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Sunday, February 21, 2010

Throat Pain: Frequently can be hard to diagnose and misdiagnosis is common.

An article (PubMed abstract below) in Janury "CRANIO journal" by Dr Wes Shankland dicusses patients with anterior throat pain. These patients have frequently seen numerous physicians and had multiple digagnostic tests and frequently ineffective treatment. There are five syndromes that frequently cause this type of problems. The five disorders are, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome.

Ernest syndrome and Ernst Syndrome are caused by calcification of stylohyoid or stylomandibular ligaments that is frequently diagnosed by panoramic radiographs and palpation of the ligaments. There are numerous cases of throat pain being referred from various muscless but Dr Shankland points to the Superior Pharyngeal constictor syndrome.

According to an article from Tulane (see PUBMED abstract below) a diagnosis of Eagle's syndrome can be difficult to make. The diagnosis is infrequent and the symptoms vary widely.

An excellent description of Eagles Synrome can be found in "South Med J. 1998 Jan;91(1):43." (see PubMed abstract below) "Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear". Some of the symptoms of Eagle's Syndrome include:
Pain on turning head
Pain associated with tongue protrusion
Cough without sputum
Voice changes
Symptoms of Sinusitis that do not respon to treatment
Dizziness and/or feelings of disequilibrium, Vertigo
Bloodshot eyes
Throat pain,Throat discomfort Throat soreness or Foreign body sensation in throat
Facial pain
Difficulty swallowing or Dysphagia
Disturbed sense of taste
Headache especially if associated with swallowing
Sensation of excessive salivation
Swallowing difficulty, throat pain associated with swallowing
Pain on opening mouth

Bafaqeeh subclassified Eagle's syndrome into two different types: its classic form and an entity he called styloid-carotid artery syndrome. Symptoms include neurological and vascular problems with at least one report of blindness. The management of styloid-carotid artery syndrome include sagittal CT angiography and/or intraoperative neurophysiologic monitoring, and a transcervical approach to resection.

Many cases of undiagnosed throat pain respond well to neuromucular diagnostic orthotics. When the orthotic and/or trigger point injections do not relieve the pain these other conditions must be explored.


Cranio. 2010 Jan;28(1):50-9.
Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Shankland WE 2nd.

TMJ & Facial Pain Center, Westerville, Columbus, Ohio, USA. drwes@drshankland.com
It is not uncommon for practitioners who treat craniofacial pain to see patients with undiagnosed throat and submandibular pain. Usually, these patients will already have been seen by their primary care physician and frequently, several others doctors including otolaryngologists, oral and maxillofacial surgeons, and even neurologists. Far too often these patients have three common features: 1. they have endured multiple expensive diagnostic tests; 2. they have received treatment of multiple courses of antibiotics; and 3. no specific diagnosis for their pain complaints has been determined and their pain persists. In this article, five disorders, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome are briefly described. All five produce common symptoms, making diagnosis difficult, which is often followed by ineffective or no treatment being provided to the patient. Diagnostic criteria and suggested treatment modalities are also presented.

PMID: 20158009 [PubMed - in process]

J La State Med Soc. 1992 Aug;144(8):343-5.
Eagle's syndrome: the Ochsner experience.
Weiss LS, Butcher RB, White JA.

Dept of Otolaryngology-Head & Neck Surgery, Tulane University Medical Center, New Orleans.
Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.

PMID: 1453090 [PubMed - indexed for MEDLINE]

South Med J. 1997 Mar;90(3):331-4.
Eagle's syndrome (elongated styloid process)
Balbuena L Jr, Hayes D, Ramirez SG, Johnson R.

Otolaryngology-Head and Neck Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Tex, USA.
Comment in:

South Med J. 1998 Jan;91(1):43.
Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa. It may develop inflammatory changes or impinge on the adjacent arteries or sensory nerve endings, leading to the symptoms described. Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Radiographic workup should include anterior-posterior and lateral skull films. The treatment of Eagle's syndrome is primarily surgical. The styloid process can be shortened through an intraoral or external approach. We present two cases and review the literature.

PMID: 9076308 [PubMed - indexed for MEDLINE]

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posted by Dr Shapira at 7:19 PM

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