Styloid-stylohyoid syndrome
This 36 year old female patient presented to the department with glossodynia of her right tongue, poorly localized moderate to severe pain on the right side of face (including the buccal and temporal regions) and intraorally in the right buccal and oropharyngeal mucosa since about 3 months. These complaints had been earlier diagnosed in various centers as temporomandibular joint pain, atypical facial pain, and pain associated with impacted right mandibular third molar, and treated accordingly with no significant relief. Patient was eventually referred to our institution for removal of the impacted tooth.\nThe impacted third molar was completely asymptomatic on examination, with no evidence of recent or past pericoronitis. Orthopantomogram (OPG) [] showed bilateral impacted third molars. Of more immediate interest were the slightly elongated styloid processes and the bilateral ossified stylohyoid ligaments, which provided an alternative diagnosis for the patient's complaints, that is, Eagle's syndrome. This diagnosis was further reiterated when elective removal of the impacted tooth (the patient being willing) did not relieve the patient's symptoms. Elongated styloid process was not palpable in the tonsillar fossa.\nShe was then apprised of the possibility of Eagle's syndrome, and its treatment modalities. Conservative treatment was thought appropriate in her case, because the styloid process itself was not significantly elongated, so its fracture and removal were likely to have little impact. Moreover, since the diagnosis of Eagle's syndrome was provisional, relief with local therapy would serve as a confirmatory test at least.\nPalesy et al., (2000), based on their cadaveric study in 1992, determined the safest pathway for injection in the styloid region, which helped guide our injection technique.[] The steroid–local anesthetic combination used was Hydrocortisone (50 mg in 2 ml) and 0.5% Bupivacaine (1 ml).\nThe ear lobe, Frankfurt horizontal plane (FHP), and attachment of masseter muscle on the ascending ramus served as landmark for the point of insertion of needle []. Patient was instructed to clench teeth, and the postero-superior border of masseter palpated. After antiseptic and local anesthetic application, needle (25-G, 38-mm long), with bevel faced posteriorly (to avoid major vessels), was inserted below the ear lobe and 2-mm distal to posterior border of the ascending ramus at a level corresponding to postero-superior border of masseter, approximately 10° posterior to perpendicular at the skin surface and parallel to FHP. On reaching a penetration depth of 12 mm, after negative aspiration, 0.5 ml of the steroid – local anesthetic combination was injected. The needle was then inserted another 6 mm in the same direction (total depth 18 mm). The syringe was now angled anteriorly, some 30° from the previous position, while keeping it parallel to FHP, and inserted further to a total penetration depth of 24 mm. 1.5 ml of solution was deposited in this position []. In this way, 0.5 ml solution was deposited in the area of stylomandibular ligament insertion at the mandibular angle, followed by 1.5 ml solution deposition around the styloid–stylohyoid apparatus.\nAnother syringe was used intraorally to administer 0.5 ml of the steroid – local anesthetic combination in the region of the lingual nerve employing the standard technique for inferior alveolar and lingual nerve block administration in the pterygomandibular space.\nThe patient had immediate relief from pain in all regions, and has remained asymptomatic for the last 1 year since injection, which is a significant relief period. Moreover, the patient can always be readministered the injections if symptoms recur, or taken up for surgical intervention if symptoms worsen.