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Eagle’s syndrome associated with temporomandibular disorder: A clinical report

Identifieur interne : 003008 ( Istex/Corpus ); précédent : 003007; suivant : 003009

Eagle’s syndrome associated with temporomandibular disorder: A clinical report

Auteurs : Célia M. Rizzatti-Barbosa ; Eduardo B. Lopesb ; José R. De Albergaria-Barbosa ; Brenda P. F. A. Gomes

Source :

The Journal of Prosthetic Dentistry [ 0022-3913 ] ; 1999.

RBID : ISTEX:619E02FEB03CC0BA8A2E6C61C753CE86A4BDA4CE

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https://api.istex.fr/document/619E02FEB03CC0BA8A2E6C61C753CE86A4BDA4CE/fulltext/pdf

DOI: 10.1016/S0022-3913(99)70102-2

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ISTEX:619E02FEB03CC0BA8A2E6C61C753CE86A4BDA4CE

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<ce:note-para><ce:sup>a</ce:sup>
Assistant Professor of Removable Prosthodontics. <ce:sup>b</ce:sup>
Undergraduate Student. <ce:sup>c</ce:sup>
Assistant Professor of Oral Surgery. <ce:sup>d</ce:sup>
Assistant Professor of Endodontics.</ce:note-para>
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<ce:article-footnote><ce:label>☆☆</ce:label>
<ce:note-para>Reprint requests to:Dr CÉlia M. R. Barbosa, Faculdade De Odontologia De Piracicaba, Departamento De PrÓtese E Periodontia, Avenida Limeira, 901—Bairro AreiÃo, Piracicaba—Sao Paulo, Cep 13414-018, Brazil, Fax: (55)19-430-5218,<ce:inter-ref xlink:href="mailto:rizzatti@fop.unicamp.br">E-MAIL: rizzatti@fop.unicamp.br</ce:inter-ref>
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<ce:title>Eagle’s syndrome associated with temporomandibular disorder: A clinical report</ce:title>
<ce:author-group><ce:author><ce:given-name>Célia M.</ce:given-name>
<ce:surname>Rizzatti-Barbosa</ce:surname>
<ce:degrees>DDS, PhD<ce:sup>a</ce:sup>
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<ce:author><ce:given-name>Eduardo B.</ce:given-name>
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<ce:author><ce:given-name>José R.</ce:given-name>
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<ce:author><ce:given-name>Brenda P.F.A.</ce:given-name>
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<body><ce:sections><ce:para>Eagle’s syndrome was first described in 1937, when W. W. Eagle reported 2 clinical situations that involved an abnormal styloid process causing, among other symptoms, pain about the ear and within the throat.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup>
</ce:cross-ref>
 Eagle also observed that a tonsillectomy had been performed on both patients.<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup>
</ce:cross-ref>
 This syndrome is characterized by an elongated styloid process (greater than 2.5 cm) or a calcified styloid ligament compressing the fifth and/or ninth cranial nerve.<ce:cross-ref refid="bib3"><ce:sup>3</ce:sup>
</ce:cross-ref>
 The diagnosis usually follows a series of clinical signs and symptoms associated with the radiographic examination, and palpation of the tonsillar fossa. Hampf et al<ce:cross-ref refid="bib4"><ce:sup>4</ce:sup>
</ce:cross-ref>
 suggested that there is a psychosomatic background to the complaints, which occur more frequently in women.<ce:cross-ref refid="bib5"><ce:sup>5</ce:sup>
</ce:cross-ref>
 Eagle’s syndrome affects approximately 27% of the population.<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup>
</ce:cross-ref>
 Leite et al<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup>
</ce:cross-ref>
 analyzed Brazilian human skulls and found that the percentage of an elongated styloid process was approximately 19.56%.</ce:para>
<ce:para>Surgical treatment is often indicated with good results after amputation of the styloid process by a pharyngeal approach.<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup>
</ce:cross-ref>
 In some situations, this syndrome may be associated with temporomandibular disorders (TMDs),<ce:cross-refs refid="bib9 bib10"><ce:sup>9,10</ce:sup>
</ce:cross-refs>
 with pain relieved by styloidectomy and arthroscopy.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup>
</ce:cross-ref>
 Some authors prefer a conservative therapy of placing local anesthetic into the styloid process and the stylomandibular ligament attachment.<ce:cross-refs refid="bib6 bib12"><ce:sup>6,12</ce:sup>
</ce:cross-refs>
 According to them, implementation of conservative and noninvasive treatments, including education, behavioral training, and pain or stress management, may reduce symptoms to a degree that further intervention is unnecessary.<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup>
</ce:cross-ref>
</ce:para>
<ce:para>This clinical report presents a conservative therapy approach to treating a patient with Eagle’s syndrome associated with TMD.</ce:para>
<ce:section><ce:section-title>CLINICAL REPORT</ce:section-title>
<ce:para>A 29-year-old woman with the chief complaint of pain in the maxillary left posterior region, which radiated to the left preauricular and postauricular areas, was examined in the Emergency Service Unit of the Dental Faculty of Piracicaba, São Paulo, Brazil, to determine whether there was any pulpal- or peri-apicalgia. After clinical and radiographic examination, the patient was referred to the graduate clinic in the Department of Prosthodontics to receive adequate treatment. The patient was examined and treated by the same operator throughout the treatment.</ce:para>
<ce:para>The patient had a maxillary complete denture and an ill-fitting mandibular removable partial denture (RPD). Her clinical history reported pain in the left side of the throat region with head movement and when swallowing. She also complained of severe headaches, ocular pain, otalgia, a popping and clicking sensation, and a pharyngeal foreign body sensation. The patient reported that she sleeps with the right side of the face on the pillow and had nocturnal clenching. She also stated that these conditions had been present for approximately 1 year and were getting worse. There was no history of trauma. After a series of medical and dental evaluations, no cause had been determined.</ce:para>
<ce:para>Since her mother’s death 1 year earlier, the patient had been going through an intense nervous crisis and constant emotional stress. The patient was undergoing psychologic therapy and was taking diazepam (Eurofoarma Laboratórios Ltd., São Paulo, Brazil) and imipramina (Itapira, São Paulo, Brazil) medications to sleep, because of frequent insomnia and depression. She also reported dysphonya, dysphagia, painful chewing, and burning pain in her left neck. There was no history of tonsillectomy. The patient had low blood pressure and postural disorder in the cervical region (Fig. 1).
<ce:display><ce:figure><ce:label>Fig. 1</ce:label>
<ce:caption><ce:simple-para>Patient ́s postural habit.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr1"></ce:link>
</ce:figure>
</ce:display>
</ce:para>
<ce:para>Early opening clicks were present reciprocally in the left temporomandibular joint (TMJ), and mandibular opening was 45 mm with pain and with deviation to the left. There was a loss of vertical dimension of occlusion (VDO) of 2 mm as determined by the same operator who used facial measurements and phonetic and esthetic guides. Pain was present when palpating the left superficial masseter, left anterior temporal, left sternocleidomastoid, left and right trapezius, left infrahyoid, and left and right internal and external pterygoids. During palpation of the TMJ, she reported pain in the external acoustic meatus, in the left lateral condyle and in the left auricular region. Tenderness to palpation of the left tonsillar fossa and retromandibular region was also recorded.</ce:para>
<ce:para>Panoramic TMJ and cephalometric radiographs were taken, along with an electromyography examination. Radiographically, a left elongated styloid process was noted, which is typical of the Eagle’s syndrome (Fig. 2).
<ce:display><ce:figure><ce:label>Fig. 2</ce:label>
<ce:caption><ce:simple-para>Elongated left styloid process diagnosed by panoramic radiography.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr2"></ce:link>
</ce:figure>
</ce:display>
A radiopaque area was observed with radiolucency around it in the area of the mandibular left second and first premolars. Further clinical and radiographic examinations of this lesion confirmed the differential diagnosis of condensing osteoitis. Because it was symptomatic and not located near the crest of the edentulous ridge, it was not removed. However, if the radiopacity becomes infected (symptomatic), it will be excised promptly. On the basis of clinical and radiographic observations, a preliminary diagnosis of Eagle’s syndrome associated with the TMD was made. Conservative therapy was initiated to treat first the TMD and, by extension, Eagle’s syndrome. Surgical removal of the impinging styloid process would be performed only in case of failure of the conservative, noninvasive treatment.</ce:para>
<ce:para>An occlusal splint (Fig. 3) was placed to open the VDO 2 mm.
<ce:display><ce:figure><ce:label>Fig. 3</ce:label>
<ce:caption><ce:simple-para>Occlusal splint to relieve symptomatology.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr3"></ce:link>
</ce:figure>
</ce:display>The patient was instructed to use the occlusal splint at all times for the first 4 weeks of treatment, except during eating and oral hygiene. Rehabilitative treatment consisted of the insertion of a new mandibular RPD and a maxillary complete denture (Fig. 4), physiotherapy with electrical stimulation, massage therapy, muscular stimulation, and relaxing exercises.
<ce:display><ce:figure><ce:label>Fig. 4</ce:label>
<ce:caption><ce:simple-para>Completed rehabilitation with partial and total removable dentures.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr4"></ce:link>
</ce:figure>
</ce:display>
It was chosen to replace her maxillary and mandibular dentures because the patient could not afford a more expensive treatment. Prosthetic rehabilitation started soon after the end of the splint therapy.</ce:para>
<ce:para>At the end of the 30 days of splint therapy, the patient showed signs of improvement, namely, reduction of the clinical reported orofacial pain and of pain on palpation. The patient also improved after prosthetic rehabilitation and undergoing physiotherapy. The aim of prosthetic rehabilitation was both to create a bilaterally stable occlusion at approximately 1 mm anterior to retruded position, obtained by the central bearing point–gothic arch tracing, and to improve function. At 1-year follow-up, the patient was free of pain. The radiopaque lesion in the left premolar area of the mandible has not enlarged and is without symptoms.</ce:para>
</ce:section>
<ce:section><ce:section-title>DISCUSSION</ce:section-title>
<ce:para>Panoramic radiographs, showing unilateral or bilateral abnormally elongated styloid process, have an important function in the diagnosis of Eagle’s syndrome, because several of the symptoms commonly associated with TMDs such as ear pain, neck pain, and headaches are also common symptoms of the Eagle ́s syndrome. Moreover, a careful palpation of the tonsillar fossa (which will detect a bone-like protuberance) and retromandibular region is imperative in the recognition of the Eagle ́s syndrome.<ce:cross-refs refid="bib9 bib12"><ce:sup>9,12</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>In our study, radiographs, together with a comprehensive health history, clinical examination and electromyography evaluation, allowed the establishment of a tentative diagnosis, a progressive treatment plan that confirmed the diagnosis, and a successful outcome of the conservative procedures. Conservative procedures related to TMD may reduce some of the symptoms associated with the Eagle’s syndrome.<ce:cross-refs refid="bib10 bib11"><ce:sup>10,11</ce:sup>
</ce:cross-refs>
</ce:para>
</ce:section>
<ce:section><ce:section-title>SUMMARY</ce:section-title>
<ce:para>In this clinical report, Eagle’s syndrome symptoms were resolved for a period of 1 year after oral rehabilitation and physiotherapy. Long-term follow-up care will provide more information on the success of the conservative treatment for patients with Eagle’s syndrome associated with TMD.</ce:para>
</ce:section>
</ce:sections>
</body>
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<name type="personal"><namePart type="given">Célia M.</namePart>
<namePart type="family">Rizzatti-Barbosa</namePart>
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<name type="personal"><namePart type="given">Eduardo B.</namePart>
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<name type="personal"><namePart type="given">José R.</namePart>
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<name type="personal"><namePart type="given">Brenda P.F.A.</namePart>
<namePart type="family">Gomes</namePart>
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<note>aAssistant Professor of Removable Prosthodontics. bUndergraduate Student. cAssistant Professor of Oral Surgery. dAssistant Professor of Endodontics.</note>
<note>Reprint requests to:Dr CÉlia M. R. Barbosa, Faculdade De Odontologia De Piracicaba, Departamento De PrÓtese E Periodontia, Avenida Limeira, 901—Bairro AreiÃo, Piracicaba—Sao Paulo, Cep 13414-018, Brazil, Fax: (55)19-430-5218,E-MAIL: rizzatti@fop.unicamp.br</note>
<note>Copyright © 1999 by The Editorial Council of The Journal of Prosthetic Dentistry.</note>
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<note>J Prosthet Dent 1999;81:649-51.</note>
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Eagle’s syndrome associated with temporomandibular disorder: A clinical report

Eagle’s syndrome associated with temporomandibular disorder: A clinical report

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