A 46-year-old male with no significant medical history presented with chronic bilateral laterocervical pain, more pronounced on the right side, evolving over several years. Clinical examination revealed a right sub-angulomandibular swelling. Bidigital palpation of the tonsillar region elicited discomfort and revealed a firm structure on the right side. Panoramic radiography demonstrated bilateral elongation of the styloid processes, consistent with Eagle syndrome (See Figure 1Figure 1).

Figure 1. Panoramic radiography of case 1.

The patient was managed conservatively with non-steroidal anti-inflammatory drugs and analgesics, resulting in partial symptom improvement at short-term follow-up.

A 19-year-old female with no relevant medical history was referred for persistent right-sided otalgia lasting three months. Otolaryngological examination was unremarkable. Panoramic radiography revealed ossification of the right stylohyoid ligament, giving the appearance of an elongated styloid process. The clinical and radiological findings supported the diagnosis of Eagle syndrome.

A conservative approach was adopted, including analgesic medication, with significant reduction of otalgia during follow-up (See Figure 2Figure 2).

Figure 2. Panoramic radiography of case 2.

A 78-year-old female presented with right-sided laterocervical pain evolving over 18 months. The pain was described as a pharyngeal paresthesia exacerbated by swallowing and head rotation and was associated with ipsilateral otalgia. Panoramic radiography showed unilateral elongation of the right styloid process, confirming the diagnosis.

Given the patient’s age and symptom severity, conservative management was preferred, leading to satisfactory symptom control during follow-up (See Figure 3Figure 3).

Figure 3. Panoramic radiography of case 3.

A 55-year-old male was referred for extraction of third molars. He reported no cervicofacial symptoms. Routine panoramic radiography incidentally revealed bilateral ossification of the stylohyoid ligaments. Although asymptomatic, the radiological findings were consistent with an anatomical elongation of the stylohyoid complex, without clinical features of Eagle syndrome (See Figure 4Figure 4).

Figure 4. Panoramic radiography of case 4.

The stylohyoid complex consists of the styloid process, the stylohyoid ligament and the lesser horn of the hyoid bone. It originates embryologically from Reichert’s cartilage of the second branchial arch. The styloid process extends from the temporal bone and lies near critical neurovascular structures, including the internal and external carotid arteries, the internal jugular vein, and cranial nerves VII, IX, X and XII [3].

The normal length of the styloid process is generally considered to be between 25 and 30 mm. Although exact measurements were not available for all cases.

Elongation beyond this range or partial to complete ossification of the stylohyoid ligament may result in mechanical irritation or compression of adjacent structures [4] (See Figure 5Figure 5).

According to Langlais et al., elongation of the styloid process can be classified into three radiological types: 1) elongated type, characterized by continuous mineralization; 2) pseudo-articulated type, where the styloid process appears jointed to a partially ossified ligament; and 3) segmented type, consisting of discontinuous ossified segments (See Figure 6Figure 6).

Eagle syndrome classically presents in two forms. The classic stylohyoid form is

Figure 5. Anatomy of the stylohyoid complex (Bensimon et al. 2005; Norton and Netter 2012).

Figure 6. Classification of styloid process elongation (Ilgüy et al. 2005, after Langlais et al. 1986).

characterized by unilateral cervicofacial pain, dysphagia and a foreignbody sensation in the tonsillar fossa. The stylocarotid form is associated with cervical pain radiating to the temporal or orbital regions, related to irritation of the carotid artery and surrounding sympathetic fibers.

In our series, symptoms ranged from chronic cervicofacial pain and otalgia to incidental radiological findings, illustrating the wide clinical spectrum of the condition [4][5]. In Case 4 represents an incidental anatomical elongation of the stylohyoid complex rather than true Eagle syndrome, as no related symptoms were present.

Diagnosis relies on a combination of clinical suspicion and imaging. Palpation of the tonsillar fossa may reproduce symptoms. Panoramic radiography is a useful screening tool, while computed tomography with three-dimensional reconstruction remains the gold standard for precise measurement and evaluation of the stylohyoid complex and its relationship with adjacent structures [5].

Differential diagnoses include temporomandibular joint disorders, glossopharyngeal neuralgia, cervical spine pathology, otitis, salivary gland diseases and neoplastic conditions.

Management may be conservative or surgical. Conservative treatment includes analgesics, non-steroidal anti-inflammatory drugs, corticosteroid or local anesthetic injections, anticonvulsants and physiotherapy. Surgical treatment consists of styloidectomy performed via intraoral or extraoral approaches [6].

Both surgical techniques have high success rates. The intraoral approach avoids external scarring but offers limited exposure, whereas the extraoral approach provides better visualization at the cost of a cervical incision and potential facial nerve risk. Treatment choice should be individualized based on symptom severity, anatomical considerations and patient preference [7][8].