Abstract
Objective: The main objective was to study the stylalgia profile in Indians and the outcome of styloidectomy in such cases.
Design: This prospective study was carried out by random selection of patients with stylalgia using periodic random numbers.
Setting: This was a hospital-based study.
Methods: Surgical excision of the symptomatic enlarged styloid process was performed by the transtonsiltar route using a dilation and curettage (D and C) curette.
Main Outcome Measures: The patients were followed postoperatively for their pain relief.
Results: Of 40 patients operated on, 31 (77.5%) became symptom free, 5 (12.5%) had considerable improvement in their symptoms, and 4 (10%) had no relief.
Conclusions: The incidence of an enlarged styloid process was found to be higher in an Indian rural population with female preponderance owing to their carrying of heavy weight on head. Styloidectomy was very rewarding. The D and C curette was found to be a very effective instrument for styloidectomy.
Sommaire
Objectif: Les objectifs de notre etude etaient d'etudier la presentation de la stylalgie en Inde et d'etudier les resultats de la styloidectomie chez ces patients.
Devis: Etude prospective avec selection aleatoire des patients vus a l'hopital.
Methodes: Exerese chirurgicale des processus styloides chez les patients symptomatiques par approche transamygdalienne et en utilisant une curette pour dilatation et curettage (D et C).
Mesures: Suivi post-operatoire quant au soulagement de la douleur.
Resultats: De 40 patients operes, 31 (77.5%) sont devenus asymptomatique, 5 (12.5%) ont note une amelioration considerable dans leurs symptomes, et 4 (10%) n'ont note aucune amelioration.
Conclusions: Nous avons trouve que l'incidence de styloide allongee est plus elevee chez les femmes Indiennes de la campagne probablement a cause des lourds fardeaux qu'elles transportent sur leur tete. La styofdectomie est tres satisfaisante. Nous avons trouve que la curette de D et C est un outil tres efficace pour la styloidectomie.
Key words: ossification, pseudoarthrosis, stylalgia, styloidectomy
Management of pain syndromes present in the head and neck region may at times be very challenging. One of the most important causes of pain in this area is styloid process neuralgia or stylalgia. It presents as a dull, nagging pain the throat, often localized to the tonsillar fossa and radiating to the ear, which becomes worse on swallowing. Digital pressure on the tip of the styloid process in the tonsillar fossa reproduces the exact symptoms. The stylalgia is usually consequent to an enlarged styloid process, which may even be palpable in the tonsillar fossa. We present here our experience with a series of 40 patients of stylalgia who underwent styloidectomy.
Materials and Methods
This prospective study was carried out in 40 patients with elongated styloid processes who underwent styloidectomy. There were 35 females and 5 males, with a mean age of 35 years (range 35-38 years). The cases were randomly selected using periodic random numbers out of 200 cases of stylalgia. The styloidectomy was not carried out in all of the patients because they did not consent for surgery. Of these, an equal number (i.e., 40) acted as controls. Styloidectomy was carried out bilaterally in 10 cases and unilaterally in 30 cases. In unilateral cases, 18 were done on the right and 12 on the left side. In 10 cases, where styloidectomy was performed unilaterally, an asymptomatic enlarged styloid process was present on the unoperated side. The presenting symptoms were pain in the throat in 35 cases, pain in the ear in 22 cases, pain in the neck or throat in 18 cases, and painful deglutition in 16 patients. All other causes of pain in the throat were excluded by examination and relevant investigations. The diagnosis of stylalgia was confirmed by palpation, 2% lignocaine injection, and radiography (Fig. 1).
Styloidectomy was carried out orally. Tonsillectomy was performed first, and the styloid process was palpated. An incision was given on the styloid process with a No. 15 Bard Parker knife, and the periosteum was elevated. A dilation and curettage (D and C) uterine curette was put at the tip of the styloid process and was gently slid upward as far as possible. This stripped the remaining periosteum from the styloid process. Then, by gentle side-to-side movements of the curette, the styloid process was broken at the root and removed. The wound was not sutured. The patients were given amoxicillin 500 mg tds, ibuprofen 600 mg tds, and antiseptic oral rinses for 10 to 14 days, depending on the healing of the fossa. There were no postoperative complications, including bleeding. However, swallowing remained painful for 1 to 2 weeks. Tonsillectomy was carried out only on the side on which the styloidectomy was done.
Results
The patients were followed up for a mean period of 16 months (range 6-24 months). Of 40 patients, 31 were symptom free, and 5 had considerable improvement to the extent that they did not require any analgesics subsequently. However, in 4 cases, there was no relief, but the symptoms did not worsen in any case. The mean length of the removed styloid process was 3.8 cm (range 3-4.5 cm). The longest styloid process was 4.5 cm (Fig. 2). On follow-up, 2 cases of the 10 who had an enlarged asymptomatic styloid process presented with stylalgia on the unoperated side. The patients who did not undergo styloidectomy continued to have symptoms and required analgesics off and on.
Discussion
The styloid apparatus, which includes the styloid process, stylohyoid ligament, lesser cornu, and the upper part of the body of hyoid, is derived from the second branchial arch of Reichert. The normal length of the styloid process ranges from 2.5 to 3 cm and is not palpable in tonsillar fossa. In our study, about 87.5% of the patients presented with symptoms of dull pain in the throat; 55% of these complained of its radiation to the ear, and 40% had painful deglutition. The most probable cause for this seems to be glassopharyngeal neuritis as the nerve lies just medial to the styloid process. Occasionally, the fifth nerve and rarely the tenth cranial nerve may be involved.' The pain can also be attributable to pseudoarthrosis between the ossified stylohyoid ligament and the styloid process, which causes intermittent locking or fixation.2 Another mechanism is bony stiff clasp formation owing to ossification of the stylohyoid ligament. This causes irritation of the sympathetic plexus around the carotid artery or carotid sinus branch of the ninth nerve, causing neck pain along the distribution of the carotid artery,3 which was also observed in 45% of our cases.
Half of our patients had bilateral enlargement of the styloid process, but 50% of these were symptomatic on one side only. Harma4 also showed bilateral elongation in 50% of his 52 cases, but only half of them had bilateral symptoms. However, Steinmann5 described the styloid syndrome even in the absence of an elongated styloid process.
The enlargement of the styloid process can be either congenital or owing to ossification of the stylohyoid ligament. The ossification of the stylohoid ligament can be both continuous or segmental (i.e., with ligamentous attachment between the ossified parts).2,6 The results of our study are in agreement with this concept because ossification of the stylohyoid ligament is part of the aging process, and all of our patients were above the age of 30 years. But our study showed a very high female-to-male ratio of 7:1; in another Indian study,7 it was 6:1. This female preponderance of stylalgia is unique to India. A study by Harma in Western people showed a female-to-male ratio of 3:2 only.4 No population-based survey was carried out, but our institution caters mainly to country-side population, and all of our patients belonged to the rural areas. The most probable reason for this increased incidence of stylalgia in rural females seems to be related to their carrying heavy loads on their head, which might be responsible for a strong or even ossified stylohyoid ligament.
Although the number of patients with an elongated styloid process was greater, only 40 consented to surgery. From our experience, it seems that the incidence of symptomatic styloid enlargement is higher in India than in Western countries, which confirms the findings of Eagle that the incidence of an enlarged styloid process increases as we go from Caucasian to Negroid characters.1
The correct diagnosis of stylalgia is very important and should be differentiated from others simulating pain syndromes (e.g., glassopharyngeal neuralgia, hyoid syndrome, and sphenopalatine ganglion neuralgia). In real stylalgia, styloidectomy is very rewarding, as in this study, about 77.5% of the patients became symptom free and 12.5% had a significant improvement in their symptoms.
During surgery the use of a D and C uterine curette (generally used in gynaecologic practice) was found to be very useful because it strips the styloid periosteum and breaks the styloid process at the base, making the removal complete and easy. The subsequent development of stylalgia on the unoperated side in two patients who had an asymptomatic enlarged styloid process raises a pertinent question: whether a bilateral styloidectomy should be performed when it is enlarged bilaterally but has symptoms on one side only.
References
1. Eagle WW. Elongated styloid process. Further observations and a new syndrome. Arch Otolaryngol 1948; 47:630-640.
2. Leighton SEJ, Whittet HB, Golding S, et al. Styloid apparatus anomaly causing dysphagia. J Laryngol Otol 1991; 105: 964-965.
3. Bhide A. Hyoid syndrome-a review. Indian J Otolaryngol 1985; 37:141-143.
4. Harma R. Stylalgia clinical experiences of 52 cases. Acta Otolaryngol (Stockh) 1967; 224:149-155.
S. Steinmann EP. Styloid syndrome in absence of an elongated process. Acta Otolaryngol (Stockh) 1968; 66:347-356.
6. Chandler JR. Anatomical variations of stylohyoid complex and their clinical significance. Laryngoscope 1977; 87: 1692-1701.
7. Verma R. Stylalgia. Indian J Otolaryngol 1996; 48:312-314.
Received 26/09/00. Received revised 31/01/01. Accepted for publication 21/03/01.
Samar P.S. Yadav, Rakesh Chanda, and Amit Gera: Department of Otolaryngology, Rohtash K. Yadav: Department of Radiology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana), India.
Address reprint requests to: Dr. Samar P.S. Yadav, 30/9J, Medical Enclave, Rohtak-124001 (Haryana), India.
Copyright Decker Periodicals, Inc. Sep/Oct 2001