Giant styloid process: causes, symptoms, diagnosis, treatment

The styloid process originates in the area of the tympanic part of the temporal bone, but its origin is not genetically related to the latter, since it is formed from the lower part of the second branchial arch, in the area of which embryonic cartilage appears in the 3rd month of intrauterine life, from the middle part of which the stylohyoid ligament is formed, which gradually ossifies with age. In children, the styloid process consists entirely of cartilaginous tissue, and since three muscles are attached to it, carrying out constant traction, then with a delay in ossification of the process, this cartilaginous tissue is lengthened and, together with the subsequent ossification of the stylohyoid ligament, forms a giant styloid process. Elongated styloid process occurs in 4% of cases, mainly in men and on the left, clinical manifestations of styloid process syndrome occur after 30-40 years of life. This syndrome most often manifests itself in weakened individuals, psychasthenics and “tired intellectuals”.

The giant styloid process, directed with its body from above-anteriorly and inwardly, reaches with its end the lower pole of the palatine tonsil. It passes in close proximity to the lateral surface of the facial nerve, between the external and internal carotid arteries. Deviations of the styloid process outward or inwardly lead to its contact with one of the carotid arteries and irritation of the carotid sympathetic plexus, which causes the occurrence of the corresponding syndrome: the internal carotid artery syndrome is manifested by pain in the parietal and orbital areas, and the external carotid artery syndrome is manifested by pain in the lower part of the temporal and retroorbital areas.

With a significant deviation of the styloid process inward, its end can reach the trunk of the glossopharyngeal nerve, and with a length of 5 cm, it can reach the capsule of the palatine tonsil. In this case, penetrating through the superior constrictor of the pharynx, the styloid process comes into contact with the palatine nerve plexus formed by the fibers of the glossopharyngeal and lingual nerves.

Clinical manifestations of this anomaly of the styloid process development, as noted above, occur approximately by the age of 40 and, depending on the direction of the styloid process, they may consist of pain when swallowing or when turning the head. Sometimes transient aphonia occurs. In some cases, the end of the styloid process may be in close proximity to the cervical vertebrae, in which case, when turning the head, the styloid process may come into contact with the second or third cervical vertebra, which causes the patient to feel a scraping sound. Irritation of the palatine plexus by the end of the styloid process leads to so-called stylalgia, which manifests itself as unilateral pain in the pharynx, radiating to the corresponding temporomandibular joint and external auditory canal. Pain radiating to the ear and occurring during swallowing is caused by irritation of the glossopharyngeal nerve, which runs along the posterior surface of the styloglossus muscle and ends at the base of the tongue, forming the lingual nerve plexus, branching in the area of the foramen cecum and the terminal groove of the tongue. Pain in the ear radiates along the tympanic nerve, which originates in the jugular ganglion of the glossopharyngeal nerve, enters the tympanic canal, the entrance of which is located on the lower-posterior wall of the petrous part of the temporal bone, and innervates the mucous membrane, eardrum and auditory tube. Stylalgia in its severity can simulate essential neuralgia of the glossopharyngeal nerve. Giant styloid process syndrome often leads to the development of cancerophobia in patients.

In some cases, the diagnosis can be established by bimanual palpation from the side of the pharynx and the angle of the lower jaw: when palpating on the left, the examiner places the index finger of the same name on the area of the lower pole of the tonsil behind the anterior arch, where a dense, slightly pliable cord is palpated. At the same time, the index finger of the right hand exerts pressure behind the angle of the lower jaw. An X-ray examination is also performed - lateral X-rays of the skull and especially important images in the frontal-nasal projection, in which the elongated styloid processes are visualized against the background of the orbits and maxillary sinus.

Treatment of giant styloid process is surgical - by external access to the area of the stylomastoid foramen (risk of damaging the facial nerve) or transpharyngeally with preliminary removal of the corresponding palatine tonsil and access through its niche. With this method, after removal of the palatine tonsil in its niche under palpation control of the second finger of the hand, which feels the styloid process, a vertical incision is made and the end of the styloid process is isolated with a blunt raspatory, onto which the ring of Luke's forceps is put on. After this, the body of the styloid process is separated, moving the forceps upward by 2-3 cm. Then the styloid process is bitten off, and 2-3 catgut sutures are applied to the wound in the niche of the palatine tonsil. The proximity of the carotid arteries requires the surgeon to be very careful when performing this surgical intervention.

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