral Eagle with ossificated ligaments on both sides and IJV compression also on both sides; left side is completely closed with collaterals all around. I have terrible symptoms and need surgery soon. I have 2 offers: Dr. Heim suggests to only remove the ligaments without touching C1 and only 1 side at the time. Dr. Aghayev suggests to remove ligaments and C1 PT and do it on both sides in the same surgery, which is probably more invasive but also more effective? Other doctors in Switzerland warn me to do something at C1 at all but they don’t really know about Eagle. Can somebody share experiences? Is the resection of the liagements enough or is a C1 resection usually needed? Thanks for sharing!!
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Hi Tina, from what I have read and learnt along the way, it is best to look at the sagittal view of your CT scans with contrast to answer your question.
If your head was in a neutral position when you had your CT scan and it is only the mass effect of the styloid and the stylohyoid ligament causing an inward compression and displacement of the wall of the internal jugular towards the transverse process of C1 then a styloidectomy and removal of the calcified stylohyoid ligament may suffice. But the problem is what happens when you turn your head from left to right? Will the transverse process of C1 then come interplay ?
If however your head was in a neutral position for the CT scan and the mass effect of the transverse process of C1 is pushing and displacing the wall of the internal jugular vein and compressing it against the styloid then you need to remove the part of the transverse process of C1 that is causing the mass effect as well as your styloids and calcified stylohyoid ligaments.
Sometime both the styloid (and its calcified stylohyoid ligament) have a mass effect in displacing and compressing the wall of the internal jugular as well as the transverse process of C1. In this case you have to remove all these structures having a mass effect.
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Without seeing any imaging it’s hard to tell I’m afraid! Some people have just compression from styloids, and removing these is enough- that was the case for me & it cured my symptoms from bilateral IJV compression. But we’ve seen on others’ scans that the C1 can be even more involved with the compression than styloids sometimes, & in that case a C1 shave would probably be needed.
There have been others posting on here recently about their experiences with Dr Aghayev; it sounds like a pretty tough surgery to recover from. Bilateral surgery is obviously a harder surgery, then adding in the C1 shaves too it will be worse to recover from…I gather from what others’ have said that he feels it’s best while he has a patient on the operating table to take care of everything, whereas other doctors are more cautious and try the styloidectomy first to see if that resolves everything, and prefer to do the two sides separately. So it’s a personal decision really, as to whether you’d rather have a tougher time & get everything over and done with, or would you rather have an easier surgery but have to do this twice, and then potentially need a C1 shave later?
Do you have your imaging from your scans?
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I have some screenshots I could send you? In my opinion, C1 is very much involved in the compression. This is also Dr. Aghayevs opinion. In all the pictures, you only see the compression on the right side. The compression on the left side is so badly, that there is no flow in the IJV except when turning the head very much to the side as seen in the Doppler sonography but in the CT, there is no flow on the left side.
Excellent & thorough explanation, @Emerald. Thank you!
@TinaSwitzerland - I agree w/ Dr. Aghayev’s opinion. The Tp of C1 is significantly contributing to the compression so just having the styloid/ligament removed might allow the IJV to open a little but you’ll need to get a bit of the TP of C1 removed for the IJVs to fully open.
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Thank you for your evaluation - very much appreciated.
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The imaging makes it clearer! It certainly looks like the C1 is very involved in the compression…
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I have a question. Do the findings on a CT scan change over time, or do they remain the same?
I had a CT scan done almost a year ago when I had no symptoms. I’m wondering if I should get a new one, or if the old one would still show the same results regardless of my current symptoms.
Thank you for your help 
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HI Sara, I read your previous thread where you explain your story. Bilateral calcification You said previously that 1 year ago you had a CT scan of your paranasal sinuses and an MRI scan (I assume thiswas a cerebral MRI scan with contrast that showed a part of your neck ? or the whole of your neck down to your thoracic inlet ?)
You said that your main symptoms, now 1 year later, are difficulty swallowing, discomfort in the chest, neck stiffness and tinnitus when lying down with your neck slightly bent or with abrupt movements; but you didn’t have these symptoms when you previously had your scans.
First of all, I’m not doctor so the following is just my take of your symptoms…… It is most likely that your styloids and calcified stylohyoid ligaments explain your difficulties swallowing and possibly neck stiffness. Also your occasional tinnitus could be explained by the styloid(s) or calcified stylohyoid ligament(s) touching the internal carotid artery or it could be explained by the internal jugular vein being compressed by loops of the internal carotid artery as found by Dr Kamran Aghayev. As there is this internal jugular vein compression and the vagus nerve is found in the carotid sheath between the internal carotid artery and the internal jugular, possible vagus nerve compression could indeed explain the discomfort in your chest.
But after saying all this it is important to have peace of mind. And this will only come with knowing that you have covered everything. So maybe you should do a cervical/neck CT angiogram/venogram with contrast seeing your symptoms have come on 1 year after your previous scans. (Make sure you are not allergic to iodine). Your styloids and calcified stylohyoid ligaments will probably be unchanged, the loops of the internal carotid artery causing internal jugular vein compression will be unchanged but maybe the collateral veins that have developed to compensate for your internal jugular vein compression have developed further causing the stiffness in your neck. Also if your previous MRI with contrast? didn’t go right down to the thoracic inlet, then this area can be looked at for completeness.
At least when you have had your surgery this CT scan with contrast will be useful to compare it with the post-operative CT scan.
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Thank you very much for the explanation, Emerald. I had a CT scan with contrast in January 2025. I only had symptoms on the right side, and that was just one month after the tonsillectomy. Actually, more severe symptoms on the left and right side suddenly worsened in July 2025, and because of the chest, neck, burning tongue, and some specific symptoms, I was sent for an MRI of the brain, cervical and thoracic spine (09.2025.). But as far as I understood, nothing is visible on the MRI, or it is visible but I don’t know how to “read/notice it.” Dr. Kamran understands everything from the previous CT scan because he says the compression is visible. It wasn’t significant back then, but now I don’t know whether to remove only the styloid ligaments or to shave down the C1 TP as well. It’s a pity I don’t have the CT in a DICOM file and that I can’t do a 3D reconstruction to see if C1 is causing problems or not. We will certainly have consultations with the doctor before the procedure, but I think that decision is ultimately ours. The doctor always recommends doing everything in one surgery, but I think that maybe there is no need to touch it if it isn’t causing any compression.
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Hi Tina, A CT scan with contrast shows up bony structures and blood vessels in particular, so it it the only scan useful in diagnosing internal jugular compression by a bony structure like the transverse process of C1, the styloid process/stylohyoid ligament or as in your case a vascular structure. An MRI only shows up soft tissues.
If Dr Kamran thinks that a C1 shave or resection is not necessary, he certainly won’t proceed with it, especially if your symptoms are not suggestive of cerebral venous outflow compression. Hence the importance of the consultation you will have with him before the surgery when he will discuss with you your symptoms and the CT findings.
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Thank you very much, Emerald!
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It sounds like you’ve had enough scans to show what’s going on; it’s more radiation to have another CT which as @Emerald says would show bony compression of your IJVs, & the MRIs you’ve had done should show if there’s soft tissue compression. The findings can change over time if the styloids continue to grow, but probably wouldn’t show an awful lots of change over a year 
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Thank you, Jules, for the explanation and your help! 
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