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2019, Number 3

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Rev Mex Ortodon 2019; 7 (3)

Prevalence of elongated ossified styloid process and Eagle syndrome in population visiting the dental Clinic at the Humanities Education Center (CEDHUM)

Fonseca Balcázar, Franco1; Salinas Basauri, Julia1; Amaya Larios, Irma Yvonne1;Martínez Ronquillo, Antonio1; Ángel Reyes, Miguel1

Language: English/Spanish [Versión en español]
References: 17
Page: 152-158
PDF size: 228.25 Kb.


ABSTRACT

Introduction: The ossified styloid process (SP) is an anatomical structure that normally measures 20 to 25 mm and can be considered elongated from 30 mm onward. Some percentage of the population has a SP growth that may affect surrounding structures and generate varied symptoms.This work aims to determine the prevalence of elongated ossified SP in population visiting the dental clinic at the Humanities Education Center (CEDHUM) in Morelos, Mexico. Material and methods: Clinical records with panoramic radiographs were reviewed from 2015 to June 2018. The presence of elongated ossified SP was observed digitally and classified into type of SP. The images were captured in the Kodak 8000C digital panoramic and cephalometric imaging system; measurements were taken in mm from the base to the end of the styloid process bilaterally. The data were analyzed in Excel and Stata SE 14 statistical package. Results: The prevalence of elongated ossified SP was 20.49% (95% C.I. 14.76-27.69), of which 95.24% (n = 40/42) was bilateral. According to sex, 21.90% women and 17.65% men were diagnosed with the condition; no statistically significant differences were observed (p = 0.478). Conclusions: The categorization as Eagle syndrome occurred in 42.86% of individuals, whose mean age was 20.47 years in women and 19.26 years in men. The location of the elongated ossified SP was bilateral in 95.24% of cases (n = 40/42). By sex, 21.90% of cases corresponded to women and 17.65% to men. The prevalence of elongated ossified SP was 20.49%, being more prevalent in women than in men. No statistically significant differences were observed.



INTRODUCTION

Eagle syndrome is an entity rarely identified clinically and radiographically. The first descriptions of this condition were those of Marchetti in 1652, Luke in 1870, Weinlecheren in 1872, and later, Dr. Watt W. Eagle in 1937, who reported several cases of elongated styloid processes associated with symptoms of vague head, neck, and orofacial pain. His works originated the term Eagle syndrome.1-8 Eagle syndrome is little-known and should be considered in the differential diagnosis of cervicalgia and in cases of glossopharyngeal neuralgia and temporomandibular dysfunction.2,4,9-14

Four percent of the general population presents an elongation of the styloid process (SP) but only 0.16% has symptomatology. The physiological length of the SP is 20-30 mm and it is classified into 5 types as follows: type I, physiological length; type II, elongated; type III, pseudoarticulated; type IV, segmented; and type V, complete ossification.

The majority of the affected patients show no symptomatology, although the pressure exerted by this altered structure against neighboring structures can trigger a wide variety of symptoms3 (Figure 1).



MATERIAL AND METHODS

This was a cross-sectional study conducted at the dental clinic at the Humanities Education Center (CEDHUM), located in the municipality of Jiutepec in the State of Morelos, Mexico, from January 2015 to June 2018.

The study included all persons over the age of 15 who sought orthodontic consultation at the clinic during the study period and signed an informed consent. The only exclusion criterion was the lack of a complete clinical record.

For the diagnosis of elongated SP, a panoramic radiograph was taken for each patient. The measurement of the SP was performed in those which looked elongated and images were captured in the Kodak 8000C digital panoramic and cephalometric imaging system. Before measurement, the measurement reading of the panoramic radiograph was individually calibrated, measuring the length of the clinical crown of an upper central incisor (#11 or #21) and then measuring in the imaging program from the base to the tip of the ossified SP (Figure 2). The values provided by the Kodak Dental Imaging Software 6.12.26.0 program, in mm, were included in the patient database.

According to the observation of the panoramic radiographs, the elongations were classified as bilateral if they occurred on both sides or unilateral if they were present only on one side. On the other hand, patients who showed an elongated ossified SP on their panoramic radiograph were interviewed and examined to identify whether they had any characteristic symptoms or were asymptomatic.

The general characteristics of the study population were age, sex, unilateral and bilateral elongated ossified SP, and being symptomatic or asymptomatic. The data were captured in Microsoft Excel®.

A description by sex of population characteristics was performed using the Mann-Whitney U test for continuous variables and χ2 for categorical variables. Risk factors associated with elongation of the SP were determined through logistic regression analysis considering variables such as age and sex. In addition, another logistic regression analysis was performed to evaluate the risk factors associated with the presence of symptomatology, considering length of the SP, age, and sex.

The statistical analysis was performed using the Stata SE 14 statistical package.



RESULTS

During the study period spanning January 2015 to June 2018, 205 clinical records of patients who visited the CEDHUM dental clinic in Jiutepec, Morelos, Mexico were reviewed.

The mean age of the study population was 20.01 years (SD 6.17 years) 66.83% (n = 137/205) were women with mean age of 20.47 years (SD 6.56 years), while the mean age of men was 19.26 years (SD 5.25 years).

The prevalence of elongated ossified SP was 20.49% (95% CI 14.76-27.69), of which 95.24% (n = 40/42) was bilateral. According to sex, 21.90% (95% CI 14.78-31.25) of women and 17.65% (95% CI 9.11-30.82) of men were diagnosed with this condition; however, no statistically significant differences were observed (p = 0.478).

The mean length of the right elongated SP was 35.35 mm (SD 10.77 mm) and of the left one was 35.8 mm (SD 1,027 mm) (Table 1).

Of the persons with elongated ossified SP, 42.86% (95% CI 25.4-67.7) were diagnosed with Eagle Syndrome because they showed typical symptomatology of that condition. By sex, Eagle syndrome was observed to be more common in women, but no statistically significant differences were found (p = 0.139) (Table 1).

In addition, the relationship between the length of the SP and the characteristic symptoms of Eagle syndrome was assessed (Figure 3).

Also, in the multivariate analysis adjusted by sex, the risk of elongation of the SP was found to increase by an average of 11% for every increase in 1 unit of age in years, and that association was statistically significant (Table 2).

However, the evaluation of the association between symptomatology and length of the SP adjusting by age and sex showed no statistically significant differences (Table 3).



DISCUSSION

In this study, elongated ossified SP was confirmed and quantified by panoramic radiographs, and Eagle syndrome was also categorized in the study population.

The prevalence of elongated ossified SP was 20.49%, which is similar to that reported by Balcázar and Ramírez, who reported a prevalence of 4 to 28%.11

The normal length of the SP varies considerably in most people, about from 20 to 30 mm. In general, it is considered elongated when it measures more than 25 mm,6,13 although some authors mention from 30 mm onward.15 The average length that we found on the right side was 35.35 mm and on the left side, 35.8 mm, which coincides with what was reported by Nazar et al.15

Sanchez et al. and D'Addino et al. report that Eagle syndrome occurs between the 3rd and 4th decade of life and between 30 and 50 years of age, respectively.7,16 In our study, the mean age of the population evaluated was 20.01 years; the mean age of women was 20.47 years and that of men was 19.26 years.

The percentage of the study population with elongated ossified SP that was diagnosed with Eagle syndrome was 42.86%. According to sex, we observed that it was more common in women, but we found no statistically significant differences. Our results agreed with those by Balcázar and Ramírez.11

Regarding location, the ossified elongated SP was bilateral in 95.24% (n=40/42) of cases, which did not agree with results by Fuentes et al., who observed more unilateral than bilateral elongations.17



CONCLUSIONS

Considering the limitations inherent to this kind of study, the following can be concluded:

  • • The prevalence of ossified elongated SP was 20.49%, (95% CI 14.76-27.69); this condition was more prevalent in women than in men, although no statistically significant differences were observed (p = 0.478), which confirms the working hypothesis.
  • • Categorization as Eagle syndrome occurred in 42.86% (95% CI 25.4-67.7) of cases.
  • • The location of the ossified elongated SP was bilateral in 95.24% (n = 40/42) of cases. After stratification by sex, 21.90% of cases corresponded to women and 17.65% to men.
  • • Of the total of ossified elongated SP cases with symptomatology, the mean age was 20.47 years in women and 19.26 years in men.
  • • In the multivariate analysis adjusted by sex, the risk of elongation of the SP was estimated to increase by an average of 11% for every increase in 1 unit of age in years, and this association was statistically significant.


REFERENCES

  1. Raffo LM. Síndrome de Eagle: reporte de un caso. Odontoestomatología. 2012; 14 (20): 26-31.

  2. González JM et al. Síndrome de Eagle. Importancia para el odontólogo. Revisión de la literatura. Acta Odontológica Venezolana. 2011; 49 (2).

  3. Espinoza ML, Ruiz MM. Características clínicas del síndrome de Eagle. Rev Esp Med Quir. 2013; 18 (3): 264-270.

  4. Garcia LA et al. Síndrome estiloideo de Eagle, caso clínico. Acta Méd Grupo Ángeles. 2016; 14 (4): 244-247.

  5. Tisner NJV et al. Calcificación del ligamento estiloideo: estilalgia de Aubin y síndrome de Eagle. Aportación de 5 casos clínicos. Trabajo de Investigación y clínica aplicada. Servicio Rehabilitación del Hosp. Universitario Miguel Servet de Zaragoza. Orl Aragon. 2003; 6 (2): 5-12.

  6. Ortega AV et al. Revisión de la elongación de la apófisis estiloides. Posible etiología genética. A propósito de tres casos clínicos. Rev Cien Dent. 2015; 12 (1): 45-50.

  7. Sanchez LE, Repetto LJL, Gallego GR. Odinofagia y cervicobraquialgia en síndrome de Eagle. Descripción de un caso. Revista ORL. 2017; 8 (1): 65-68.

  8. Hassan MK et al. Fractured styloid process masquerading as neck pain: Cone-beam computed tomography investigation and review of the literature. Imaging Sci Dest. 2018; 48: 67-72.

  9. Gino ML. Síndrome de Eagle. Revisión de la literatura. Rev Otorrinolaringol Cir Cabeza y Cuello. 2016; 76: 121-126.

  10. Mareque BJ et al. Abordaje intraoral en el síndrome de Eagle. Presentación de un caso clínico. Rev Esp Cirug Oral y Maxilofac. 2011; 33 (4): 157-161.

  11. Balcázar RLE, Ramírez AYL. Síndrome de Eagle. Gac Med Me. 2013; 149: 552-554.

  12. Villalba LMA, Miranda VE. Síndrome de Eagle; reporte de un caso. Asociación Mexicana de Cirugía Bucal y Maxilofacial. 2009; 5 (1): 26-31.

  13. Thoenissen P et al. Eagle's syndrome – A non-perceived differential diagnosis of temporomandibular disorder. Int J Surg Case Rep. 2015; 15: 123-126.

  14. Smerilli A, Flores JM. Síndrome de Eagle. Caso clínico. Rev Fac Odontología. 2014; 29 (67): 35-37.

  15. Nazar SR et al. Síndrome de Eagle en otorrinolaringología. Revista Hospital Clínico Universitario Chile. 2008; 19: 156-161.

  16. D'Addino JL et al. Síndrome de Eagle, apófisis estiloides con prolongación hasta el hioides. Archivos de Medicina. 2017; 17 (2): 434-436.

  17. Fuentes FR et al. Proceso estiloides en una muestra de radiografías panorámicas de la ciudad de Temuco-Chile. Int J Morphol. 2007; 25 (4): 729-733.



AFFILIATIONS

1 Centro Educativo de Humanidades (cedhum).



CORRESPONDENCE

Franco Fonseca Balcázar. E-mail: ortho_frank@hotmail.com




Received: Julio 2019. Accepted: Diciembre 2019.

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