Eagle Syndrome Treatment – A Different non-surgical approach

Ross Hauser, MD

If you have landed on this page, it is very likely that you have been on a medical journey of discovery for many years. What you are obviously trying to discover is the mysterious and seemingly untreatable group of symptoms you have. As you will see in some of our sample stories below, you are not alone in this. It is extremely rare that someone will be given a first diagnosis of Eagle Syndrome, it is usually a diagnosis made after, in some cases, the realization of “what else could it be? It must be Eagle syndrome or its close companion Ernest Syndrome.

Here are some of the things we hear that helped people get to a diagnosis of Eagle syndrome.

Eagle syndrome and the diagnosis of stylohyoid complex syndrome

An note of explanation: Eagle syndrome and the diagnosis of stylohyoid complex syndrome are very similar. Researchers over the years have written of the main distinction being Eagle Syndrome is acquired after a neck injury, stylohyoid complex syndrome that develops in childhood, adolescence or earlier in life. There is no history of previous injury, surgery or trauma. The symptoms can be the same, the treatments can be the same.

My doctors are confused by my symptoms

I have been diagnosed with Eagle Syndrome, my doctors are confused by my symptoms. My symptoms are all isolated on the right side of my head and neck. 

I was in a car accident as a teenager, I had a whiplash type injury. I have had chronic neck and back pain since. Over the years I have felt a grinding and crunching in my neck. My most recent MRI has revealed that the grinding was my C5-C6. They are grinding against each other and have caused developing bone spurs in that joint. I had been seeing a chiropractor and was prescribed physical therapy for problems in my neck that I thought were more related to C0-C1. It feels like my C1 is banging against the back of my skull.

I also developed a severe and terrible ear pain. None of my doctors could figure it out. The ENT sent me to an ear specialist, I had lots of tests, no answers. I was put on medication for Meniere’s disease because there seemed to be nothing else to do. I have so many symptoms and so many problems. I have been searching online to see if I can possibly help myself and my doctors. One doctor suggested “Eagle Syndrome,” and I found some articles.

After all these years I think I may have found “ground zero,” to my problems. My vertigo, tinnitus, numbness in my face. The constant pain at the base of my skull and countless neurologic symptoms that had my doctors looking at ALS and MS. I am trying to get all my doctors on board. The problem is is that each specialist is so focused on their part of the body. My spinal specialist may as well be a million miles away from my ENT as much as they communicate. But I am going to concentrate on my neck and going to focus on that.

Throat inflammation

I was finally diagnosed with Eagle syndrome. My ENT initially suspected cancer. I was sent for a barrage of tests. Once it was NOT cancer, my ENT felt more free to explore other possibilities. He suggested Eagle syndrome. Cancer entered into this because no one could figure out why I had so much throat inflammation.

Novocaine and the dentist

I have been on a long medical journey. It started over 10 years ago with some dental work. I had numerous novocaine injections into my jaw at the TMJ. After the dental work the symptoms then progressed over the years. Burning pain and numbness in my face and neck. Then, ear pain and fullness, balance problems, dizziness and vertigo, difficulty swallowing food stuck in throat, throat inflammation, vision problems, pain at the back of my head and the sensation when I wake up that I was punched at the base of my skull.

My neurologist figured that all this was coming from nerve compression in my neck and I had a C5-C7 fusion. Symptoms continued. The result of the surgery was an increase in my medications. The Diazepam does help with a multiple of my symptoms including the muscle pain and this odd sweating I have. I also have to take Vicodin when the pain is severe.

I took it upon myself to see what more I can do for myself besides relying on these medication. My interest was peaked in understanding the stylomandibular ligament, Ernest Syndrome, Eagles syndrome, and Barre Liéou syndrome as your description of these symptoms is actually describing me.

My ENT then suggested Trigeminal Neuralgia

My doctors and I have been searching for almost 20 years to try to figure out what is wrong with me. All my pain is limited to the left side of my body. Each specialist I see limits how much I can be helped by their specialty. I have been putting off a neck surgery because I already had some surgical attempts to fix the pain in my shoulders and arms. I am not really sure how much the neck surgery will help me when these other surgeries did not. My ENT then suggested Trigeminal Neuralgia. So I went home and started researching that. Things started to make sense because the Trigeminal Neuralgia possibility lead me to Ernest and Eagles Syndromes and the burning and tingling I feel in my mouth and face, the ear pain and fullness, the swallowing difficulties, sinus pressure, and neck pain, it started to come together for me.

If there is an injury involved, whiplash, fall, accident, your doctor should be more aware of the possibility of Eagle Syndrome

Doctors at The New York Eye and Ear Infirmary of Mount Sinai Hospital have published their recommendations for Eagle Syndrome in the journal Clinical neurology and neurosurgery.(1) Here are the study highlights:

  • A comprehensive literature review was conducted on peer-reviewed publications of Eagle syndrome across multiple disciplines in order to gain a thorough understanding of the presentation, diagnosis, and management of this disorder.
  • Diagnoses of Eagle Syndrome have increased, in part due to the awareness of physicians to patient symptomatology.
  • While cervical pain and dysphagia (swallowing difficulties) are among the typical symptoms, patients can present with a wide spectrum of benign and dangerous symptoms.
  • Treatment strategies include medical management (analgesics, corticosteroids, antidepressants, and anticonvulsants) and varied surgical approaches.
  • Increased understanding by providers treating patients with Eagle Syndrome allows for a more comprehensive treatment plan. With a variety of medical regimens and more definitive surgical approaches, Eagle Syndrome can be treated safely and effectively.

Most physicians have not heard of Eagle syndrome and do not know where the stylomandibular ligament is located. For this reason, many people receiving the treatments mentioned above do not obtain relief from their pain as in the symptoms listed below.

The problems of nerve and artery compression: Elongated styloid process and carotid artery syndrome

In our sample stories above and the many problems they describe we see that at the base of these people’s problems is a lack of diagnosis and understanding of what their symptoms are. This is not unique to Eagle Syndrome people. It is a common characteristic in the many of the patients we see with upper cervical spine instability.

This is what your doctors know: Eagle syndrome is medically known as the elongation of the styloid process and stylohyoid ligament calcification. This typically occurs with aging, and often results in sharp, intermittent pain along the glossopharyngeal nerve that is located in the hypopharynx and at the base of the tongue.

What are we seeing in this image?

The image is from a medical paper, published in the Journal of occupational medicine and toxicology.(2)

  • This is an image of the neck of a 42 year old secretary. She complained of a long history of neck pain and limited movement of the cervical spine. To her doctors surprise, radiologic examination revealed a bilateral ossification of the stylohyoid ligament complex.
  • Her symptoms did not resolve or her condition improve with conservative treatment consisting of anti-inflammatory medication as well as physical therapy. The patient was admitted to surgical resection of the ossified stylohyoid ligament complex. Afterwards she was free of any complaints and went back to work.
    • Our note: Surgery was the only tool in this patient’s case. In some people surgery may be the only tool. For others, non-surgical options can work as well and this will be discussed below.

What is ossification of the stylohyoid ligament complex?

Simply, the ligament is taking on the characteristic of bone. It is calcifying, thickening, hardening and losing its natural elasticity. When the cervical spine ligaments lose their natural elasticity, they can lead to a “fusion,” where the neck does not move, or to hypermobility, where the vertebrae move too much and this can cause pinching and compression of the nerves and arteries and the myriad of symptoms associated with this problem.

Do you also see something in this image that we see? Lots of fillings in the back teeth.

By Kirchhoff G, Kirchhoff C, Buhmann S, Kanz KG, Lenz M, Vogel T, Kichhoff RM. A rare differential diagnosis to occupational neck pain: bilateral stylohyoid syndrome. J Occup Med Toxicol. 1, 14. 2006. doi:10.1186/1745-6673-1-14. PMID 16800878., CC BY 2.0, Link

The styloid process is a piece of bone that starts at the base of the skull and attaches to a number of muscles and ligaments that are connected to the throat and tongue. Elongation of the stolid process, as well as a calcification of the stylohyoid ligament, can result in Eagle Syndrome. The stylohyoid ligament is located between the styloid process and the hyoid bone, a bone in the front of the throat, to which a number of throat muscles are attached.

Discussing arterial compression or carotid artery syndrome

A 2018 paper (3) discussed five case histories of patients with “rare” neurological symptoms of unknown origin: Here are the learning points observed in these five patients:

  • In addition to symptoms of  recurrent throat pain, neck pain, dysphagia (swallowing difficulties), or facial pain due to an elongated styloid process or calcified stylohyoid ligament, clinical findings related to lower cranial nerve compression have also been reported.
    • Explanatory note on the lower cranial nerves : This comes from a paper titled: “Disorders of the lower cranial nerves.”(4)
  • In some cases, it is reported that carotid artery compression or dissection can be seen due to elongated styloid process and this is called carotid artery syndrome. Carotid artery compression causes flow reduction and carotidynia (also called Fay Syndrome – face and neck pain of unknown origin) or neurological symptoms can be seen. Dural sinuses and the jugular vein can be compressed. Eagle syndrome with neurological symptoms has been rarely reported.

The five patients:

  • The 5 patients were between 22 and 68 years old.
  • They all had various neurological symptoms, each patient underwent computed tomography (CT) that revealed a long styloid process.

The findings:

  • An elongated styloid process caused neurological symptoms.
    • Two patients had venous compression by the styloid process.
    • The other patients had transient ischemic attacks due to internal carotid artery compression by the styloid process.
    • Only one patient underwent surgical removal.
    • In conservative care patients, outcomes were good after treatment and no symptoms remained.

The compression of the jugular vein

In January 2020 a team of researchers publishing in the journal CNS neuroscience and therapeutics (5) offered a series of findings in the patients that they were seeing that allowed the researchers to come up a diagnosis label called cervical spondylotic internal jugular venous compression syndrome. Let me explain this briefly because this syndrome is what we are seeing in our patients and can be applied to many diagnosis including Eagle Syndrome.

The possible compression of the jugular vein in Eagle Syndrome: The learning points of the research:

  • Cervical spondylosis is a commonly encountered degenerative disorder of the cervical spine. Abnormal structures, repetitive movements, and aging degeneration can exacerbate bone hyperplasia (overgrowth) and losses of intervertebral disc contents (the disc flattens) and subsequently cause the disc to bulge outward, which in turn hasten the damage to the disc and surrounding structures gradually.
  • Cervical spondylosis may contribute to many symptoms such as cervical radiculopathy, cervical myelopathy, axial neck or shoulder pain, and vertebral artery insufficiency.
  • The researchers noticed in their clinical practice, a group of of patients with unexplained nonfocal (not a nerve problem) neurological dysfunctions display cerebral venous outflow disturbance in relation to the atlas (C1) compression of the superior segment of the internal jugular vein.

Before we finish looking at this research, a brief note: We have published extensive articles on the problems we are going to mention below. The links are provided.

  • Internal jugular vein stenosis has been associated with several central nervous system disorders, including transient monocular blindness, Ménière disease, Alzheimer’s disease, idiopathic intracranial hypertension (please see our article Cervical Spine Instability, Vein blockage, fluid build up and intracranial hypertension), and multiple sclerosis.
  • Decreased cerebral perfusion (blood flow to the brain – see our article Dynamic Analysis of Blood Flow Measurements to the Brain, Brainstem, Cervical Spinal Cord, and Cranial Nerves), cerebral microvascular structures impairment (This is the network where arteries and veins connect by way of the arterioles (the part of the artery that leads to the capillaries), capillaries (that connect the arterioles to the venules), and venules (which bring the connection to the vein), impaired cerebrospinal fluid (CSF) dynamics, and elevated intracranial pressure may be the underlining mechanisms of internal jugular vein‐induced brain structural and functional disorders.
  • This study saw many of the things we see: That some nonfocal neurological symptoms like headache, head noise, tinnitus, and visual impairment are tightly correlated to unilateral or bilateral internal jugular vein syndrome.

Internal jugular vein gets compressed by anterior subluxation of C1 and C0-C1 instability

In December 2019, a paper appeared in the European archives of otorhinolaryngology.(6) The paper was the combined effort of a university hospital’s department of radiology, computer engineering department, and the anatomy department. The goal was to help doctors better identify stylohyoid complex syndrome by offering a standardization of measurements of how long the styloid process should be and at what angle should it jut from the temporal bone (base of the skull). Deviations in these measurements can help with a diagnosis of Eagle syndrome.

While this would be helpful, Dr. Enrico Nastro Siniscalchi, a maxillofacial surgery and assistant professor at the University of Messina took it one step further and more in agreement with what we have seen in our patients. Basically the styloid process does not have to be that elongated or even display the type of angulation or measurements deviations discussed in the previously mentioned study. A normal size styloid process can cause arterial compression if there is cervical spine instability.

Here are his learning points in his published response. (7)

  • Even in the presence of a styloid process of normal length, lateral (side) and medial (middle) deviations can occur, in fact, in a normal styloid process can cause compression of vessels and nerves.
  • (Dr. Siniscalchi’s) recent experience focuses the attention on the “dynamic” relationship between stylohyoid process and near structures. (In other words the relationship in motion). In particular, above all in the vascular variant, neurological (symptoms) seem to be often influenced by the position of head and neck, varying in the same patient from a position to another.
    • Note: What Dr. Siniscalchi is saying is what we see in our digital motion x-ray images. A digital motion x-ray is an x-ray movie. It reveals the “dynamic” elements of neck instability. That is, what is happening to the neck in movement and does moving the neck into different positions cause neurological symptoms? For example does turning you head to the right make you pass out or get dizzy. Does looking up “clog” your ears. Does looking down create a brain fog, etc.
  • Dr. Siniscalchi suggests that as a consequence of this strong influence of head and neck position and symptomology, in the case of a suspected Eagle Syndrome, a standard “static” tool could not be sufficient to better clarify the relationship between styloid and other structures. In other words, in the case of suspected Eagle Syndrome an imaging tool like MRI and ultrasonography of the head and neck region should be taken in different position of the head, being the structures involved in such syndrome conditioned by the different positions of the entire head and neck region.
  • Dr. Siniscalchi suggests taking an image in five positions of the head: rest position, maximum extension, maximum flexion of the head, maximum right and maximum left rotation.

Digital motion X-ray showing C1-C2

This is one of our videos, it gives a clearer view of the DMX demonstrating C1-C2 instability in a patient.

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
  • This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.

Prolotherapy Treatment of Eagle syndrome

In this section we are going to discuss a possible treatment. That treatment is Prolotherapy. In simple terms, Prolotherapy repairs ligaments. In the case of Eagle syndrome. The cervical spine ligaments.

In the research and clinical observations explained above, we have been able to demonstrate that some neurological symptoms are related to the compression of the cervical nerves, arteries, and even the jugular vein, In Eagle syndrome this compression may be caused by a weakened or damaged set of cervical ligaments, here focused on the stylohyoid ligament complex. Prolotherapy injections at the stylomandibular ligament bony attachments will start the repair process. Once the stylomandibular ligament is strengthened, the chronic ear-mouth pain, tinnitus, dizziness, vertigo, and other pain complaints subside.

Research on cervical instability and Prolotherapy

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. Here are some.

In our paper Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability we wrote: 

“To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment which is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”

In other words, Prolotherapy may treat the very difficult to treat.

 

Caring Medical research

If this article has helped you understand the problems of cervical spine instability and Eagle Syndrome and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

References:

1 Badhey A, Jategaonkar A, Kovacs AJ, Kadakia S, De Deyn PP, Ducic Y, Schantz S, Shin E. Eagle syndrome: A comprehensive review. Clinical Neurology and Neurosurgery. 2017 May 6. [Google Scholar]
2 Kirchhoff G, Kirchhoff C, Buhmann S, Kanz KG, Lenz M, Vogel T, Kichhoff RM. A rare differential diagnosis to occupational neck pain: bilateral stylohyoid syndrome. Journal of Occupational Medicine and Toxicology. 2006 Dec;1(1):1-5. [Google Scholar]
3 Aydin E, Quliyev H, Cinar C, Bozkaya H, Oran I. Eagle syndrome presenting with neurological symptoms. Turk Neurosurg. 2018 Jan 1;28(2):219-25. [Google Scholar]
4 Finsterer J, Grisold W. Disorders of the lower cranial nerves. Journal of neurosciences in rural practice. 2015 Jul;6(3):377. [Google Scholar]
5 Ding JY, Zhou D, Pan LQ, Ya JY, Liu C, Yan F, Fan CQ, Ding YC, Ji XM, Meng R. Cervical spondylotic internal jugular venous compression syndrome. CNS neuroscience & therapeutics. 2020 Jan;26(1):47-54. [Google Scholar]
6 Ayyildiz VA, Senel FA, Dursun A, Ozturk K. Morphometric examination of the styloid process by 3D-CT in patients with Eagle syndrome. European Archives of Oto-Rhino-Laryngology. 2019 Dec 1;276(12):3453-9. [Google Scholar]
7 Siniscalchi EN. Dynamic imaging in suspected Eagle syndrome. European Archives of Oto-Rhino-Laryngology. 2020 Jan 1;277(1):307-. [Google Scholar]

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