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Introduction
Primary survey
Secondary survey
Management
Introduction
Differences in the proportions of a child's head and skeleton affect outcome in paediatric
"maxfax" injury. The relative prominence of the child's cranium, compared to mid-face and
mandible, together with the elasticity of the immature facial skeleton, account for the low
incidence of facial fractures in children. However, soft tissue injuries are common.
Soft tissue injury patterns include burn injury, electrical injury, and lacerations.
Falls are the most common cause of facial trauma in the paediatric group, followed by blunt
trauma from sports activities, motor vehicle accidents and assaults. Non-accidental trauma
may also need to be considered.
Patterns of injury that may lead one to suspect child abuse include multiple bruises in various
stages of healing.
Maxillofacial injuries are commonly associated with cervical spine and intracranial injury.
Emergency evaluation of a facial trauma patient should always begin with attention to the
ABCs. In general, facial injuries rarely require emergency management.
In all aspects of trauma management, the primary survey is the first priority
Primary survey
Airway with c-spine stabilisation (see chapter 1.3) Breathing (see chapter 1.4) Circulation (see
chapter 1.5) Disability Neurological examination.
The secondary survey should include visual acuity testing (even in the presence of
marked periorbital swelling).
Adequate exposure is imperative to facilitate a thorough examination.
Airway
Airway assessment is of primary importance in evaluating facial injuries.
If no cervical spine injury is suspected, attempts to open the airway may be made carefully
with the head tilt/ chin lift manoeuvre. Avoid overextension of the airway by placing the
patient in the neutral position for infants or sniffing position for children.
In cases in which cervical spine injury is suspected, the jaw thrust manoeuvre is preferred.
(From Advanced Paediatric Life Support, The Practical Approach, 3rd edition, BMJ Books,
2001, pg. 23-24.)
Blood, vomitus, tooth fragments and foreign bodies may obstruct the airway, and clearance
of the upper aerodigestive tract of all debris is a priority.
Special anatomic considerations of the pediatric airway that can contribute to airway
obstruction include: (From Kaban, Troulis. Pediatric Oral and Maxillofacial Surgery, Saunders,
2004, pg. 86).
Lymphoid hypertrophy/ enlargement of the tonsils and adenoids between the ages of 4 and
10.
Relative macroglossia, with the tongue positioned higher in the oral cavity.
A softer and floppier epiglottis may complicate pediatric endotracheal intubation.
Tongue-displacement secondary to comminuted anterior mandibular fractures may also
compromise the airway.
Bleeding may be profuse (and occult) from scalp lacerations and fractures of the mid-face.
Control of bleeding by local pressure and, if required, scalp sutures or staples as well as
temporary reduction of fractures may be indicated immediately.
Concurrently, the cervical spine must be stabilized and protected until further assessment for
cervical spinal injury is undertaken.
A quick method for determining the proper size endotracheal tube includes adding 16 to the
child's age in years, and dividing by 4. Ie., the proper sized tube for a 4 year old child would
be (16+4)/4 =5mm (internal diameter)
Fiberoptic intubation may be necessary to control the airway of the pediatric trauma patient.
Trauma x-rays
A chest x-ray to exclude aspiration of dental fragments or foreign bodies may be indicated.
Secondary survey
A detailed craniomaxillofacial examination should be performed during the secondary survey, after
initial stabilization of the patient.
Open wounds should be covered with moist, clean dressings and tetanus prophylaxis administered if
required.
Management
While facial injuries in children are rarely fatal, they may have significant functional and cosmetic
sequelae. Paediatric mortality in trauma is usually secondary to airway compromise or associated
neurological injuries. Consultation with a Maxillo-facial Service should be arranged early in the
evaluation of patients with facial injuries.
The principles of managing paediatric facial trauma are the same as for adults. However, there are
anatomical differences that influence the approach to treatment.
Factors to consider in the paediatric maxillofacial skeleton:
The maxillofacial skeleton is growing, and the cancellous space is proportionally larger than in
the adult.
The maxillo-mandibular complex is proportionately smaller in relation to the cranium
The maxillary and paranasal sinuses are less developed.
The mandibular condylar neck is shorter, and the articular surface is broader.
Temporomandibular joints are active growth centers.
The jaws contain the developing teeth.
Permanent tooth buds are located close to apices of primary teeth.
The overlying soft tissues are thicker than in the adult.
Nasal fractures
Isolated nasal fractures are the most commonly seen fractures in facial trauma. However, nasal
injuries may be associated with severe mid-facial trauma involving the naso-orbito-ethmoidal (NOE)
complex, the frontal sinuses and the orbito-zygomatic complex.
Nasal bones should be X-rayed when:
There is swelling and deformity of the nasal dorsum, epistaxis and periorbital ecchymosis;
There is nasal obstruction;
There is septal deviation due to fracture of the cartilaginous septum.
Isolated nasal fracture is treated clinically and X-Rays are not normally necessary.
Note:
A septal haematoma is uncommon, but requires early drainage to avoid necrosis of septal
cartilage.
In NOE fractures there is depression of the nasal radix and telecanthus with posterior
"telescoping" of the complex.
CSF rhinorrhoea may be present if the fractures of the NOE complex involve the base of the
skull and a dural breach.
Crepitus may not be palpable as the immature nasal complex has greater elasticity.
Investigations:
Radiographs:
Lateral nasal projection
Waters' view 30 degrees.
However, interpretation of nasal fractures on plain films is difficult due to complex sutural anatomy
and cartilaginous components. The need for treatment of an isolated nasal fracture is usually based
on clinical evaluation, and X-rays are not considered routine unless suspicion of other facial injuries
exists
If NOE complex injury is suspected, a CT scan with both axial and coronal views is required.
In addition, 3-D CT reconstructions may be indicated.
Treatment:
Reduction of nasal bones and straightening of the septum should take place at 5-7 days post-
injury.
Support of the reduced nasal bones is often provided by intranasal packing and an external
nasal splint.
Note:
The most common complication is obstruction of the nasal airway caused by undiagnosed or
untreated deviation of the septum.
There is no evidence that mid-facial growth-deficiency occurs after a nasal fracture in
childhood.
Zygomatico-maxillary complex fractures (ZMC)
ZMC fractures in children are usually greenstick fractures, and can be managed conservatively.
However, when there is marked displacement of the orbital rim, zygomatic prominence and/or arch,
open reduction - with or without internal fixation - is indicated.
Clinical Features:
Periorbital swelling, ecchymosis;
Subconjunctival hemorrhage with no lateral posterior limit;
Diplopia secondary to extraocular muscle dysfunction ;
Enophthalmos;
Loss and flattening of the zygomatic body prominence;
Epistaxis;
Paraesthesia of the infraorbital nerve distribution (cheek, lateral nose, upper lip, upper
anterior teeth and gingiva);
Trismus (limited mouth-opening) due to impingement on the coronoid process of the
mandible;
Tenderness and diastasis at the fronto-zygomatic suture;
Palpable depression of the infraorbital rim and zygomatic arch;
The development of proptosis of the globe, reduced or lost vision and severe orbital pain,
are features of retrobulbar haemorrhage. This is an emergency with the potential for
permanent blindness, and requires urgent surgical intervention. If a retrobulbar
haemorrhage is suspected, a facial trauma surgeon and an ophthalmologist should be
contacted immediately, and the child kept fasted in preparation for surgery.
Investigations:
Radiographs -Waters' sinus (occipitomental) views 150, 300 (fig. 1) -Submental-vertex view.
CT scans of the orbits and mid-face with fine-cut axial and coronal views;
3-D CT reconstructions, if available, give an additional appreciation of the injury.
Fig 1: Campbell's and Trapnell's lines to guide the survey of an occipitomental x-ray
Treatment:
Early review by Ophthalmology, if there is difficulty in performing an adequate eye
examination or if an injury to the globe is suspected.
Conservative management of non-displaced fractures: avoidance of nose-blowing, antibiotic
prophylaxis and a nasal decongestant.
Reduction of displaced fractures if there is appreciable contour deformity or functional
impairment. Open approaches are performed for fracture reduction, with or without the use
of internal fixation. Exploration and reconstruction of the orbital floor may also be necessary.
Isolated orbital fractures
Orbital fractures may present as either :
an orbital rim disruption, with extension of the fracture on to the orbital floor; or
an isolated localized fracture of the orbital floor - the "blow-out" fracture. The medial wall of
the orbit is often concomitantly involved. It is frequently caused by a direct frontal blow from
a round blunt object, such as a squash or tennis ball, baseball or fist.
Associated globe injuries must be excluded by early ophthalmological assessment, as eye
injuries may occur in over 50% of these fractures.
Clinical Features:
Symptoms and signs are essentially the same as those noted with orbital involvement of
zygomatic complex fractures (fig. 2). In addition, the signs and symptoms of a retrobulbar
haemorrhage should be examined (see above, section). Particular attention is required to
assess the presence of enophthalmos and muscle entrapment.
Patients with entrapment due to 'trap-door' type fractures of the orbital floor, may also have
significant concomitant nausea and/ or vomiting, bradycardia or hypotension. These
symptoms usually resolve promptly following surgical repair.
Fig 2: A 4 year old child with right orbital 'blow out' fracture associated with entrapment
Investigations:
Radiographs- Waters' sinus views 30, 45 degrees (The classic "tear drop" sign may be
present if the orbital soft tissues have herniated through the floor into the maxillary antrum)
A CT scan with fine-cut axial and coronal views, provides the best radiological assessment of
orbital wall fractures (fig.3)
Fig 3: Isolated right orbital floor fracture
Treatment:
Large orbital floor defects, resulting in ocular muscle entrapment and/or significant
enophthalmos, are indications for surgical management.
Exploration of the orbit is usually performed at 5-7 days post-injury, following the resolution
of swelling and oedema. The prolapsed periorbital soft tissue is reduced and the bony defect
repaired with an autogenous bone graft or alloplastic material.
Patients with symptoms of the oculocardic reflex (nausea, bradycardia and Hypotension)
should undergo immediate surgery for exploration of the orbital floor
Early surgery may be indicated if the injury can be well characterized and/or if the patient is
undergoing surgery for other injuries.
Maxillary fractures
Maxillary fractures are uncommon in childhood. The maxillae are proportionately smaller and denser
than in adults, with a relative lack of sinus development. Consequently, isolated displacement of part
or all of the maxillary complex is rare.
When fractures do occur, however, they are generally a component of more extensive craniofacial
injuries. Approximately 40% of children with mid-facial fractures have associated skull fractures, and
CSF rhinorrhoea may also be present. There is also a high incidence of cervical spine injuries in
patients with severe mid-facial fractures. The cervical spine must be stabilized until a cervical spine
injury can be excluded.
Clinical Features:
Bilateral periorbital swelling and ecchymoses.
Bilateral sub-conjunctival hemorrhage.
Facial deformity: asymmetry, facial flattening or elongation may be apparent in older
children.
Infraorbital paraesthesia.
Palpable steps of the infraorbital margins and tenderness at the fronto-zygomatic sutures
Mobility of the maxilla at different levels, usually representing 3 recognizable patterns of
fracture (Le Fort I, II, III) (fig 4)
Le Fort I - maxilla is mobile to the level of the base of the nose with a stable upper mid-face;
Le Fort II - maxilla and nose are mobile as one unit, with movement detected medially at the
infraorbital rims;
Le Fort III (craniofacial dysjunction) - mobility of the complete mid-face, with movement
detected at the frontonasal and frontozygomatic sutures.
Midline palatal fractures may result in independent movement of the right and left maxillae,
and are frequently associated with laceration of the palatal mucosa.
Malocclusion (inability to bring teeth together in a normal "bite" position) may be difficult to
assess in the presence of associated dento-alveolar injuries and poor cooperation, but may
demonstrate an anterior open bite where the posterior teeth are occluding with an inability to
bring the anterior teeth together.
CSF rhinorrhoea due to dural tear and fracture of the anterior cranial fossa
Haemotympanum (blood in the middle ear) if there is a concomitant base of skull fracture.
Le Fort I
Le Fort II
Le Fort III
Fig 4: Le Fort fractures
Investigations:
Radiology -Waters' views: 150, 300,450 (occipitomental views); -Poster-anterior and lateral
skull views; -CT scan of the full facial complex, from vertex to clavicles, with axial and coronal
views;
-3-D CT reconstruction if possible.
Assessment of paediatric head injuries often requires an early CT scan of the brain, plus
review by the Neurosurgery Unit. Depending on the condition of the patient, this may be an
ideal opportunity to continue the scan to include the facial complex (which is often
overlooked).
Examination by the Ophthalmology Unit of any mid-facial injuries, including injury of the
orbital region.
Analysis of any clear nasal discharge for beta 2 transferrin suggesting a CSF leak
Imaging of mid-facial injuries may be difficult to interpret. It is not a substitute for a detailed
clinical assessment whenever this is possible.
Treatment:
Non-displaced, stable fractures with normal occlusion may be managed conservatively.
Displaced or unstable fractures are reduced and stabilized to restore functional occlusion,
facial contour and symmetry. Internal fixation may be indicated with trans-osseous wire
fixation, mini-plate fixation, or the use of resorbable plate and screw fixation. Intermaxillary
fixation is not normally used today. Access to the facial bones may be via a coronal and/or
intraoral approach. Incisions for orbital access are placed in the transconjunctival or subciliary
skin creases.
The presence of a persistent CSF rhinorrhoea indicates the need for exploration of the
anterior cranial fossa followed by a dural repair.
Frontal bone fractures
Fractures of the frontal bone may occur:
in association with extensive facial injuries; or
in isolation, as a result of direct blunt trauma to the forehead in an MVA, sporting collision or
assault.
Some frontal sinus fractures may be clinically obvious, with a depression or an open wound
permitting direct visualization. In other cases, however, there may be no clinical signs.
A high degree of suspicion is therefore required, based on the presenting history and mechanism of
injury.
Considerable force is required to fracture the frontal bone and the patient should be
maintained in cervical spine precautions until an injury to the cervical spine is excluded.
Clinical features:
Soft tissue oedema over the frontal region, periorbital ecchymosis and oedema;
Soft tissue contusions and/or lacerations over the frontal and glabellar regions.
Complex injuries
Oedema may preclude the palpation of underlying fractures of the anterior table of the
frontal sinus
Epistaxis or CSF rhinorrhoea may be present with nasal fractures and NOE .
Investigations:
CT scan, with both brain and bony windows of cranium and orbits, axial and coronal views.
Treatment:
Will be based on the assessment of the involvement of the anterior and posterior tables of
the frontal sinus, and on the presence of persistent CSF leak.
Non-displaced or minimally-displaced fractures of the anterior table can be managed
conservatively; i.e. no nose blowing and antibiotic therapy.
Displaced fractures of the anterior table require surgical management, with open reduction
and internal fixation of the anterior table via a coronal approach.
Displaced fractures of both the anterior and posterior table are managed in conjunction with
the Neurosurgery Unit, and may necessitate a transcranial procedure to manage the posterior
table fractures.
Mandibular fractures
Mandibular fractures occur in all age groups. Fractures of the condyle and subcondylar regions, are
the most common due to trauma to the chin from falls.
Fig 5: Common sites of mandible fractures. (a) symphyseal / parasymphyseal, (b) body, (c) angle, (d)
subcondylar, (e) condylar head
Clinical Features:
Pain and swelling over the fracture site.
Restricted mouth opening.
Gingival lacerations.
Buccal and sub-lingual haematoma.
Malocclusion - the inability to bring the teeth into a normal occlusion: -step in the occlusal
plane (action of muscle attachments of fragments)
wide displacement between teeth (often mistaken as an avulsed tooth) (fig 6)
Mobile dento-osseous segments; (do not dismiss as just "loose teeth")
Paraesthesia in distribution of inferior alveolar nerve (lower lip and chin)
Bleeding from laceration of anterior wall of the external auditory canal due to a condylar
injury
Fig 6: Avulsion of 2 lower incisors and a step in the occlusal plane associated with a mandibular
symphyseal fracture
Investigations:
Radiology
The mandible is ideally imaged in two planes -Orthopantomogram (OPG) -PA mandible (may require
paramedian PA view) -Reverse Towne's view (for suspected condylar injuries)
In uncooperative patients, or patients unable to sit or stand for an OPG, right and left lateral oblique
views of the mandible or a CT scan are imaged.
Fig 7: Right parasymphyseal and left angle mandibular fractures - (a) OPG (b) PA mandible
Treatment:
Generally, early reduction and internal fixation is best for displaced or mobile fractures of the
body and angles of the mandible. This helps gain early mandibular mobilization.
Non-displaced stable fractures may be treated conservatively, with a soft diet and early
mobilisation.
Resorbable fixation is now considered a good option if available
Condylar fractures and temporo-mandibular joint injuries:
Intra-articular injuries of the condyle constitute the highest risk of growth disturbance
and joint hypomobility. Treatment should aim for continued normal jaw growth to
maintain symmetry and a balanced occlusion.
The majority of condylar injuries are managed conservatively with soft diet and early
mobilization. A short period of immobilization by intermaxillary fixation may be indicated in
older children with bilateral fractures, malocclusion and persistent pain.
Absolute indications for open reduction of condylar fractures include either central or lateral
dislocation of the condylar head with subsequent mechanical blocking of normal movement.
Abstract
The close proximity of the styloid process to many of the vital neurovascular structures in the neck makes it
clinically significant. The styloid process is said to be elongated if it is longer than 3.0 cm in length. Anatomical
variations are very common and clinical symptoms arising from such variations have to be recognized. Elongated
styloid processes may cause chronic throat pain along with foreign body sensation, dysphagia, vague facial pain,
and otalgia. Surgical excision of an elongated styloid is considered as a satisfactory treatment for such cases.
Here, we present a unique case of bilaterally elongated styloids that could be visualized just by depressing the
tongue, when they appeared like the tusks of an elephant in the oropharyngeal region.
Keywords: Anatomical variations, Eagle syndrome, elongated styloid, oropharyngeal
styloid, styloid process of temporal bone
How to cite this article:
Thotappa LH, Doni BR. Oropharyngeal styloids: An unusual presentation. Indian J Dent Res 2012;23:559
How to cite this URL:
Thotappa LH, Doni BR. Oropharyngeal styloids: An unusual presentation. Indian J Dent Res [serial online] 2012
[cited 2014 May 23];23:559. Available from: http://www.ijdr.in/text.asp?2012/23/4/559/104980
Eagle, an otorhinolaryngologist, first described Eagle syndrome, also known as elongated styloid process, in
1937.
[1]
'Elongated styloid process' is a term used in reports concerning findings in both dentomaxillofacial and
ear-nose-throat patients.
[2]
Eagle syndrome is an uncommon but important cause of head and neck pain.
[1]
The
diagnosis is usually made by digital palpation of the styloids in the tonsillar fossa and can be confirmed by
radiographs.
[3]
The case reported here is unique in that the grossly elongated styloids projected in the
oropharyngeal region like the tusks of an elephant.
Case Report
A 40-year-old female patient reported to the department of dentistry with the chief complaint of pain and foreign
body sensation in the throat since 3-4 months. The pain was dull, pricking in nature, radiated to both the ears,
and was aggravated by swallowing. She gave no history of trauma or tonsillectomy. On general physical
examination, the patient was moderately built and nourished, with no obvious abnormalities. Intraoral
examination revealed bony projections in the right and left tonsillar fossae [Figure 1], palpation of which elicited
pain in the tonsillar region and base of the tongue. No other intraoral abnormality was detected. The patient was
referred to the department of ear, nose, and throat (ENT) for further management.
Figure 1: Intraoral photograph showing two bony projections,
appearing like the tusks of an elephant, in both tonsillar fossae
Click here to view
The ENT surgeon examined the oropharyngeal region and found two bony projections arising from the
anteroinferior parts of each tonsillar fossa, piercing both sides of the tongue base. The bony projections were
sharp and tender on palpation. Routine examination of the ear and nose was normal. Indirect laryngoscopy and
blood and urine investigations were within normal limits. The patient was subjected to radiography, including
reverse Towne view of the skull, which showed very long slender styloid processes on both sides[Figure 2]. A
diagnosis of elongated styloids was thus made.
Figure 2: Reverse Towne view of the skull showing very long, slender,
styloid processes on both sides
Click here to view
Under general anesthesia, after tonsillectomy, surgical removal of both styloids was done intraorally by
subperiosteal dissection and excision with bone punches [Figure 3]. Muscles and ligaments attached to the styloid
process were in continuity with the periosteum, and the attachments to the periosteum were restored. The
excised styloids were about 6.0 and 4.5 cm in length [Figure 4] on the right and left sides, respectively, from their
caudal end. The tonsillar bed was closed with sutures. The postoperative period was uneventful. The patient is
asymptomatic 3 months after surgery.
Figure 3: Intraoperative view of the surgical field showing
elongated styloids
Click here to view
Figure 4: Photograph of excised styloid processes
Click here to view
Discussion
The styloid process, stylohyoid ligament, and the lesser cornu of the hyoid bone are derived from Reichert
cartilage, which arises from the second branchial arch during embryogenesis.
[3]
There can be several variations
of the styloid chain, including variations in the length of the process, thickness of the segments, angle and
direction of the deviation, and the degree of ossification.
[1]
Ossification of stylohyoid ligament is said to be one of
the causes of elongated styloid process. Stylalgia may be due to formation of a stiff bony clasp, which hampers
the elastic movement of the stylohyoid ligament during contraction of the pharyngeal muscles, the pain being
secondary to irritation of the sympathetic plexus around the carotid arteries or the sinus branch of the
glossopharyngeal nerve. Elongated styloid process can cause dysphagia due to the formation of a
pseudoarthrosis between the styloid process and the stylohyoid ligament, causing intermittent locking or
fixation.
[4]
The elongated styloid process in our patient was due to bony extension itself and no ossification of the
stylohyoid ligament was present.
The normal length of the styloid process varies greatly, although in the majority of patients it is 20-30 mm long. It
is considered elongated when it is longer than 30 mm, and this occurs in around 4% of the general population.
However, of these, only 4% present with symptoms that are attributable to the elongation.
[1],[5]
An earlier study
has reported that the average lengths of the left and right styloids were 1.52 cm and 1.59 cm, respectively, in
Indian subjects.
[6]
In the present case, the lengths of the right and left styloids were about 6.5 cm and 5.0 cm,
respectively. Elongated styloid process is reported more frequently in women than in men. Symptomatic patients
are usually over 40 years of age,
[1]
and this was true in the present case also.
A wide variety of symptoms have been attributed to elongated styloid processes, including cervical pain, throat
pain, earache, foreign body sensation in the throat, pain on changing head position, headache, pain in the
cervicofacial region, pain on swallowing, shoulder pain, and sensation of a lump in the throat.
[5]
The patient had
throat pain, foreign body sensation, earache, and pain on swallowing.
The diagnosis of elongated styloid process is based on the history and clinical examination, with aggravation of
symptoms on palpation of the styloid process in the tonsillar fossa. The diagnosis is supported by the relief of
symptoms following an injection of an anesthetic solution into the tonsillar fossa and is confirmed by
radiography.
[1],[5]
In this patient there was no history of trauma or tonsillectomy, and clinical examination of the
oropharyngeal region revealed prominent bony projections in the tonsillar fossae, with tenderness on palpation;
diagnosis was finally confirmed by a radiograph. Hence this is a case of styloid process carotid artery syndrome.
This case is unique because there has been no report of oropharyngeal styloids in the literature to date.
The elongated styloids can be treated surgically and non-surgically. A pharmacological approach, with
transpharyngeal infiltration of steroids or anesthetic into the tonsillar fossa, can relieve symptoms, but
styloidectomy is the treatment of choice.
[7]
Partial styloidectomy was performed by the intraoral approach in the
present case. Some authors have suggested that excision of the styloid process without disturbing the
attachments of muscles and ligaments to the periosteum of the styloid process is an important factor in relieving
postoperative pain and complications.
[8]
We followed this approach in the present case.
Conclusion
Variation is the law of nature. Every human is unique anatomically and even identical twins are not alike. It is
important that clinicians, especially dentists and otolaryngologists, be aware of the anatomical variations of the
styloid process. The presented case is unique in that the grossly elongated styloid processes projected into the
oropharyngeal region like the tusks of an elephant.
References
1. Ilguy M, Ilguy D, Guler N, Bayirli G. Incidence of the type and calcification patterns in patients with
elongated styloid process. J Int Med Res 2005;33:96-102.
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elongated? DentomaxillofacRadiol 2004;33:119-24.
3. Balbuena L Jr, Hayes D, Ramirez SG, Johnson R. Eagle's syndrome (elongated styloid process). Southern
Med J 1997;90:331-4.
4. Leighton SE, Whittet HB, Golding S, Freeland AP. Styloid apparatus anamoly causing dysphagia. J
LaryngolOtol 1991;105:964-5.
5. Prasad KC, Kamath MP, Reddy KJ, Raju K, Agarwal S. Elongated styloid process (Eagle'ssyndrome): A
clinical study. J Oral MaxillofacSurg2002;60:171-6.
6. Thot B, Revel S, Mohandas R, Rao AV, Kumar A. Eagle's syndrome. Anatomy of the styloid process. Indian
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[PUBMED]
7. Politi M, Toro C, Tenani G. A rare cause for cervical pain: Eagle's syndrome. Int J Dent 2009;1-
3.2009:78297.
8. Yavuz H, Caylakli F, Erkan AN, Ozluoglu LN. Modified intraoral approach for removal of an elongated
styloid process. J Otolaryngol Head Neck Surg 2011;40:86-90.
Correspondence Address:
Bharati R Doni
Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand
India