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Oral Surgery Surgical Management of a Symptomatic Fractured, Ossified ora! surgery oral medicine oral pathology with sc~c~r;orl.so,I endodontics CIrlC~dental radiology Volume 52, Number 6, December, 1981 oral surgery ROBERT B. SHIRA, D.D.S. School qf Dental Medicine, Tufts Universit\ I Kneeland Strwt Boston Massachusetts 02 I I I Surgical management of a symptomatic fractured, ossified stylohyoid ligament Stephen X. Solfanelli, D.M.D.,* Thomas W. Braun, D.M.D., Ph.D.,** and George C. Sotereanos, D.M.D., M.S.,*** Pittsburgh, Pa. PRESBYTERIAN-UNIVERSITY HOSPITAL Because of the number of symptoms on presentation and the overlapping with adjacent anatomic areas, cases of symptomatic styloid processes and ossified stylohyoid ligaments may be misdiagnosed and mistreated. Careful clinical examination, history, and evaluation of radiographs enhance accurate diagnosis. The case presented here required excision of the stylohyoid ligament by disarticulation at the hyoid bone and removal of the styloid process at the cranial base. As in this case, extraoral cervical incision may be the only rational surgical approach, depending on the size and extent of the process and its areas of articulation I n the case that follows a symptomatic, ossified temporomandibular Joint dysfunction. At the time of stylohyoid ligament was totally removed via an examination the patient’s chief complaint was that of extraoral approach. Despite radiographic and clini- left-sided otalgia and left-sided sore throat. She stated cal findings, the case was initially misdiagnosed. that 2 months previously she had developed a common While most of the literature suggests management cold which was followed by a constant. dull. left-sided sore throat and left auricular pain. Further questioning by an intraoral surgical procedure, the findings in revealed that occasionally the pain was located over the this case mandated a surgical approach through the left temporomandibular joint. with retromandibular radi- neck. ation. The patient also experienced occasional periods of dysphagia. CASE REPORT Past medical history revealed no significant medical A 31-year-old white woman was referred to the Oral illnesses or allergies. The only previous surgery involved and Maxillofacial Surgery Service for evaluation of left the removal of multiple jaw impactions. Sixteen months previously. with the appearance of left submandibular tenderness and swelling and left-sided sore throat. the *Senior Resident in Oral and Maxillofacial Surgery. patient sought help at another clinic. A tentative diagnosis **Chief, Oral and Maxillofacial Surgery, Western Pennsylvania of acute sialadenitis was made. However, the sialogram Hospital, and Assistant Professor of Anatomy and Oral and Maxillofacial Surgery, University of Pittsburgh and Presbyterian- was normal, all symptoms resolved within 2 weeks, and University Hospital. treatment was deferred. With the reappearance of symp- ***Chairman, Department of Dentistry, Western Pennsylvania toms, the patient was referred to us for evaluation of the Hospital, and Director, Oral and Maxillofacial Surgery. Presby- temporomandibular joint. Head and neck examination terian-university Hospital. revealed no signs of cervical or submandibular lymphad- CO30-4220/81/120569 + 05$00.50/O@ 1981 The C. V. Mosby Co. 569 570 Solfanelli, Braun, and Sotereanos Oral Surg. December. 1981 Fig. 1. Radiographs open and classed mandible demonstrating the ossified stylohyoid ligament and styloid process. Note the “ball-and-socket” appearance at the articulation with the lesser cornu of the hyoid bone in the closed view (A) and the radiolucent areas at the styloid process, stylohyoid ligament junction, and at the most superior aspect of the styloid process seen on the open view (B). enopathy. Palpation over the left preauricular and retro- attention directed to the left tonsillar fossa and left mandibular regions caused moderate discomfort. The submandibular triangle. Palpation of the left hyoid region patient had normal mandibular excursions but experienced revealed tenderness and hyoid fixation during swallow- pain on maximum mandibular opening. Intraoral occlu- ing. Tomograms verified the plain film findings (Fig. 3). sion was Class I. No intraoral lesions were present. The left Plans were then made for surgical excision of the styloid internal (medial) pterygoid was tender to palpation. process and ossified stylohyoid ligament. Open and closed orthopanoramic radiographs immedi- Three weeks later the patient was admitted to the ately revealed a massive ossified stylohyoid ligament (Fig. hospital. The following day she was operated on under 1). The most inferior aspect of the stylohyoid ligament general halothane. nitrous oxide, and oxygen anesthesia. demonstrated a pseudoarticulation consisting of a ball The neck was prepared with Betadine solution and joint appearance articulating with a depression at the draped in the usual sterile fashion. Intravenous steroids lesser cornu of the hyoid. Also, there were two radiolucent were administered to minimize edema. Methylene blue regions along the superior portion of the ossified stylo- was used to demarcate a left submandibular, curvilinear hyoid ligament. Review of the previous sialogram also incision. The incision was made and sharp dissection was clearly showed the ossified stylohyoid ligament (Fig. 2). carried down to the investing layer of the deep cervical Comparison of old and recent radiographs demonstrated fascia. Via blunt dissection, both the left submandibular that the more superior radiolucency along the stylohyoid gland and the left hypoglossal nerve were reflected process was new. superiorly. The digastric sling was released along with the At this point the patient was re-examined, with specific most posterior portion of the mylohyoid muscle fibers Volume 52 Symptomatic fractured, ossified stylohyoid ligament 571 Number 6 Fig. 2. Left submandibular sialogram demonstrating the ossified ligament and styloid process. Fig. 3. Tomograms revealing the apparent styloid process-stylohyoid ligament junction (lower radiolu- cent line) and the fracture line of the styloid process at the base of the skull (upper radiolucent line). from the hyoid bone. Reflection of the mylohyoid muscle irrigated and packed with microfibrillar collagen (Avi- exposed a thick fibrous connective tissue layer overlying tine). Closure was begun by reapproximating the mylo- the ossified stylohyoid ligament. This connective tissue hyoid fibers and digastric sling to be hyoid bone with was incised longitudinally and elevated. At the lesser interrupted 4-O chromic sutures. The fascial layers were comu, the small “ball joint” head was disarticulated. Five then closed with 4-O chromic sutures. Final closure was centimeters superiorly, at the estimated styloid process- accomplished with interrupted subcutaneous 5-O Dexon stylohyoid ligament junction, there was a linear fibrous and interrupted 6-O silk sutures. A pressure dressing was tissue region representing either a previous fracture site or placed. The remainder of the patient’s hospital stay was some type of pseudoarticulation. Two centimeters uneventful, and she was discharged on the fourth postop- superior to this junction was the mobile, fractured part of erative day. Upon discharge she had transient minor the styloid process. It was at this point that the ossified weaknessof the left side of the tongue, the full recovery of structure was detached and removed in toto (Fig. 4). The which occurred in 2 weeks. By the time of her 6-month remaining portion of the styloid process stump was recall visit, the patient was free of symptoms, with a recontoured with the Hall drill. The wound was well well-healed left submandibular incision. 572 Solfanelli, Braun, and Sotereanos Oral Surg. December,198 1 Fig. 4. Excised styloid process and ossified ligament. Note the ball appearance at the hyoid articulation and compare morphology with radiographic findings. DISCUSSION foreign body lodged in the throat, and pain along The totally ossified stylohyoid ligament is an the carotid arteries (carotodynia). Numerous possi- interesting and rare anomaly of the head and neck bilities, such as impingement of the glossopharyn- region which has produced a myriad of clinical geal, trigeminal, or vagus nerves against the elon- symptoms and diagnoses in the past. This anomaly gated styloid process, fibrous tissue scarring after is known as Eagle’s syndrome or styloid process tonsillectomy; hyoid bone fixation, traumatically syndrome.2 In the past decade excellent articles have fractured processes, arthritis; hyoid bursitis, im- been published, reviewing the historical, anatomic, pingement of the internal or external carotid arte- embryologic, and etiological aspects of this syn- ries, and insertion tendonitis have been implicated drome.‘-’ Because both the styloid process and the as causing these symptoms. Differential diagnoses stylohyoid ligaments are cartilaginous (second bran- must include trigeminal, glossopharyngeal, or sphe- chial arch derivatives), there exists the potential for nopalatine neuralgias, impacted third molars, varying amounts of ossification from the styloid chronic tonsillitis or pharyngitis, migraine head- process tip to the lesser cornu of the hyoid bone. The aches, cervical arthritis, esophageal diverticuli, and incidence of elongated styloid processes has been benign or malignant neoplasms. reported at from 1 to 4 percent in the general Interestingly, the present case had been misdiag- population.” In a study of 484 patients, Kaufman nosed approximately 16 months before.
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