ULTRASOUND-GUIDED

FOR EAGLE SYNDROME

CLINICAL PERPECTIVES

Eagle syndrome, The styloid

is caused by: compress of:

Abnormaly Calcified Internal jugular Branches of the

Internal carotid vein
elongated styloid stylohyoid glossopharyngeal
artery
process ligament nerve
CLINICAL PERPECTIVES
PAIN CHARACTERISTICS:

• sharp stabbing pain that occurs with turning

of the neck or mandible.

• The pain starts below the angle of the

mandible

• Radiates into the tonsillar fossa,

temporomandibular joint, and the base of
the tongue.

A trigger point may be present

in the tonsillar fossa in a The anatomy of the styloid process and stylohyoid ligament and their
manner analogous to surrounding anatomic structures.
glossopharyngeal neuralgia.
CLINICAL PERPECTIVES

A–E: Bilateral hypertrophied styloid processes as shown

with three-dimensional computed tomography (CT) scan.
CLINICAL PERPECTIVES

Sign and Symptom Epidemiology Treatment

• Otalgia, • Often in the third to • The ultrasound-

• Dysphagia, and fifth decade although guided injection
• Tinnitus. can occur at any age. technique for Eagle
• More common in syndrome serves as
females. diagnostic and
therapeutic maneuver.
• Ultimately, surgical
resection of the
elongated styloid
process and/or
calcified stylohyoid
ligament may be
required to cure the
syndrome.
RELEVANT ANATOMY
A,B: Sagittal CT angiographic views show the narrowing of the jugular vein caused by
compression between the right styloid process (S) and the right C1 lateral tubercle. C:
Axial CT angiographic view shows the same compression (circled area). Note the
absence of the left internal jugular vein (IJ).

• The temporal styloid process extends from

the temporal bone in a caudad and ventral
direction and serves as the cephalad
attachment of the stylohyoid ligament

• The ligament attaches caudally to the hyoid

bone.
RELEVANT ANATOMY

• The glossopharyngeal nerve exits from the

jugular foramen in proximity to the vagus and
accessory nerve and the internal jugular vein
and passes just inferior to the styloid
process.

• All three nerves lie in the groove between

the internal jugular vein and internal carotid
artery.

• When treating with the ultrasound-guided

injection, the key anatomic landmark is the
styloid process of the temporal bone.
ULTRASOUND-GUIDED TECHNIQUES
Patient in supine position with the head turned away from the side to
be blocked.

An imaginary line is drawn from the mastoid process to the angle of

the mandible

The styloid process lies just above the midpoint of this line.

After preliminary identification, the skin is prepped with antiseptic

solution

A 5 mL of local anesthetic is drawn up in a 10-mL sterile syringe,

40 to 80 mg of depot steroid added if the condition have an

inflammatory component.

A linear ultrasound transducer is then placed over the previously

identified location in the transverse plane
ULTRASOUND-GUIDED TECHNIQUES
• Identify the styloid process and the carotid artery
and jugular vein

• Color Doppler may be utilized to help confirm

location of the vessels and their relationship to the
styloid process

Transverse ultrasound image demonstrating the

relationship of the carotid artery, jugular vein,
glossopharyngeal nerve, and vagus nerve to the
mastoid bone.

Color Doppler image of the carotid artery and jugular vein.

ULTRASOUND-GUIDED TECHNIQUES
A 22-gauge, 3½-inch styletted spinal needle is inserted with
ultrasound guidance toward the styloid process.

The styloid process should be encountered within ~3 cm.

After contact with the styloid process, the needle is withdrawn

slightly out of the periosteum or substance of the calcified ligament.

After careful aspiration 5 mL of solution should be slowly injected.

Subsequent daily nerve blocks are carried
out in a similar manner.

The needle is removed

Pressure is placed on the injection site to avoid bleeding.

COMPLICATIONS
Needle-induced to the internal jugular
trauma vein and/or carotid
artery.

dysphagia secondary
Motor portion of the
to weakness of the
glossopharyngeal
stylopharyngeus
nerve
muscle.

Dysphonia
secondary to
paralysis of the
ipsilateral vocal cord.
Inadvertent blockade Vagus nerve

A reflex tachycardia.

Hypoglossal and weakness of the

spinal accessory tongue and trapezius
nerves muscle.

pressure is applied
Bleeding and use of cold
can be decreased if
complications packs to the injection
site.
CLINICAL PEARLS

This ultrasound-guided injection technique can relief for patients suffering from
Eagle syndrome.

The proximity of the styloid process to carotid artery and jugular vein means
the possibility for needle trauma and/or inadvertent intravascular injection.

The careful identification with ultrasound imaging of all is crucial to

decreasing the incidence of fatal complications.

Incremental dosing while carefully monitoring the patient for signs of local
anesthetic toxicity can further decrease the risk to the patient.

Postblock hematoma and ecchymosis can occur.

CLINICAL PEARLS
Although glossopharyngeal neuralgia and Eagle syndrome share some common symptoms,
the clinician must distinguish between the two syndromes as curative treatments for each
syndromes are very different.

Glossopharyngeal neuralgia Eagle syndrome

• Paroxysms of shock-like pain • The sharp, shooting pain on

in a manner more analogous head and neck movement.
to trigeminal neuralgia • Serious cardiac
• Serious cardiac bradyarrythmias
bradyarrythmias • Syncope
• Syncope

The clinician should always evaluate the patient who suffers from pain in this anatomic
region for occult tumors of the larynx, hypopharynx, and anterior triangle of the neck
that may mimic Eagle syndrome
Three patients demonstrating extralaryngeal spread. CT studies
were done in all patients. The spread outside the pharynx was not
detectable in any of the patients on the basis of the clinical
examination. A–C: Patient 1. A low-volume but locally aggressive-
appearing pyriform sinus carcinoma invading the right superior
laryngeal neurovascular bundle (arrows in A) and spreading
outside the larynx. In (B), that spread pattern along the superior
neurovascular bundle can be seen again (arrows) with an
associated metastatic lymph node. In (C), submucosal spread to the
junction of the hypopharyngeal and oropharyngeal posterior walls
is present (arrow), and there is a positive level 2 lymph node
containing multiple peripheral metastatic deposits (arrowheads).
D,E: Patient 2. There is an almost entirely exophytic pyriform sinus
and aryepiglottic fold cancer (arrow). However, the tumor can be
seen spreading along the superior laryngeal neurovascular bundle
outside the larynx (arrowhead). There is an associated level 3
metastatic lymph node that is completely replaced by tumor (white
arrow). In (E), the tumor, which on its surface appears relatively
lobulated and exophytic, shows evidence of probable early thyroid
lamina invasion (arrow). F–H: Patient 3. A very aggressive cancer
can be seen growing through the thyrohyoid membrane along the
superior laryngeal neurovascular bundle (arrows in F and G). The
carotid artery is encased by this tumor growth, as seen in (G).
Spread along the superior laryngeal neurovascular bundle is
sometimes associated with or due to lymph nodes (arrow) along this
bundle, as demonstrated in (H).