Over 2 years of chronic pain - could this be Eagle?

[Michael]

Anyway, after reading a lot of literature about Eagle and Ernest Syndrome, here’s my guess for the diagnosis I’m gonna get on Monday:

My neck trauma 2013 led to a fraction of both my styloid processes. My jaw remained intact as no fraction can be seen on CT pictures. In the course of the next two years, I noticed that my jaw stiffened a little and that I developed a mild but permanent congestion. A bad cough in Dublin in October 2015 ultimately set off a chain of symptoms, starting with the feeling of something being stuck on the right side of my throat. The symptoms began on the right side, which is supported by the fact that my right styloid appears to be more severly broken, I have a more intense calcification of the right stylohoid ligament and that my disc between C6/7 was herniated only on the right side. In the next two years, my symptoms increased, probably due to compression of the glossopharyngeal (GN) and vagus nerve (VN), since my throat is irritated permanently on the right side (GN) and I have a weird feeling that goes right down my stomach (VN, this lady experienced the same: https://www.youtube.com/watch?v=NO-ZT8tqxw0&t=70s). I might have developed a mild to moderate Ernest Syndrome because of the styloid fraction, again more prevalent on the right side, but it’s not that severe as palpating the ligament doesn’t reproduce serious pain. Due to this constant irritation of nerves, my neck, shoulder and arms stiffened and started tingling, even hurting at times. This vicious circle of pain and muscle tension led to a steady increase of my symptoms. The nerves get even more irritated when I turn my head to the right side, which again makes everything worse. I only have tinnitus and no real ear pain, which might be because the fractured part of my styloid process doesn’t compress nerves running to the ear.

In most cases with trauma-induced fractured, but not elongated styloid processes, conservative therapy is indicated (local injection, soft diet, heat therapy). If local injections into the tonsillar fossa and/or stylomandibular ligament don’t alleviate my pain, surgical procedure is without any alternative. Either way, the chances of full recovery are good.

In short: Fracture of both styloid processes, minor calcification of both stylohyoid ligaments (more severe on the right side), compression of GN and VN, increased muscle tension due to constantly irritated nerves, TMJ symptoms (supported by the fact I can evoke a loud click on my right side, but not on my left). Treatment: Conservative, if improvements are inappreciable, surgical approach.

I’m no doctor, but I can’t see any errors in my theory; all I do is reading available literature, just as any doctor. Next monday will be interesting!

[Isaiah_40_31]

WOW, Michael, maybe you should consider going into medicine & studying rare diseases/syndromes instead of Communications/History. You certainly write like a well-researched & well-educated person. I totally agree w/ your prior comments about doctors, arrogance & imcompetance. Even one of the more prominent ES docs in the US had a bout w/ all that some years ago, but, I think, learned a lesson that hopefully won’t be repeated. The patient in question quietly slid into anonymity & is living w/ the consequences. “Pride cometh before a fall” holds true all to often.

I will pray that the diagnosis you receive on Monday will support your own findings & you will feel gratified at having done your homework well. Please continue to keep us updated.

[Michael]

Thank you, I will!

I did some research on fractured styloid processes. Oftentimes, this rare condition occurs when the jaw is fractured as well. However, there are rare cases where only the styloid process is fractured, as in my case. I’ll put all the links down below for you to download.

Summarising the literature, there is one point I find absolutely crucial:

“Treatment [of a fractured styloid process]: Planning should be determined by two main factors: (1) length of
the styloid process and localization of the fracture and, (2) degree of dislocation
of the distal fragment. When there is a fracture of the styloid process of up to
3 cm. with minimal dislocation of the distal fragment, as in the present case,
treatment should be conservative. However, if discomfort and pain persist in
the postimmobilization phase, surgical intervention is necessary. Either an elongated
fractured styloid process or a grossly dislocated distal fragment indicates
that surgical removal via the transpharyngcal approach is necessary”. (Reichart and Sooss, 1976)

Now, this is vital in my case. I don’t have an elongated styloid process, which would indicate conservative treatment. However, looking at my 2D-pictures, the doctor in Klinikum Rechts-der-Isar in Munich said that my right styloid process looks more inbound. This might hint at a grossly dislocated distal fragment, meaning that the fractured part of my styloid process isn’t on the natural line where styloid processes usually grow, but somehow shifted into a more interior part of my jaw.

Ok, so why did this happen? Why did my symptoms start after a bad cough in Dublin? This is also explained in the same case study: “However, in unusual
or complicated movements, such as are brought about by strained swallowing or severe coughing, the hyoid bone may act as a fixed base, with the muscles
that comprise the hyoid apparatus contracting and pulling against the styloid
process, thus causing a strain fracture. The fragment is usually displaced toward
the hyoid bone, i.e., medially, caudally, and ventrally.” My inference is that my styloids got fractured after my neck trauma four years ago, but they remained in the same line where styloids usually grow, thus not causing any serious issues. My constant cough strained the ligaments attaching to the styloid bone (stylomandibular ligament, stylohyoid ligament, stylopharyngeus muscle) so much that they sort of pulled my styloid process into a place where it shouldn’t be: lower and more inward. This led to a constant irritation of the nerves in this place because they are compressed by a distal fragment of my styloid process. Here’s an important picture of the styloid process structure:

This should solve the riddle. Local injections into the strained ligaments (stylohyoid ligament, stylomandibular ligament) should eliminate the pain temporarily. If this is not enough, surgical removal of the styloid processes has to be conducted.

[Michael]

Almost forgot the links:

Fractured styloid process Case Report 1.pdf (798.8 KB)
Fractured styloid process Case Report 2.pdf (1.3 MB)
Coexistence TMJ and Fractured Styloid Process.pdf (199.2 KB)
Fractures Styloid Process Case Report and Review of Literature.pdf (697.8 KB)
Surgical Management of Fractured Styloid Process.pdf (4.6 MB)
Traumatic Eagle Syndrome aka Fractured Styloid Process.pdf (475.5 KB)

If I hadn’t had free access to these articles, this wouldn’t have been possible.

The final, watertight and concise self-diagnosis of my two-year-long pain is:

‘Bilateral fracture of the styloid process, also called traumatic Eagle Syndrome, enhanced by a dislocation of the fractured styloid processes due to a bad cough which led to a constant strain on the attached ligaments.’

This should also explain why people started having pain after a cold, cough, flu, yawning or laughing hard. Basically, the styloid process was fractured beforehand, but the fractured parts remained close to each other. Since the styloid process is broken, though, it can be easily pulled by the attaching ligaments. This happens when you cough (all the muscles in your jaw strain completely). In consequence, the broken part of your styloid process is drawn somewhere in your jaw where it doesn’t belong, hence causing pain.

I find it utterly unbelievable that the styloid processes actually break after yawning, coughing, laughing, etc. The styloid process is attached to one of the most solid structures in our body, the skull. People suffer the craziest accidents, but so many times their skull remains completely unharmed. Saying that the styloid process can break by yawning, coughing, etc. implies that two tiny ligaments in our jaw could create an impact that literally breaks a solid bone that is attached to our skull.

It’s simple common sense that this is impossible, unless your styloid process is already severely broken after a previous trauma, or you have serious osteoporosis.

It’s like wrapping a rope around a loose branch of moderate weight and then pulling. The branch will invariably come closer to you. But if that branch is attached to a trunk, you won’t be able to move the branch one inch. Transferring this logic to the anatomy of a human body, the loose branch is a fractured styloid process, the trunk is the skull, the rope are the styloid and stylomandibular ligament, and the pulling is the straining of the ligaments.

[Jules]

Makes sense!

[Isaiah_40_31]

I truly think you need to get yourself into a scientific field. I’m in awe of your ability to dig & find detailed & varied info on the subject of ES!!

I need your desire/ability to research to the degree you have as I have a 20-30 min. power point presentation to make in early 2018 regarding orthopedic pilates & how to apply it to (my pick of) some dysfunction or function in the human body. I can’t even come up w/ a topic to research (there are soooo many). The info has to be backed by 3-5 peer reviewed papers. UGH! I’ve gone “back to school” at the ripe old age of 61 & haven’t had to do this sort of thing for many years!! Wish there was some way to apply it to ES recovery, but I’ve been requested to research something more common like sports injury. Nerve recovery or fascial damage/repair might be interesting topics to research, too.

Just make sure to take all the links for all the info you’ve found with you even if you feel like the doctor you see on Monday will see eye to eye w/ you. Even a “proud” doctor hopefully wouldn’t dispute what his peers have discovered medically.

[Michael]

Thanks for your advice Isaiah, I’ll bring my laptop with me!

Update: I’ll probably get the results tomorrow, they had a busy day at the ambulance today and no time to check my CT. Patience is key, I guess.

I found another article that is crucial. It offers a protocol how to treat fractured styloid processes, with or without concomitant mandibular fractures. According to it, I will need surgery. Here’s the figure:

I’ve highlighted my case on the tree diagram. I’ve got a fractured and displaced styloid process, and it is pressing on vital structures. Therefore, my styloid fragment (=the broken part of the bone) will most likely have to be excised.

Why do I think it is close to vital structures? “The fracture of styloid may eventually lead to development of Traumatic Eagle syndrome which is characterized by all the
clinical features of eagle syndrome following fracture/surgery of styloid process.
Fracture induced fibrosis or infection has been attributed to this phenomenon. Fur-
ther, the displaced fracture fragment can impinge on adjacent vital structures to pro-
duce consequences like glossopharyngeal neuralgia, atypical facial pain.”

I’ve got both glossopharyngeal neuralgia and atypical facial pain. Thus: “Surgery is mandatory when the tip is in close proximity to vital structures such as carotid
arteries, the internal jugular vein, the facial, glossopharyngeal, vagus and hypoglossal nerve.”

On the one hand, this is bad news, on the other hand I’ve kind of expected it anyway. Let’s see what the doctors say. My inference from this article should be correct, though. It is from 2016 and it’s the most holistic summary of fractured styloid processes (= post-traumatic Eagle Syndrome).

Stylo-Mandibular Complex.pdf (1.1 MB)

[Isaiah_40_31]

If these doctors agree to surgery, they should take out all the parts of your styloids & any remnant still attached to your skull as regrowth has been known to occur when partial styloids are left. You’re still young enough that this could be a possible scenario for you. Most surgeons will also remove the stylohyoid ligaments, too, which keeps their calcification from being a possibilty.

[Michael]

Update: Still no confirmation, but I got the 3D pictures at least. The styloids still look pretty broken to me, but not too long. Opinions?

[Jules]

They certainly don’t look normal! Obviously we’re not doctors, just untrained volunteers, but there shouldn’t be loose pieces like that. And you can’t exactly tell from the angles, but on the last scan pic, the right styloid piece looks very close to the vertebrae process, so that could potentially cause compression of nerves.

[Michael]

Once again, thanks for your help!
That makes perfect sense, actually. I always have a dull sensation right under the base of the right side of my skull which intensifies whenever I do some kind of sport. It starts from the base of the skull, goes right over my head and stops somewhere behind the ear, if that makes sense. It was one of the first symptoms I developed. One of my doctors called this “occipital neuralgia”, but he said it’s not measurable. I’ve got this feeling on my left side as well, but not nearly as intense as on the right side.

Edit: I’ve looked at the pictures in various angles. The right fragment is always pretty close to the vertebrae - when you look at it from behind, it is almost on the same line. In contrast, the left fragment is almost hidden behind the vertebrae, meaning it’s way more anterior. Thanks Jules, another radiographic evidence, I suppose!

This is probably a long shot, but this would perfectly explain why I’ve got tinnitus on the right yet not on the left side: http://www.tinnitusjournal.com/articles/secondary-tinnitus-as-a-symptom-ofinstability-of-the-upper-cervical-spineoperative-management.pdf

[Isaiah_40_31]

I agree w/ both your & Jules’ assessments. Didn’t read the article you linked yet. But have to say, aren’t our skeletons amazing things! They’re so complex w/ all their sutures, joints, protuberances, sockets, etc. It is totally awesome that we have the technology to see our “foundations”!!

[Michael]

Update: I went to see the doctors at Rechts-der-Isar again. They said the gap in my styloid process might be an anatomic variation or actually a fraction. Considering my history with two neck traumas, I think the latter is more likely. Moreover, they said that the stylohyoid ligament is more calcified on the right side, again hinting at a previous trauma, fracture of both styloid processes and subsequent ossification.

Since I’ve been adamant and my conclusions are coherent, they offered me surgical excision of the styloid process, but obviously they can’t guarantee 100% relief of pain. I’ll get the full radiographic report in the next days.

This is good news. Now I can send my pictures and reports to every specialist in Germany, and if that doesn’t go well, I can take the risk of taking the surgery in Munich. To start with, I’d only take my right styloid process out.

I’ve sent the pictures to a doctor in Nürnberg, he excluded the possiblity of my styloid causing issues because the fractured part is “too small”. I don’t think he’s right, though. I try not to be oblivious to what the doctors say. But I don’t think the size of the fragment is that relevant. It’s the position of the fragmented parts that matters, and the CT pictures confirm that at least my right styloid process is in an awkward place. If it’s just a tiny bit pressing on vital nerves, I can’t believe that the length makes any difference.

Whatever, I’ll take the risk of getting surgery. My train of thought, my history, the CT pictures, it just matches perfectly to Traumatic Eagle Syndrome. I just hope to find a doctor who’s done Eagle surgery before and who’s willing to do it again.

[Michael]

Haven’t posted in a while, so here’s an update.

I contacted three experts about my suspicion about broken styloids. Two promised to look at my pictures, I’ll get the answers next week
probably. Christmas holidays and all.

I had an appointment with the other one in Bochum today. He denied Traumatic Eagle Syndrome and had good reasons for that: Apparently, there are anatomic variations where the styloid process has a gap, so the styloid itself isn’t completely ossfied. He said a lot of CTs show the same gap. Plus: The fragment isn’t heavily dislocated and not really long, therefore it’s really unlikely that this is a cause of pain. He suggested that my trauma basically f*cked up my neck and suggested physio therapy, TMJ bite splint and psycho therapy. I’ll definitely try all of it and will go to the pain clinic I cancelled three weeks ago. If my cervical spine and jaw are the cause for all my issues, it’s best I accept that. Even though it’s really hard as I already tried almost all therapies to get better, but maybe I’ll have a breakthrough next time.

I’ll wait for the other opinions, but I can live with it and try to free myself of my belief in Eagle Syndrome. It was definitely worth a shot and I learnt a lot. Nonetheless, it’s devastating. I felt like I really got to the heart of this entire mess, and I just didn’t consider this outcome. I even searched for anatomic variations of the styloid chain yet never found a styloid process that is split in half, like mine. But it is a thing, apparently.

Thanks again for your help. I’ll update this thread regularly.

[Isaiah_40_31]

With all the research you did, I can imagine this new info was quite a blow. Seems illogical that the styloid would form in 2 parts even if not fully ossified & w/ a gap I’d still expect some sort of bony connection between the 2 parts. Not to be dismissive of this doctor’s opinion, but even a little piece of bone at the wrong angle or in the wrong place could produce a world of hurt. It’s also possible if the dislocated piece isn’t anchored down by a muscle or ligament, it’s a free agent in there moving around as you move your head & neck & creating trouble by virtue of its mobility. Just some food for thought & maybe for discussion w/ future doctors.

[Michael]

Hey, I’ve completely overlooked this article, it explains a lot:

https://www.ncbi.nlm.nih.gov/m/pubmed/3086788/

Variability Styloid Process.pdf (529.3 KB)

“Variations in styloid process and stylohyoid ligaments are not uncommon, especially segmentation of the process in young subjects.”

I can’t recall the exact figure, but about 30-40 percent had segmentation of the styloid process. My fragment looks thicker than the ones in the illustration, but still: It’s best I don’t pursue Eagle’s any longer, I’m afraid.

[Jules]

Thank you for all the research you have done Michael- I’m sure that it will help others, even if it’s not the answer for you… I’ve seen research showing styloid processes can grow in a jointed way, but not in segments before. I hope that you get some answers/ help with trying other therapies again- at the very least your muscles are likely to be tense from being in pain & maybe if you can free them a bit it might help break a bit of the cycle.
Please keep in touch & let us know how you get on. Best wishes!

[Michael]

Thanks, I will!

[Isaiah_40_31]

Just a comment on the article links that Michael has sent. In the U.S., unless you’re a college or graduate student, professor or involved in research & have access through the university library or an internet research system, the links only lead to the abstracts for the articles. In order to view the full articles there is a fee that must be paid. It can take a bit of sleuthing as well to find the link to buy a given article.

[Michael]

I’ve updated my post, you can now download the article directly.