New here. How to diagnose if I have eagle syndrome. Whom to see? ENT or TMJ specialist or neurologist?

There is a few of us discussing facial and tooth pain and the origins of it. I personally have had about 8 root canals and have had hyper-sensitive teeth. TMJ guy of course wants you 4.5 K. Sorry Im suspicious given my history.
As to styloid process and the ligaments. I dont think these films display them to make the determination of no calcifications. My pain started on my right, then shifted to left. I went thru this back and forth for 5 years, Doc wanted to do right first because it was longer. My pain was worse on left and I talked him into doing the left first. Now that I have taken care of the left, the right is starting to rear its ugly head. Our bodies compensate and hold according to pain. You are getting alot of information at once so slow down and digest information and see what fits for you. My experience may not be yours. These films don’t show accurately the info you need to rule out Eagles. Start from there. Hope that helps

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I have been and am still treating the TMJD with a combination of nerve blocks, botox and steroids after trying other things. I also have done some acupuncture in jaw with TENS unit with some success more recently. I am going to start getting low level laser light therapy soon to see if that cuts down the inflammation because I cannot take NSAIDS or any type of anti-inflammatory. I have been getting almost weekly massage therapy…only because I have good PT benefits and that helps keep me stabilized.

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When I am in an extreme pain flair, I take oxycotin, lay in bed and put ice on the side of head and neck. It can take days to come out of this.

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Thank you so much @Snapple2020. I appreciate it.

Yeah, I am taking a pause and trying to understand what’s going on. This all started after a day where I was chewing my food more than usual. It was meat without bone and I was chewing it harder on the right side.
I felt soreness in the molars immediately after the meal.

Next day I heard a pop in the jaw and this pain started. I was digging to past to know what happened before the pain started and what could be the root cause.

I am also doing PT. Did for 3 weeks so far. Tried dry needling. PT doesn’t help me much. Not even a temporary relief. PT takes time. So, planning to continue for few more weeks and see how it goes.

I am not immediately accepting to the tmj specialist treatment plan. It’s very expensive and not under insurance. If the pain is still the same, I will go ahead with that.

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I got the cbct scan from the tmj specialist office in a disc. I am trying to open it with some software. Couldn’t open it in 3d yet. I sent this scan to a radiologist and got the report. The styloids are of length 26.51,27.06 mm. The report says within normal.

What is the normal length for styloids? I try to attach those images here. What else do we need to check for eagles apart from styloids length?

styloid processes.pdf (838.3 KB)
3d images.pdf (1.8 MB)
3d images TMJ.pdf (2.2 MB)
Lab Report 1-10-2020.pdf (226.6 KB)

Hi Newuserhere,

I edited your files to hide your personal information. As far as your styloids go, I also annotated a couple of the slides w/ arrows pointing to things I noticed about your styloids. I will put the link at the bottom of my comments.

First, it was noted your right styloid is segmented. It doesn’t appear segmented to me but appears to be in two pieces. In my non-medical opinion, this could either mean your styloid process has broken, & the lower piece is the dislocated tip of the styloid. Another option is, the lower piece is actually not styloid process but a section of your stylohyoid ligament which has calcified. Either way, this is not normal & could be causing ES symptoms. Your left styloid appears thick at the top then tapers into a very thin almost invisible line at the tip. I believe this is either the beginning of elongation, or again, calcification of the stylohyoid ligament (which extends from the tip of the styloid to the lesser horn of the hyoid bone). Because the image doesn’t show the area down to your hyoid, there is no way to tell if you have further calcification on your stylohyoid ligament(s) closer to the hyoid bone.

Other things to look at w/ the styloids are how thick, pointed, twisted or angled they are. Even normal length styloids w/ one or more of those features can cause ES symptoms.

styloid processes.pdf (838.3 KB)

Calcification of the stylohyoid ligament(s) alone, without elongation of the styloids, is also Eagle Syndrome. I believe you should still try to get a CT scan of the area between your skull base & hyoid bone to get a better look at the styloids & stylohyoid ligaments. The ligaments won’t be visible if they don’t have calcification on them. If you can see them then there is calcification, & they can surely be causing the symptoms you have. Seeing a doctor who is familiar with ES would also be a good idea. If you haven’t done so yet, take a look at our doctors’ list.

I hope this helps.

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2.5cms is generally used as the ‘average’ styloid length, but measuring them from scans is often not that accurate. As Isaiah says the angle & width cause symptoms too.

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Thank you @Jules. Appreciate it.
How to measure them then if not measuring them from scans? Any other way to check the length?
I don’t know about the width. It was not mentioned in my scan report.

Thank you so so much @Isaiah_40_31 for reading these reports. Appreciate it.

I haven’t seen any ent yet. I have only one eagles ent provider in my place. What does it mean ct scan of area between skull base and hyoid bone? Is it ct of neck or ct of head?

So, the segmented styloids indicates eagles? How about the length? Is it considered normal or higher?

Tmj specialist who took this cbct scan said he couldn’t see any calcification. I got the report from a radiologist. He couldn’t see any calcification too.

Does it looks segmented to you ??

Hi Newuserhere,

If you see an ENT doctor he’ll know the right area to recommend for a CT scan of the styloid process & stylohyoid ligaments. It’s the neck between the hyoid bone & the base of your skull. Your hyoid bone is a very thin bone that sits where your neck meets the underside of your chin. Both styloid process & hyoid bone are noted in the link below.

It is my opinion that your “segmented” styloid process could be giving you ES symptoms. Your styloids don’t look especially long but the extra information I gave you about them indicates to me that you may have calcification beyond what your pictures show & that would be seen in a CT scan. A CT scan is what is used to diagnose ES. It seems radiologists & doctors don’t always use the same method of measure the styloids so the actual styloid lengths can be based on the opinion of the person measuring them.

I’m not sure what calcification, the TMJ specialist was looking for - extra length on your styloids or calcified spots on your s-h ligaments or both.

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Thank you so much @Isaiah_40_31 for the detailed response with images.

I am not sure what did tmj specialist look for in the cbct scan. I don’t have much knowledge about eagles too. I didn’t ask further. He said he couldn’t see any calcification and I can take eagles out of my mind.

So, as you mentioned there are 3 things to be seen for eagles. I am just trying to understand about it.

  • length of styloids process(should be less than 2.5cm)
  • calcification of stylohoid ligaments( will be seen on ct scan if calcification present)
  • length of hyoid bone( how much is normal)

Are these three things considered for eagles diagnosis? Are my understanding correct?

In my cbct, nothing mentioned about stylohyoid ligaments and hyoid bone. I don’t know if they were not covered on that scan.

They do measure them from the scans, but it’s not 100% accurate, because of the medium; we often see members have longer styloids than estimated when they’re removed.

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My CBCT scan was done at a major oral health dept of university. They overlooked the calcification of the stylohyoid ligament and even though I came back 5 years later as asked for them to look for it, they claimed it should not cause any issues. It appeared segmented and was not measured from the styloid process. They only measured the segment. The CT scan of neck showed segmented as well. The radiologist measured from the styloid process. Everyone measures the length differently. When I saw Dr. Samji and he read my scan in front of me, he explained that these scans only show slices of the neck and interprets in between the slices which is often inaccurate and only an estimate. He said the scan showed the calcifications longer than what radiologist measured. He also indicated that it is not that common for them to be segemented. When he operated on me, it was all connected and longer. Parts were narrow and thin, almost razor like edges.
The CBCT is not ideal for looking at these areas in any detail. Even the CT Scan of Neck is only giving you a window or estimate which is considered “gold” standard for detection of Eagles.

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Thank you @Snapple2020. Appreciate it.

So, do you mean that CT scan of neck is also not show the accurate measurements and findings related to eagles. Only way is to check with eagles doctor?

I don’t know if my cbct covered it properly. I am planning to see an ENT and see if he can order neck ct to check it out. Do we need to say anything in specific to check during the scan?

How long were your styloids and calcification? Stylohoids?

I don’t know what should be my next best step. My dentist suspecting a tooth root fracture which doesn’t show up in the x-ray and he feel that this could cause my pain and symptoms. He wants me to try extraction and see if it helps. I am stuck with this now. I had a rct on that tooth 4 weeks back to see if it helps. I don’t have any pain on that tooth though. Dentist suggest to do RCT to see if it helps and Endo couldn’t spot any fracture after opening the tooth. But the dentist is not doing crown on it and want me to try extraction.:frowning:

Even the CT scan of neck doesn’t necessarly reflect 100% accuracy because of the nature of the scan re: doing slices (pictures) of the area. Chances are there is more in there than what is reflected in the scan. In my case and often it shows segmented but was not. The software interprets what might be there between the slices. This was explained to me by ENT surgeon who specializes in neck surgeries. Usually they have a cancer sub specialty.
The CBCT is not ideal for these purposes and rarely gives full coverage of the neck area. A CT scan of neck with order for radiologist to evaluate for Eagles is what you need to rule in or out Eagles. My scans shows 3.2 and 3.5cm. The 3.2cm side that was operated on was longer however surgeon didn’t note actual length in the operative report.
I would tend to go for root canal before doing an extraction.

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@Snapple2020 did root canal 4 weeks back and still same symptoms.

Thank you @Snapple2020. My length was mentioned like 26.51mm on right (symptom side) , 27.01mm on left. I am not sure if these are normal length. These are measured by oral medicine radiologist. So he check with respect to all dental scans radiology.

I am stuck with this tooth issue now. I went to dentist to get temp crown and he want me to try the extraction to see if it helps. I don’t want to do extraction of molar #30 without knowing a definite diagnosis. He suspect a probability of fracture.

Well in my opinion and others here on list, Dental radiologists seem to overlook this and are not knowledgable on Eagles. They do not have the expertise to diagnose eagles. If they do, it would be very rare. I had the head of the oral health department tell me the calcifications shouldn’t be problematic. Well I had to push my PCP to order the CT scan and proved them all wrong. A dentist probably wouldnt be willing to order a CT scan of the neck. You need to find a doctor who will so you can rest assured you don’t have Eagles. I read your report and it is pretty extensive…at least what I understand. Id have to research some of the terms to understand some of the root issues. I do understand the the tmj joint because I have similiar findings. The right styloid process being segmented is suspicious. As what you were told by Isaiah, the CBCT doesnt go down far enough to follow this.

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Hi Newuserhere,

Your styloids are close to normal length though anything longer than 2.54 cm can be considered elongated. Yours are 2.65cm & 2.7cm so very slightly elongated. Again, the side that shows up in two parts could be causing ES symptoms because the second piece lower in your neck makes the styloid “act” like it’s elongated.

As far as your tooth goes, you’re very wise not to get it pulled out especially if the endodontist doesn’t see a fracture in the root. The trigeminal nerve is often irritated by ES & many of our members have had teeth pulled & unnecessary dental work done because of tooth pain because of the trigeminal nerve causing them to hurt & not because the teeth themselves had anything wrong with them. Once the styloids were removed, the tooth pain stopped. It may be worth it to get a crown on the sore tooth, but if there’s no cavity or crack in the tooth, then getting treated w/ nerve pain medication like Gabapentin or Amitriptyline would be helpful until you find out if you have ES.

As Snapple2020 said, an ENT cancer specialist is usually the type of doctor who does the type of surgery necessary to end ES symptoms. I recall you said there is an ENT near you who knows about ES (is it someone off our doctors’ list?). It would be wise for you to see that doctor.

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Thank you @Snapple2020. Appreciate it.
Yeah I understand that cbct doesn’t cover much. My PCP is also not seeing the ct scan. Once my dentist said I have to rule out eagles,I immediately contacted my PCP to ask about it. I asked her because she is the one who ordered me neck ultrasound last month since I have neck pain and she see a small lump on the neck. But no abnormalities found in the ultrasound.
I asked her about eagles and she didn’t reply anything about it. The reply was, she think it could be trigeminal neuralgia and sent me a referral to neurologist. I didn’t see a neurologist yet. I didn’t contact my PCP after that.
I have to get an ENT or neurologist to check this out. Whether anyone from the group get diagnosed with neurologist?