Eagle Syndrome: An Unforgettable Cause of Atypical Cranial Nerve Neuralgias and Facial Nerve Palsy – A Case Series

Eagle Syndrome: An Unforgettable Cause of Atypical Cranial Nerve Neuralgias and Facial Nerve Palsy – A Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Eagle Syndrome: An Unforgettable Cause of Atypical Cranial Nerve Neuralgias and Facial Nerve Palsy – A Case Series Ni Made Ayu Regina Karasugi, Michella Chiara Heriyanto, Iwan Irawan Karman, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6952890/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jan, 2026 Read the published version in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background Eagle syndrome (ES) is a rare entity caused by elongation of the styloid process or calcification of the stylohyoid ligament, leading to compression of surrounding anatomical structures. This can result in a variety of symptoms, including atypical cranial neuralgias and, in rare cases, cranial nerve palsy. Due to its nonspecific presentation, ES is often misdiagnosed as more common conditions such as trigeminal neuralgia or temporomandibular joint disorders. Case Presentation We report two cases of ES with distinct clinical manifestations. The first case involves a 41-year-old female with chronic headache and facial pain with allodynia that progressed to left-sided peripheral facial palsy. Cervical Computed Tomography (CT) scan with 3D reconstruction revealed an elongated styloid process with narrowing of the pre-styloid space. The second case describes a 24-year-old female who presented with Ludwig’s angina and a history of intermittent unilateral headaches and facial pain that were resistant to pain medication. A cervical CT scan incidentally identified an elongated styloid process. Both imaging results identified ES as the cause of these atypical pain presentations. Both patients initially received conservative management, with one patient later undergoing surgical treatment and achieving significant pain relief. Conclusions These cases highlight the need for clinicians to consider ES in patients with atypical and treatment-resistant cranial neuralgia or facial nerve palsy. Diagnosis relies on a combination of clinical findings and imaging, with 3D CT reconstruction as the gold standard. Increased clinical awareness are crucial for timely diagnosis and management. atypical presentation cranial nerve neuralgia eagle syndrome facial nerve palsy Figures Figure 1 Figure 2 BACKGROUND Eagle syndrome (ES) is a rare condition characterized by elongated styloid process of the temporal bone or the calcification of the stylohyoid ligament which then compromises the surrounding anatomical structure and triggers the clinical manifestations. Eagle syndrome, also known as stylohyoid syndrome, was first described by otolaryngologist, Watt Weems Eagle, at Duke University in 1937 [ 1 ]. A styloid process longer than 25 mm is abnormal, but some sources stated it should be longer than 30 mm to be considered abnormal [ 2 , 3 ]. An elongated styloid process is observed in approximately 4% of the general population, with only around 4% of these individuals exhibiting symptoms directly attributable to the elongation. Incidence of symptomatic elongation is approximately 0.16% with female-to-male predominance was found to be 3:1 [ 4 ]. The variation in symptoms is related to the compression of surrounding tissues by the styloid process, which includes cervicofacial pain accompanied by headaches, difficulty swallowing (dysphagia), painful swallowing (odynophagia), a persistent sensation of a lump in the throat (globus sensation), and otalgia. Several lower cranial nerves (cranial nerves V, VII, IX, and X) are located around the styloid process and contribute to the symptoms experienced by patients with ES [ 5 ]. Patients with ES are often initially suspected of having trigeminal neuralgia, glossopharyngeal neuralgia, myofascial pain syndrome, or temporomandibular joint disorders, leading to ES remaining undiagnosed. This results in prolonged pain and a decreased quality of life for the patient [ 6 ]. Here, we present two female patients diagnosed with ES at our hospital, each exhibiting different clinical manifestations. The first case demonstrates an atypical presentation of cervicofacial pain with facial nerve palsy, serving as a diagnostic clue for ES. The second case presents with atypical neuralgia symptoms, with an elongated styloid process discovered incidentally. These cases highlight the importance for clinicians to be aware of this rare condition as one of the differential diagnoses for atypical cranial neuralgia and nerve palsy. CASE PRESENTATION Case 1 A 41-year-old woman presented to the Emergency Department with complaints of worsening headaches over the past two months. The headache had been present for approximately one year prior and was described as a tight band around the head and neck, usually worsening with activity and improving with rest and over-the-counter pain medication. In the past two weeks, the patient suddenly developed continuous radiating pain from the left mandibular angle and ear extending into the left side of the face, which worsened with chewing and turning the head to the left. Allodynia on the left side of the face was also noted, leading to a suspicion of atypical trigeminal neuralgia. The patient was prescribed carbamazepine; however, after several days, no improvement was observed, and the patient continued to experience severe pain. On the third day of hospitalization, the patient suddenly developed left-sided peripheral facial paralysis, classified as grade V on the House-Brackmann scale. Other cranial nerve examinations were normal. At this stage, ES was suspected. A physical examination revealed tenderness upon palpation of the tonsillar fossa, while other ear, nose, and throat examinations were unremarkable. Head Magnetic Resonance Imaging (MRI) and MR-Angiography were performed to rule out other possible causes, but no abnormalities were detected. A cervical Computed Tomography (CT) scan with three-dimensional (3D) reconstruction was subsequently conducted to evaluate the potential underlying etiology. The results indicated elongation of the left styloid process (3.3 cm) with narrowing of the pre-styloid space on the left side (Fig. 1 ), leading to the diagnosis of ES. The patient was initiated on methylprednisolone therapy for a total duration of 14 days. Pain management was achieved with a combination of gabapentin and tramadol. Surgery was planned but was declined by the patient. During follow-up consultation, the patient's facial palsy had improved significantly, with only slight facial muscle weakness and normal facial symmetry at rest. The patient continued to experience pain in the left side of the face and headaches, but these symptoms were manageable with pain medication. The patient later agreed to undergo a left styloidectomy. During follow-up, the patient reported significant pain relief with only occasional mild discomfort and minimal reliance on analgesics. Case 2 A 24-year-old female presented to the emergency department with complaints of an acute, painful, progressively enlarging lump in the lower neck region, accompanied by systemic symptoms such as fever, dysphagia, and odynophagia, leading to a diagnosis of Ludwig’s angina. The patient also reported experiencing a chronic, sharp, intermittent headache radiating to the right side of the face and ear for the past seven years. The pain was considered as atypical neuralgia. She had regularly visited the neurology department and received multiple drug regimens, but no improvement was observed. The patient had also been taking over-the-counter paracetamol 6–8 times per day, but the headache would only subside momentarily. A cervical CT scan without contrast was performed due to the suspected Ludwig’s angina. However, the scan incidentally revealed elongation of the right styloid process. Further 3D CT reconstruction confirmed the diagnosis of ES as a possible cause of the patient's chronic headaches (Fig. 2 ). The patient underwent surgery for Ludwig’s angina but did not undergo any surgical intervention for the elongated styloid process. The pain was managed by analgesics. DISCUSSION Eagle syndrome is a collection of craniofacial and neck pain symptoms caused by elongation of the styloid process and/or calcification of the stylohyoid ligament [ 7 ]. The styloid process is a long, bony projection arising from the inferior surface of the petrous part of the temporal bone, situated anterior to the stylomastoid foramen. Eagle syndrome causes a wide range of symptoms due to the various tissue structures surrounding the styloid process [ 3 ]. The anatomical structures located medial to the styloid process include the glossopharyngeal, vagus, and accessory cranial nerves, as well as the internal jugular vein. Laterally, the styloid process is adjacent to the facial nerve, hypoglossal nerve, and external carotid artery [ 8 ]. The exact cause of ES remains unclear [ 3 ]. Eagle syndrome is differentiated into two phenotypes: classic ES, which is associated with the compression of surrounding tissues and lower cranial nerves, and vascular ES, which is related to the compression of vascular structures such as the carotid artery and the jugular vein [ 9 ]. The two patients reported in this case exhibit variations of clinical manifestations consistent with classic ES. Classic ES is characterized by recurrent pain, most commonly reported in the ear, throat, neck, and below the angle of the mandible. The pain can be exacerbated by swallowing, yawning, and head rotation. Approximately 70% of patients also report tinnitus, dysphagia, and pain worsened by head rotation [ 8 ]. Palpation of tonsillar fossa will produce local tenderness and aggravation of other symptoms. Pain in ES occurs due to the mechanoreceptor discharge of cranial nerves V, VII, IX, and X, triggered by mechanical irritation from the styloid process [ 10 , 11 ]. Allodynia in the first patient and intermittent facial pain in the second patient can be caused by compression of the trigeminal nerve. The Gasserian ganglion is located in Meckel's cave, near the petrous part of the temporal bone and adjacent to the styloid process. This proximity makes the trigeminal nerve vulnerable to compression or a secondary inflammation caused by an elongated styloid process or calcified stylohyoid ligament in ES. This condition often leads to ES being initially misdiagnosed as trigeminal neuralgia [ 12 , 13 ]. Another cranial neuralgia that is most frequently considered a differential diagnosis for ES is glossopharyngeal neuralgia. Pain extending from the pharyngeal region to the ear, which worsens with chewing, resembles the characteristics of glossopharyngeal neuralgia. Compression of the glossopharyngeal nerve by the styloid process can occur as the nerve passes through the superior constrictor muscle [ 7 , 14 ]. Pain in ES is often unresponsive to analgesics, which should serve as a key clue for clinicians to suspect ES as the underlying cause of neuralgia that is resistant to pain management. Some cases, including the second patient in this case series, have reported neuralgia that was unresponsive to medication, leading to prolonged pain before ES was ultimately identified as the cause [ 1 , 4 , 12 ]. The first patient, despite initially exhibiting the classic manifestations of ES, then proceeded to show more uncommon symptoms which involved facial nerve dysfunction. Several cases, including the first patient in this report, have experienced facial nerve palsy as a manifestation of ES [ 15 – 17 ]. Recurrent facial nerve palsy also has been documented in one case report [ 18 ]. To the best of our knowledge, this is the first case report of facial nerve palsy associated with ES from Indonesia. Facial nerve palsy associated with ES is very uncommon. This condition may be attributed to the compression of the extratemporal portion of the facial nerve, secondary to the elongated styloid process [ 15 , 16 ]. Since the patient in our case experienced only facial muscle weakness, the compression of the facial nerve must be below the stylomastoid foramen, allowing the functions of taste, sublingual, submandibular, and lacrimal glands to remain intact. The most frequent cause of facial nerve palsy, Bell’s palsy, is not typically associated with neuralgia. The presence of atypical cervicofacial pain should prompt further investigation into secondary causes of nerve palsy, one of which is ES. Conversely, in the first case, facial nerve palsy was also the key finding that led to the suspicion of ES as the underlying cause of the patient's atypical neuralgia. The diagnosis of ES requires a combination of clinical manifestations, pain characteristics, and imaging findings that demonstrate elongation of the styloid process. A CT scan of the head and neck, especially a 3D CT scan, is regarded as the gold standard for imaging the anatomically intricate styloid process, as it eliminates the issues caused by overlapping structures [ 8 ]. Although imaging often reveals bilateral elongation of the styloid process, most patients report pain on only one side, as seen in both cases in this report [ 19 ]. Another interesting finding from the first case is that the styloid process on the left side was shorter than the asymptomatic right side. It is suspected that compression is more likely caused by abnormal angulation of the styloid process rather than mere elongation. This is supported by imaging findings showing a narrowing of the pre-styloid space on the symptomatic side [ 6 ]. The rarity of ES and its nonspecific symptom variations often lead to misdiagnosis as more common conditions. Differential diagnoses include temporomandibular joint disorders, otitis, mastoiditis, primary headaches, temporal arteritis, cranial nerve neuralgia, and cervical spine disease. One important differential diagnosis to consider is Ernest Syndrome, which is an inflammatory and painful irritation of the submandibular ligament. Similar to ES, Ernest Syndrome can present with temporo-mandibular joint pain, temporal pain, ear and mandibular pain, and dysphagia. While ES shares similarities, its pathogenesis involves calcification, whereas there is no clear evidence of calcification in Ernest Syndrome [ 20 ]. The exclusion of other potential causes of pain is essential, as demonstrated in this case series [ 12 , 18 ]. There are two treatment options available for ES: a conservative approach and a surgical approach. The conservative option involves using non-steroidal anti-inflammatory drugs, steroid, antidepressants, and anticonvulsants. Additionally, analgesic injections with lidocaine or steroids can be administered through the tonsillar fossa [ 5 ]. Some cases reported the improvement in facial nerve palsy by steroid administration, but the pain persisted [ 15 , 16 ]. In our second case and other case series, pain was controlled by gabapentinoid drugs [ 7 ]. If conservative treatment fails, the definitive approach is surgery, specifically styloidectomy. Surgical styloidectomy in patients diagnosed with ES has an 80% success rate in providing a cure [ 5 , 16 ]. CONCLUSION Eagle syndrome is a rare entity, but should be considered as one of differential diagnosis in cases of trigeminal neuralgia, glossopharyngeal neuralgia, and/or peripheral facial nerve palsy with atypical presentation, idiopathic appearance, and resistance to medication. A thorough history-taking, physical examination, and exclusion of other etiologies are essential. The diagnosis of ES is based on a combination of clinical manifestations and elongated styloid process in imaging findings, with 3D CT reconstruction being the gold standard. Abbreviations ES Eagle Syndrome MRI Magnetic Resonance Imaging CT Computed Tomography Declarations Ethics approval and consent to participate The study did not require ethical approval as it involved two case reports with no experimental procedures. Consent for publication Written informed consent were obtained from the patients for publication of this manuscript. Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests in this section. Funding There is no funding for this manuscript. Authors’ contributions N.M.A.R.K. and M.C.H. designed and wrote the article and also participated in acquisition, analysis, and interpretation of data; A.V. and O.D. participated in patient care and critically revised the article; I.I.K. participated in patient care, performed the surgery, and critically revised the article. J.F.A.B. critically revised the article. All the authors reviewed the manuscript. Figures All figures presented in this manuscript are original and were chosen by the authors. Acknowledgements Not applicable. References Searle E, Searle A. An overview of Eagle’s syndrome. Br J Pain. 2021;15:388–92. 10.1177/2049463720969741 . Scavone G, Caltabiano DC, Raciti MV, Calcagno MC, Pennisi M, Musumeci AG, et al. Eagle’s syndrome: a case report and CT pictorial review. Radiol Case Rep. 2019;14:141–5. 10.1016/j.radcr.2018.10.008 . Pagano S, Ricciuti V, Mancini F, Barbieri FR, Chegai F, Marini A, et al. Eagle syndrome: An updated review. Surg Neurol Int. 2023;14:389. 10.25259/SNI_666_2023 . Saccomanno S, Greco F, De Corso E, Lucidi D, Deli R, D’addona A, et al. Eagle’s Syndrome, from clinical presentation to diagnosis and surgical treatment: a case report. Acta Otorhinolaryngol Ital. 2018;38:166–9. 10.14639/0392-100X-1479 . Swanson D, Evensky CH, Yusuf S, Long H, Hasoon J, Mohamed M, et al. Eagle Syndrome: Pathophysiology, Differential Diagnosis and Treatment Options. Heal Psychol Res. 2023;10. 10.52965/001c.67851 . Xu Z, Shi P, Zhang P. Eagle syndrome: A rare neuropathic disorder affecting head and neck. Med (Baltim). 2024;103:e38128. 10.1097/MD.0000000000038128 . González-García N, Porta-Etessam J, García-Azorín D. Eagle syndrome: toward a clinical delimitation. Neurol (English Ed. 2021;36:412–7. 10.1016/j.nrleng.2018.03.007 . Held ME, Farsi S, Creighton ERW, Davis KP, King DL, Suen JY. Eagle syndrome presentation and outcomes in a large surgical case series. Laryngoscope Investig Otolaryngol. 2024;9. 10.1002/lio2.1289 . Hassani M, Grønlund EW, Albrechtsen SS, Kondziella D. Neurological phenotypes and treatment outcomes in Eagle syndrome: systematic review and meta-analysis. PeerJ. 2024;12:e17423. 10.7717/peerj.17423 . Mahmoud NR, Ashour EM. Cervico-facial pain associated with Eagle’s syndrome misdiagnosed as cranio-mandibular disorders. A retrospective study. J Cranio-Maxillofacial Surg. 2020;48:1009–17. 10.1016/j.jcms.2020.07.016 . Diab E, Masmoudi I, Leclercq C, Flores C, Louin L, Bettoni J, et al. A pain like no other: From cluster to headache to Eagle’s syndrome, a case report. Cephalalgia. 2020;40:1394–7. 10.1177/0333102420954544 . De Barros JF, Rodrigues MV, Barroso LA, Amado IC. Eagle Syndrome: An underdiagnosed cause of orofacial pain. BMJ Case Rep. 2021;14:1–5. 10.1136/bcr-2020-238161 . Baena-Caldas G, Rojas-Zuluaga S, Peckham X. Anatomical and clinical relevance of elongated styloid process in a sample of the Colombian population. J Morphol Sci. 2017;34:036–9. 10.4322/jms.103916 . Hall S, Michell K, Howlett D. A rare cause of atypical facial pain. Clin Med (Northfield Il). 2024;24:100254. 10.1016/j.clinme.2024.100254 . Al-Hashim M, Al-Jazan N, Abdulqader A, Al-Ghamdi M. Eagle’s syndrome with facial palsy. J Fam Community Med. 2017;24:128. 10.4103/jfcm.JFCM_134_16 . Nunes F, Fernandes MJ, Silva M, Porteiro B, Dutschmann R. Eagle’s Syndrome Presenting as Peripheral Facial Palsy. Cureus. 2022. 10.7759/cureus.22499 . Freitas LF, Alves I, Toldo LDY, Curioni OA, Carlotti FA, Velludo SF, et al. Giant Eagle syndrome with pseudoarthrosis and peripheral facial palsy. Rev Neurol. 2023;77:203. 10.33588/rn.7708.2023209 . Péus D, Kollias SS, Huber AM, Huber GF. Recurrent unilateral peripheral facial palsy in a patient with an enlarged styloid process. Head Neck. 2019;41:E34–7. 10.1002/hed.25384 . Abdul Halim N, Md Yassin M, Mohamad Ali ND, Miptah HN. An Uncommon Presentation of Eagle Syndrome in a Primary Care Patient with Chronic Neck Pain: A Case Report and Literature Review. Am J Case Rep. 2024;25. 10.12659/AJCR.944399 . Domínguez J, Bornhardt T, Wen S, Iturriaga V. Ernest Syndrome: A Systematic Review of the Literature. J Oral Facial Pain Headache. 2020;34:167–73. 10.11607/ofph.2551 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Jan, 2026 Read the published version in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery → Version 1 posted Editorial decision: Revision requested 05 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviews received at journal 27 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviewers invited by journal 17 Jul, 2025 Editor assigned by journal 30 Jun, 2025 Submission checks completed at journal 30 Jun, 2025 First submitted to journal 23 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6952890","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":487877539,"identity":"89adbf92-f1c8-4e5f-ab1d-69ae05e6e8a6","order_by":0,"name":"Ni Made Ayu Regina Karasugi","email":"","orcid":"","institution":"Atma Jaya Catholic University of Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Ni","middleName":"Made Ayu Regina","lastName":"Karasugi","suffix":""},{"id":487877540,"identity":"cc716eda-7813-44c0-a2d8-ca2705d35419","order_by":1,"name":"Michella Chiara Heriyanto","email":"","orcid":"","institution":"Atma Jaya 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arrow)\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6952890/v1/342620117059f99a41d322dd.jpg"},{"id":87380175,"identity":"b3ac2175-a428-4be6-9bb4-494b40e1beba","added_by":"auto","created_at":"2025-07-23 08:32:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":212722,"visible":true,"origin":"","legend":"\u003cp\u003eCT-3D reconstruction (Case 2) showing elongation of the right styloid process (3.3 cm) (white arrow).\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6952890/v1/497a28c93ec68d5ee092cddd.jpg"},{"id":101151821,"identity":"e9daf6c2-b999-4ed5-bbfe-aa344389449d","added_by":"auto","created_at":"2026-01-26 16:06:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":758358,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6952890/v1/11ef4ec0-2ce3-4021-bae3-1537955a8f13.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Eagle Syndrome: An Unforgettable Cause of Atypical Cranial Nerve Neuralgias and Facial Nerve Palsy – A Case Series","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eEagle syndrome (ES) is a rare condition characterized by elongated styloid process of the temporal bone or the calcification of the stylohyoid ligament which then compromises the surrounding anatomical structure and triggers the clinical manifestations. Eagle syndrome, also known as stylohyoid syndrome, was first described by otolaryngologist, Watt Weems Eagle, at Duke University in 1937 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A styloid process longer than 25 mm is abnormal, but some sources stated it should be longer than 30 mm to be considered abnormal [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. An elongated styloid process is observed in approximately 4% of the general population, with only around 4% of these individuals exhibiting symptoms directly attributable to the elongation. Incidence of symptomatic elongation is approximately 0.16% with female-to-male predominance was found to be 3:1 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe variation in symptoms is related to the compression of surrounding tissues by the styloid process, which includes cervicofacial pain accompanied by headaches, difficulty swallowing (dysphagia), painful swallowing (odynophagia), a persistent sensation of a lump in the throat (globus sensation), and otalgia. Several lower cranial nerves (cranial nerves V, VII, IX, and X) are located around the styloid process and contribute to the symptoms experienced by patients with ES [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Patients with ES are often initially suspected of having trigeminal neuralgia, glossopharyngeal neuralgia, myofascial pain syndrome, or temporomandibular joint disorders, leading to ES remaining undiagnosed. This results in prolonged pain and a decreased quality of life for the patient [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Here, we present two female patients diagnosed with ES at our hospital, each exhibiting different clinical manifestations. The first case demonstrates an atypical presentation of cervicofacial pain with facial nerve palsy, serving as a diagnostic clue for ES. The second case presents with atypical neuralgia symptoms, with an elongated styloid process discovered incidentally. These cases highlight the importance for clinicians to be aware of this rare condition as one of the differential diagnoses for atypical cranial neuralgia and nerve palsy.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCase 1\u003c/h2\u003e\u003cp\u003eA 41-year-old woman presented to the Emergency Department with complaints of worsening headaches over the past two months. The headache had been present for approximately one year prior and was described as a tight band around the head and neck, usually worsening with activity and improving with rest and over-the-counter pain medication. In the past two weeks, the patient suddenly developed continuous radiating pain from the left mandibular angle and ear extending into the left side of the face, which worsened with chewing and turning the head to the left. Allodynia on the left side of the face was also noted, leading to a suspicion of atypical trigeminal neuralgia. The patient was prescribed carbamazepine; however, after several days, no improvement was observed, and the patient continued to experience severe pain. On the third day of hospitalization, the patient suddenly developed left-sided peripheral facial paralysis, classified as grade V on the House-Brackmann scale. Other cranial nerve examinations were normal. At this stage, ES was suspected. A physical examination revealed tenderness upon palpation of the tonsillar fossa, while other ear, nose, and throat examinations were unremarkable. Head Magnetic Resonance Imaging (MRI) and MR-Angiography were performed to rule out other possible causes, but no abnormalities were detected. A cervical Computed Tomography (CT) scan with three-dimensional (3D) reconstruction was subsequently conducted to evaluate the potential underlying etiology. The results indicated elongation of the left styloid process (3.3 cm) with narrowing of the pre-styloid space on the left side (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), leading to the diagnosis of ES. The patient was initiated on methylprednisolone therapy for a total duration of 14 days. Pain management was achieved with a combination of gabapentin and tramadol. Surgery was planned but was declined by the patient. During follow-up consultation, the patient's facial palsy had improved significantly, with only slight facial muscle weakness and normal facial symmetry at rest. The patient continued to experience pain in the left side of the face and headaches, but these symptoms were manageable with pain medication. The patient later agreed to undergo a left styloidectomy. During follow-up, the patient reported significant pain relief with only occasional mild discomfort and minimal reliance on analgesics.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cp\u003eA 24-year-old female presented to the emergency department with complaints of an acute, painful, progressively enlarging lump in the lower neck region, accompanied by systemic symptoms such as fever, dysphagia, and odynophagia, leading to a diagnosis of Ludwig\u0026rsquo;s angina. The patient also reported experiencing a chronic, sharp, intermittent headache radiating to the right side of the face and ear for the past seven years. The pain was considered as atypical neuralgia. She had regularly visited the neurology department and received multiple drug regimens, but no improvement was observed. The patient had also been taking over-the-counter paracetamol 6\u0026ndash;8 times per day, but the headache would only subside momentarily. A cervical CT scan without contrast was performed due to the suspected Ludwig\u0026rsquo;s angina. However, the scan incidentally revealed elongation of the right styloid process. Further 3D CT reconstruction confirmed the diagnosis of ES as a possible cause of the patient's chronic headaches (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The patient underwent surgery for Ludwig\u0026rsquo;s angina but did not undergo any surgical intervention for the elongated styloid process. The pain was managed by analgesics.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEagle syndrome is a collection of craniofacial and neck pain symptoms caused by elongation of the styloid process and/or calcification of the stylohyoid ligament [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The styloid process is a long, bony projection arising from the inferior surface of the petrous part of the temporal bone, situated anterior to the stylomastoid foramen. Eagle syndrome causes a wide range of symptoms due to the various tissue structures surrounding the styloid process [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The anatomical structures located medial to the styloid process include the glossopharyngeal, vagus, and accessory cranial nerves, as well as the internal jugular vein. Laterally, the styloid process is adjacent to the facial nerve, hypoglossal nerve, and external carotid artery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The exact cause of ES remains unclear [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEagle syndrome is differentiated into two phenotypes: classic ES, which is associated with the compression of surrounding tissues and lower cranial nerves, and vascular ES, which is related to the compression of vascular structures such as the carotid artery and the jugular vein [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The two patients reported in this case exhibit variations of clinical manifestations consistent with classic ES. Classic ES is characterized by recurrent pain, most commonly reported in the ear, throat, neck, and below the angle of the mandible. The pain can be exacerbated by swallowing, yawning, and head rotation. Approximately 70% of patients also report tinnitus, dysphagia, and pain worsened by head rotation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Palpation of tonsillar fossa will produce local tenderness and aggravation of other symptoms. Pain in ES occurs due to the mechanoreceptor discharge of cranial nerves V, VII, IX, and X, triggered by mechanical irritation from the styloid process [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Allodynia in the first patient and intermittent facial pain in the second patient can be caused by compression of the trigeminal nerve. The Gasserian ganglion is located in Meckel's cave, near the petrous part of the temporal bone and adjacent to the styloid process. This proximity makes the trigeminal nerve vulnerable to compression or a secondary inflammation caused by an elongated styloid process or calcified stylohyoid ligament in ES. This condition often leads to ES being initially misdiagnosed as trigeminal neuralgia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother cranial neuralgia that is most frequently considered a differential diagnosis for ES is glossopharyngeal neuralgia. Pain extending from the pharyngeal region to the ear, which worsens with chewing, resembles the characteristics of glossopharyngeal neuralgia. Compression of the glossopharyngeal nerve by the styloid process can occur as the nerve passes through the superior constrictor muscle [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Pain in ES is often unresponsive to analgesics, which should serve as a key clue for clinicians to suspect ES as the underlying cause of neuralgia that is resistant to pain management. Some cases, including the second patient in this case series, have reported neuralgia that was unresponsive to medication, leading to prolonged pain before ES was ultimately identified as the cause [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe first patient, despite initially exhibiting the classic manifestations of ES, then proceeded to show more uncommon symptoms which involved facial nerve dysfunction. Several cases, including the first patient in this report, have experienced facial nerve palsy as a manifestation of ES [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recurrent facial nerve palsy also has been documented in one case report [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To the best of our knowledge, this is the first case report of facial nerve palsy associated with ES from Indonesia. Facial nerve palsy associated with ES is very uncommon. This condition may be attributed to the compression of the extratemporal portion of the facial nerve, secondary to the elongated styloid process [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Since the patient in our case experienced only facial muscle weakness, the compression of the facial nerve must be below the stylomastoid foramen, allowing the functions of taste, sublingual, submandibular, and lacrimal glands to remain intact. The most frequent cause of facial nerve palsy, Bell\u0026rsquo;s palsy, is not typically associated with neuralgia. The presence of atypical cervicofacial pain should prompt further investigation into secondary causes of nerve palsy, one of which is ES. Conversely, in the first case, facial nerve palsy was also the key finding that led to the suspicion of ES as the underlying cause of the patient's atypical neuralgia.\u003c/p\u003e\u003cp\u003eThe diagnosis of ES requires a combination of clinical manifestations, pain characteristics, and imaging findings that demonstrate elongation of the styloid process. A CT scan of the head and neck, especially a 3D CT scan, is regarded as the gold standard for imaging the anatomically intricate styloid process, as it eliminates the issues caused by overlapping structures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although imaging often reveals bilateral elongation of the styloid process, most patients report pain on only one side, as seen in both cases in this report [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another interesting finding from the first case is that the styloid process on the left side was shorter than the asymptomatic right side. It is suspected that compression is more likely caused by abnormal angulation of the styloid process rather than mere elongation. This is supported by imaging findings showing a narrowing of the pre-styloid space on the symptomatic side [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The rarity of ES and its nonspecific symptom variations often lead to misdiagnosis as more common conditions. Differential diagnoses include temporomandibular joint disorders, otitis, mastoiditis, primary headaches, temporal arteritis, cranial nerve neuralgia, and cervical spine disease. One important differential diagnosis to consider is Ernest Syndrome, which is an inflammatory and painful irritation of the submandibular ligament. Similar to ES, Ernest Syndrome can present with temporo-mandibular joint pain, temporal pain, ear and mandibular pain, and dysphagia. While ES shares similarities, its pathogenesis involves calcification, whereas there is no clear evidence of calcification in Ernest Syndrome [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The exclusion of other potential causes of pain is essential, as demonstrated in this case series [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are two treatment options available for ES: a conservative approach and a surgical approach. The conservative option involves using non-steroidal anti-inflammatory drugs, steroid, antidepressants, and anticonvulsants. Additionally, analgesic injections with lidocaine or steroids can be administered through the tonsillar fossa [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Some cases reported the improvement in facial nerve palsy by steroid administration, but the pain persisted [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our second case and other case series, pain was controlled by gabapentinoid drugs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. If conservative treatment fails, the definitive approach is surgery, specifically styloidectomy. Surgical styloidectomy in patients diagnosed with ES has an 80% success rate in providing a cure [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eEagle syndrome is a rare entity, but should be considered as one of differential diagnosis in cases of trigeminal neuralgia, glossopharyngeal neuralgia, and/or peripheral facial nerve palsy with atypical presentation, idiopathic appearance, and resistance to medication. A thorough history-taking, physical examination, and exclusion of other etiologies are essential. The diagnosis of ES is based on a combination of clinical manifestations and elongated styloid process in imaging findings, with 3D CT reconstruction being the gold standard.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eES\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEagle Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study did not require ethical approval as it involved two case reports with no experimental procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent were obtained from the patients for publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests in this section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no funding for this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.M.A.R.K. and M.C.H. designed and wrote the article and also participated in acquisition, analysis, and interpretation of data; A.V. and O.D. participated in patient care and critically revised the article; I.I.K. participated in patient care, performed the surgery, and critically revised the article. J.F.A.B. critically revised the article. All the authors reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll figures presented in this manuscript are original and were chosen by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSearle E, Searle A. An overview of Eagle\u0026rsquo;s syndrome. Br J Pain. 2021;15:388\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2049463720969741\u003c/span\u003e\u003cspan address=\"10.1177/2049463720969741\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScavone G, Caltabiano DC, Raciti MV, Calcagno MC, Pennisi M, Musumeci AG, et al. 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Am J Case Rep. 2024;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12659/AJCR.944399\u003c/span\u003e\u003cspan address=\"10.12659/AJCR.944399\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDom\u0026iacute;nguez J, Bornhardt T, Wen S, Iturriaga V. Ernest Syndrome: A Systematic Review of the Literature. J Oral Facial Pain Headache. 2020;34:167\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11607/ofph.2551\u003c/span\u003e\u003cspan address=\"10.11607/ofph.2551\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejnp","sideBox":"Learn more about [The Egyptian Journal of Neurology, Psychiatry and Neurosurgery](http://ejnpn.springeropen.com)","snPcode":"41983","submissionUrl":"https://submission.springernature.com/new-submission/41983/3","title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"atypical presentation, cranial nerve neuralgia, eagle syndrome, facial nerve palsy","lastPublishedDoi":"10.21203/rs.3.rs-6952890/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6952890/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEagle syndrome (ES) is a rare entity caused by elongation of the styloid process or calcification of the stylohyoid ligament, leading to compression of surrounding anatomical structures. This can result in a variety of symptoms, including atypical cranial neuralgias and, in rare cases, cranial nerve palsy. Due to its nonspecific presentation, ES is often misdiagnosed as more common conditions such as trigeminal neuralgia or temporomandibular joint disorders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report two cases of ES with distinct clinical manifestations. The first case involves a 41-year-old female with chronic headache and facial pain with allodynia that progressed to left-sided peripheral facial palsy. Cervical Computed Tomography (CT) scan with 3D reconstruction revealed an elongated styloid process with narrowing of the pre-styloid space. The second case describes a 24-year-old female who presented with Ludwig’s angina and a history of intermittent unilateral headaches and facial pain that were resistant to pain medication. A cervical CT scan incidentally identified an elongated styloid process. Both imaging results identified ES as the cause of these atypical pain presentations. Both patients initially received conservative management, with one patient later undergoing surgical treatment and achieving significant pain relief.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese cases highlight the need for clinicians to consider ES in patients with atypical and treatment-resistant cranial neuralgia or facial nerve palsy. Diagnosis relies on a combination of clinical findings and imaging, with 3D CT reconstruction as the gold standard. Increased clinical awareness are crucial for timely diagnosis and management.\u003c/p\u003e","manuscriptTitle":"Eagle Syndrome: An Unforgettable Cause of Atypical Cranial Nerve Neuralgias and Facial Nerve Palsy – A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 08:32:50","doi":"10.21203/rs.3.rs-6952890/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-05T11:14:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T03:25:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T09:03:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106646055488288268510390537453446025296","date":"2025-09-27T06:42:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158467766223422962797184680813705781968","date":"2025-09-26T16:29:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-17T12:18:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-30T04:07:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-30T04:06:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","date":"2025-06-23T05:13:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejnp","sideBox":"Learn more about [The Egyptian Journal of Neurology, Psychiatry and Neurosurgery](http://ejnpn.springeropen.com)","snPcode":"41983","submissionUrl":"https://submission.springernature.com/new-submission/41983/3","title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0383cef0-af5f-42ec-bec6-0609549da8de","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:36+00:00","versionOfRecord":{"articleIdentity":"rs-6952890","link":"https://doi.org/10.1186/s41983-026-01072-w","journal":{"identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isVorOnly":false,"title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery"},"publishedOn":"2026-01-22 15:57:08","publishedOnDateReadable":"January 22nd, 2026"},"versionCreatedAt":"2025-07-23 08:32:50","video":"","vorDoi":"10.1186/s41983-026-01072-w","vorDoiUrl":"https://doi.org/10.1186/s41983-026-01072-w","workflowStages":[]},"version":"v1","identity":"rs-6952890","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6952890","identity":"rs-6952890","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}