Pavan, A. J., Camarini, E. T., Macedo, D. de V., Jacomacci, W. P., Bachesk, A. B., & Piacentini, M. (2017).Estiloidectomia intrabucal em paciente portador de Síndrome Estiloide-estilo-hioide . JBCOMS, 3(3)
I found this article written by Brazilian researchers and published in JBCOMS (Journal of the Brazilian College of Oral and Maxillofacial Surgery). Interesting how they presented the causes for ES and they indicated a internal oral surgery. I’ve made a translation of the text here:
The causes of styloid process elongation are discussed in the literature. Steinmann proposed three theories to explain this phenomenon. The hyperplastic reaction theory suggests that, if the styloid process is adequately stimulated by a pharyngeal trauma, ossification may occur at its terminal portion. The osseous metaplasia theory also involves prior traumatic stimulus, which would induce some sections of the stylohyoid complex to undergo metaplastic changes and thus become intermittently ossified. The third theory proposes an anatomical variation, in which the stylohyoid ligament and/or styloid process develop as ossified structures during the early years of postnatal growth.
Regarding semiological aspects, two variants are described in the literature: the classic syndrome and the carotid artery–styloid process syndrome. The first is related to the healing process following tonsillectomy or cervical trauma. It presents with recurrent throat pain, otalgia, dysphagia, a sensation of a foreign body in the pharynx, and in some cases, hypersalivation. It may occur at any age, and the pain is believed to be due to distortion and compression of the nerve endings of cranial nerves V, VIII, IX, and X. The carotid artery–styloid process syndrome is not related to tonsillectomy and occurs due to compression of the internal and external carotid arteries, resulting in stimulation of the sympathetic chain present in the vessel walls. The resulting symptoms are temporal or frontal headache, otalgia, dizziness, and tinnitus, and in some cases, syncope and visual loss.
The incidence of Styloid–stylohyoid syndrome in the general population is variable. Authors such as Carlini et al. and Chrcanovic et al. have reported it between 1.4% and 30%. Its prevalence is higher in females, and regarding age group, the mean age reported ranges from 30 to 53 years. The literature emphasizes that elongation of the styloid process does not necessarily mean the patient has the syndrome. It is only characterized in the presence of symptoms. Some authors argue that the reason only a small portion of individuals with elongated styloid processes present with syndromic symptoms lies in the direction and angulation in which they are located. Since there is no pathognomonic sign or symptom, the set of symptoms can be confused with those attributed to a wide range of facial neuralgias, dental diseases, and temporomandibular joint disorders. Therefore, proper anamnesis, physical examination, and imaging are essential for accurate diagnosis.
In the physical examination, through careful palpation of the tonsillar fossa, the elongated styloid process may be felt as a firm and pointed resistance. This maneuver usually exacerbates pain, but after infiltration of local anesthetic into the tonsillar fossa, the symptoms subside, assisting in the diagnosis of the disease. The diagnosis is confirmed through imaging findings—such as panoramic radiography, posteroanterior and lateral skull films, and three-dimensional reconstructed computed tomography.
Treatment for the syndrome includes both conservative and surgical methods. The conservative approach consists of using nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and local anesthetics (1% lidocaine) into the lower horn of the hyoid bone or the tonsillar fossa to minimize pain. This approach is not definitive and should be reserved for cases without severe pain or for patients who cannot undergo surgical procedures due to systemic conditions, advanced age, or the presence of other diseases.
The surgical procedure consists of fracturing and removing the styloid processes, and it can be performed through an intraoral/transpharyngeal or extraoral incision. The extraoral approach is favored by authors who claim it provides better exposure of vital structures, avoiding injury to cranial nerves and major vessels. It also offers a lower risk of bacterial contamination and blood loss. However, this approach requires a longer surgical time, general anesthesia, and may result in postoperative cutaneous scarring and morbidity involving adjacent anatomical structures. Two surgical complications have been reported in the literature: internal carotid artery thrombosis and cervical subcutaneous emphysema.
Conversely, other authors advocate treatment through the intraoral approach, reporting good outcomes with this technique. Although it shows an increased risk of infection in the deep neck spaces, nerve and arterial damage, and greater likelihood of hemorrhage, this procedure is simpler and safer. It requires a shorter surgical time, provides better postoperative recovery, leaves no cutaneous scar, and in certain cases, can be performed in an outpatient setting. Furthermore, the potential complications can be avoided through careful dissection and separation of tissues, allowing treatments to be successful and without complications. In the clinical case presented here, no infection of the deep neck spaces or any other unexpected alteration occurred.