X-ray Interpretation Help - Also Dental Hygienist here

[Alisha]

Hello all,

This is my first post here and I was looking for some insight into my own x-rays along with helping to further educate myself in my career as a dental hygienist.

I am 31F, Lyme disease at 22, unilateral tinnitus in my right ear since 23, with various joint/ muscle pains since the onset of Lyme disease. MRI was performed to evaluate possible acoustic neuroma, negative finding.

In the past year I have been diagnosed with an umbrella “connective tissue diseases", I saw a geneticist as my sister has ehlers danlos syndrome, however I do not as I do not meet the criteria. I am actually generally very stiff throughout my body with limited ROM.

Fast forward to this past month, I reviewed with my PCP that my right shoulder has been increasing in pain, especially after a day of working. I get a burning sensation in my neck/ occipital region which causes headaches and overall malice. I saw a orthopedist whom took x-rays and found that I have a straight neck.

When I was looking at my x-ray and researching straight neck I came across a radiology post on Reddit in which someone had straight neck along with calcified stylohyoid ligaments. I keep looking at my x-ray and honestly I can’t tell if mine is calcified or not. Neck x-ray is from this past week and dental pan is from 2024.

All my issues are on my right side, the grinding in my shoulder/ scapula region, the tinnitus in my ear (constant high pitch not pulsatile), the popping of my TMJ, all on my right side.

I will also add that on a previous x-ray I have a “partial fusion of the anterior aspect of the left third and fourth ribs.” - this offsets my collar bones as my left collar bone is much higher than my right, this is clinically observable as well.

Lastly I have a MRI scheduled in October: MRI spine cervical WO contrast, and MRI shoulder right WO contrast.

I’m curious what anyone’s opinion may be?

X-rays here:

[Jules]

I’m sorry that you’re getting pain and stiffness, ES can cause shoulder pain and arm weakness, as well as neck & occipital pain. I can’t see your styloids in your first two images, but it looks like there’s a shadow each side on the 3rd one which could be styloids- it could just be that the first 2 aren’t that clear though. I can’t label x-rays as I not up with the tech, but I would say looking at the x-ray , your hyoid bone processes look pretty long & close to your C-spine…That can cause swallowing issues and clicking in your throat, plus vascular issues if they’re close to carotid arteries. A CT with & without contrast would be better to show the styloids, if you’re able to get one of those done?
Your neck is very straight & has lost it’s curve- we do see that quite a bit with members, there are exercises to do which can sometimes help. There’s been lots of discussions about that, here’s a link to one:
List of my favourite resources on YouTube to learn anatomy - General - Living with Eagle

[Alisha]

Hello Jules,

Thank you so much for taking the time to read my post and respond, it’s much appreciated! When it comes to vascular issues I was evaluated for POTS as I get lightheaded with a raised pulse when changing positions (I literally sit to empty the bottom of the dishwasher, I sit to shave my legs in the shower etc) - they did the tilt table test but my resting HR was 100 laying down and went up to about 120 when they tilted me up, my normal HR at home is about 60 however and when I get up it spikes to about 115. I also get blood pooling (salami hands), and I can get pins and needles easily if I’m in certain positions (which I just avoid at that point).

The MRI is scheduled to evaluate my neck. back and shoulder due to the pain I’ve been experiencing. I have also completed a few months of PT with no avail. PT seemed to help a bit but not much, and if I’m being honest sometimes I felt like it was aggravating things further. ’

I’ve seen some posts on here evaluating MRI’s for Eagle syndrome, would that be sufficient enough to piece my puzzle pieces together would you suspect? I know the CT w/o contrast would be ideal but I’m almost wondering if I have an atypical situation with multiple things going on.

Lastly when it comes to the clicking in the throat I’m not sure exactly how that feels, I have a very high epiglottis visible easily clinically, I can feel a sensation in my throat like something is there but I’ll be frank it’s always been that way. When I swallow I hear bubbles in my ears but they’ve always attributed that to sinuses/ allergies.

[TML]

@Alisha xrays aren’t optimal for assessing styloids, but I think I’ve located the styloid. Hard to say how long it is. Have you happened to ever have a head and neck CT by chance?

[Alisha]

Thanks so much - I noticed that as well where your arrow is and I also noticed what Jules pointed out as well I’ll include a photo of that. I came across a reddit post just a few moments ago of someone with a very similar dental pan as mine link here: Reddit - The heart of the internet

When it comes to the length if I had to make a very rough educated guess based on what I know the length of crowns of molars to be (however I’m not fully taking into account orientation etc) - I would estimate around 10mm?? Would you say this is the ligament or the bone? (my apologies if you don’t know just curious)

When it comes to a CT scan, I have never had one. Just a MRI to check for an acoustic neuroma (8 years ago) for the tinnitus that I still have (only in my right ear). I have a MRI scheduled in October.

Xray highlight:

[TML]

Hard to say whether it’s an elongated styloid, or whether it’s a pocket of calcified stylohyoid ligament, either way definitely longer than 10mm (1.0cm). Eagle syndrome typically happens when the styloid exceeds 30mm. A styloid as short as 1cm wouldn’t even show on a dental pano, so it’s definitely longer than that! I’d guess around 3cmm ish

[Alisha]

oof wow I guess I was off on the size. I’ve seen some x-ray images where you can see the calcification is very extensive that’s why I was unsure if mine was even notable or not. I definitely think I have symptoms that have been misdiagnosed as just “allergies” or “clenching/ grinding your teeth” like how I always mention the bubble sounds in my ears even when swallowing, or the fact that I would literally feel like I have an ear infection just for them to say I’m completely fine.

This is also been great for me to learn about so far because I see patients that have TMJ complications and some patients with trigeminal neuralgia, going forward I will certainly be more conscious of evaluating their PAN observing for any signs of calcified/ elongated stylohyoid/s.

[TML]

When they did your cervical xrays, did they take an odontoid view (i.e., xray where your mouth is wide open so they can look at C1/C2)? This is the best xray view IMO for styloids! CT is the best (especially with contrast), then xray, then MRI

[Alisha]

The orthopedic unfortunately did not, however I can certainly ask for that x-ray after my MRI. Eagle syndrome is something I recently come across and I don’t believe the orthopedic was suspecting Eagle syndrome. I am a bit weary as I did send him a message in the health portal a few days ago, I had stated “I know I very briefly told you about my tinnitus in my right ear (started when I was 22ish), is my stylohyoid calcified? I can’t quite tell by my picture of my xrays but I was wondering if you could see/ notice that? It would possibly explain why that’s been going on for many years since I have no other reason to have unilateral tinnitus. Thank you again.” Drs response : “Your stylohyoid is not calcified since its a muscle, that is your hyoid bone which is what you are seeing on the x-ray which is normal”

So I will say I’m not overly optimistic but I will give him the benefit of doubt as I also didn’t have the information I have now (so maybe poorly worded on my part), and he also has not seen my dental x-ray. I think what I will do is wait for my MRI results, meet with him, review what I now know, and go from there whether that be with a different specialist or something who can hopefully help.

[TML]

What is the aim of the MRI?

If you are to pursue a better understanding of whether you have ES or not, a CT with contrast is the best imaging and will allow you access to most surgeons in the US. I wouldn’t bother with getting an odontoid xray if you are pursuing it, definitely just the CT. Don’t want to much radiation exposure!

[Alisha]

That is a great point, wasn’t sure if the odontoid xray would help solidify if a CT scan would be warranted. Regarding the MRI, I’m actually not 100% sure why, my orthopedic loosely recommended it and said due to my failed PT (no resolution of my straight neck), he suggested doing a MRI to make sure there’s not something else going on/ causing my muscle tension on my right side.

[TML]

If it is ES, then the muscle tension would like stem from vagus nerve and spinal accessory nerve irritation from the calcification.

Since the MRI doesn’t involve radiation it’s worth getting for sure. But they won’t be able to determine anything ES-wise from it. Would be great if you can get a req for a CT, and a CT with contrast would be even better!

[Alisha]

I will definitely ask because I highly suspect Eagle Syndrome and its interesting that there are findings on my xrays so its not completely out of field especially given my symptoms.

Like today I had work, vacuumed and my whole neck feels so hot, I now have a headache, used a lidocane patch, it didnt help with the deeper pain, took ibuprofen and now Im laying in bed.

I know taking tylenol/ ibuprofen on a regular basis isnt good, but the pain only gets worse if I dont do something about it. Sigh

[TML]

I’ve been taking ibuprofen and Tylenol combo for a year now (like 2ish extra strength each per day). Just make sure you are eating when you take them, especially Ibuprofen since it can cause stomach ulcers

[Isaiah_40_31]

Drinking at least 8-12 oz of water is also mandatory to stave off stomach irritation from NSAIDS. I got ulcers in my stomach from taking too much Advil. Learned the hard way.

[Jules]

An MRI is useful to rule out anything else (sometimes it’s easiest to go along with the hoops doctors want you to jump through!), but it’s not easy to see the styloids on that so a CT would be better if you can be referred for one…
If the vagus nerve is irritated it can cause BP & g heart rate issues. Ear ache is common too with ES, I used to have that alot without ear infections, I put it down to impacted wisdom teeth but don’t get that since my surgery!

[Alisha]

I definitely need to be more cognizant of that, I typically don’t (and I know I should).

[Alisha]

Exactly - I have been sick a few times and swore I had an ear infection only to be told everything is fine. Did you get the bubble popping sensations? I can even massage around my TMJ and I hear bubbles popping sometimes. Always bubbles when swallowing and yawning without fail. My hearing is also very muffled, has been for years now. I get POTS like symptoms, I’ve been drinking more water and electrolytes without much if any improvement. I definitely need to get a CT scan after my MRI I will highly advocate for one. I will likely seek out a specialist first, I saw there is Dr. Cognetti in Philly? Funny enough I live in PA and I’m not too far from Philadelphia.

Also I will add, after learning about Eagle syndrome, I recalled having a patient who had trigeminal neuralgia symptoms. I looked up her chart yesterday along with her pan and I couldn’t believe it, her stylohyoids were completely calcified and *thick* . I notified the dentist I work for and he is going to be calling her to inform her of Eagle syndrome and hopefully she can get some relief, she was in much pain when I saw her for her last prohpy.

There definitely needs to be more awareness of Eagle syndrome!

[Alisha]

oof that is tough I hope you feel better now! I definitely try to drink 8oz of water when I take medication in general but sometimes I know I get lazy about it. It’s a good reminder to not do that.

[Isaiah_40_31]

@Alisha - The ulcers were many years ago so yes, they’re all healed up now. I was very surprised as I had no symptoms. They were actually discovered when I had an upper GI because I kept choking (Heimlich necessary) on food when I ate. That was my earliest ES symptom before the neck, face, & other pain started. My gastroenterologist scoped my esophagus & stomach. The esophagus was fine but he found the little ulcers in my stomach. It was several years later before my elongated styloids were discovered by an ENT.

Dr. Cognetti is a very experienced ES surgeon, but he is currently booking initial consults in March or April of next year. He puts his cancer patients first & only does ES consults & surgeries one day/month which pushes those appointments quite far into the future. If you don’t mind waiting, he is well worth seeing. You can also request to be put on his cancellation list if you decide to see him.

AWESOME!! That you remembered the patient who had trigeminal neuralgia & thought to look at her pan x-ray. You’re already helping others even though you haven’t been helped much yet yourself! You’re definitely in the right field!! If you’re able to have contact w/ the gal, by all means refer her to our forum so we can support her, too.