Eagle syndrome

Eagle syndrome refers to symptomatic elongation of the styloid process or calcified stylohyoid ligament 1-2. It is often bilateral. In most cases, the cause is unknown; however, the condition is sometimes associated with disorders causing heterotopic calcification such as abnormal calcium/phosphorus metabolism and chronic renal failure.

Clinical presentation is varied and establishing a causative relationship between the styloid process/stylohyoid ligament and symptoms can be challenging. Classically, the pain develops following tonsillectomy, presumably due to distortion of the local anatomy following surgery; however, it is frequently found in patients who have not had regional surgery 1-3.

The syndrome can be divided into two main subtypes 1,3:

  • due to compression of cranial nerves
  • due to compression of the carotid artery

Patients can have symptoms related to compression and irritation of cranial nerves in the region (cranial nerves V, VII, IX and X) such as 1,3:

  • facial pain when turning the head
  • dysphagia
  • foreign body sensation
  • pain on extending tongue
  • change in voice
  • sensation of hypersalivation
  • tinnitus or otalgia

On palpation of the styloid process tip, symptoms should ideally be exacerbated.

Compression of the carotid artery may produce vascular/ischaemic symptoms as well as pain along the artery to the supplied territory (thought to be mediated by the sympathetic plexus), including 2-3:

  • mechanical compression
  • sympathetic plexus irritation (carotidynia)
    • eye pain
    • parietal pain

The normal length of the styloid in an adult is thought to be approximately 2.5 cm while an elongated styloid is considered longer than 3 cm. If this definition is used, ~4% of the population have an elongated process; however, only a small proportion of them (4-10%) are symptomatic. Elongation can be unilateral or bilateral 1-3.

Orthopantomograms and CT can both be used to assess the styloid process/stylohyoid ligament complex.

It has also been proposed that in cases where mechanical vascular compression is the potential cause of ischaemic symptoms, an angiographic examination (CT angiography or catheter angiography) obtained with the patient's head positioned to reproduce symptoms may demonstrate mechanical stenosis of the carotid artery 3.

In many cases, once the cause of pain has been attributed to the styloid process rather than a more sinister entity, no further treatment is required, or perhaps analgesics can be offered for pain alleviation.

Transpharyngeal injection of steroids/local anaesthetic agents have also been attempted 6.

In severe cases, surgical excision may be performed, either via a transoral approach or a lateral approach. The transoral approach has the disadvantage of increased infection rates, but does not cause external scarring 1,6. Pain may persist even after surgical excision in as many as 20% of patients 6.

It was first described by Watt Eagle in 1937 4.

However, there are reports that ossification of the stylohyoid ligament had been described as early as the 17th century by Italian anatomist Pietro Marchetti.

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Article information

rID: 5115
System: Head & Neck
Synonyms or Alternate Spellings:
  • Eagle's Syndrome
  • Stylohyoid syndrome
  • Styloid syndrome

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Cases and figures

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    Figure 1: styloid apparatus
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    Case: 1
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    Long styloid proc...
    Case 2: asymptomatic
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    Case 3
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    Case 4
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     Case 5
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     Case 6
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    Case 7
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    Case 8
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    Case 9: with ICA compression
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    Case 10: comparison to normal side
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    Case 11
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