A Rare Radiologic Finding of Type III Unilateral Styloid Process Elongation in Dental Panoramic Radiograph: A Case Report and Short Review

Abstract

The styloid process (SP) is a pointed component of the temporal bone that protrudes downward toward the front. If its length exceeds 30 mm, it is considered elongated, and there is a possibility that it will cause symptoms or be asymptomatic. In general, panoramic radiography helps identify the type of SP elongation. The objective of this case report was to demonstrate the rare finding of type III unilateral SP elongation on a panoramic radiograph and to provide a short review of various case reports on this topic. A 61-year-old female patient presented to our hospital with the chief complaint of right facial swelling extending to the ear. The patient experienced persistent swelling and pain for 3 months. Panoramic radiography revealed a 65.06-mm elongation of the right SP consisting of three fragments, classified as type III based on the Langlais classification. Additionally, a fracture-like appearance was observed in the head of the right condyle. Additional diagnostic procedures, including fine-needle aspiration biopsy and computed tomography of the head, confirmed the presence of swollen parotid glands, leading to the diagnosis of parotitis. Type III SP elongation could be clearly observed on a panoramic radiograph. As this is a rare radiographic finding, it is necessary for the clinician to recognize bone morphology abnormalities that appear on panoramic radiographs to identify this condition.

 

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Keywords

styloid process - calcifications - elongated styloid process - Eagle's syndrome - panoramic radiograph

Introduction

The styloid process (SP) is a bony protrusion that projects downward, forward, and slightly medially from the temporal bone. It is long, slender, and pointed.[1] [2] Its apex is located between the internal and external carotid arteries. Anatomically, this area connects to the lateral walls of the tonsillar fossa and pharynx and acts as a point of attachment for the masticatory muscles.[3]

The typical length of the SP ranges from 2 to 2.5 cm when measured on a panoramic radiograph. SP elongation is defined as having an SP of length greater than 3 cm.[4] Its diagnosis is determined by evaluating the findings from clinical and radiographic examinations. Various dental radiographic techniques, including panoramic radiography and cone-beam computed tomography (CBCT), can be employed to assess alterations in typical anatomical morphology. Despite the superiority of CBCT in providing three-dimensional (3D) views, panoramic radiography continues to be the primary tool in numerous studies owing to its accessibility.[5]

Although as much as 4% SP elongation occurs symptomatically; typically, an elongated SP is not associated with any pathology.[3] If symptomatic, symptoms that can be caused by SP elongation include sore throat, earache, or even symptoms such as a sensation of foreign object in the throat due to interactions between the pharyngeal and neck nerves, which is known as Eagle's syndrome.[6] Most physicians have no experience in this diagnosis and often misdiagnose it as temporomandibular disorder.[1] Apart from physicians, dentists should also increase their awareness regarding varied presentations of elongated SPs to avoid misdiagnosis of orofacial pain complaints, especially if the SPs are observed in close proximity to the mandibular angle on panoramic radiographs.[7] The objective of this case report is to present a radiograph characteristic of the type III SP elongation (based on the Langlais classification[8]) on a panoramic radiograph from a patient who complained of swelling in the right cheek. Furthermore, we conducted a short review to explain the differences in the morphological classifications of elongated SP from various case reports.

 

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Case Report

A 61-year-old woman arrived at the Universitas Gadjah Mada (UGM) Dental Hospital complaining of swelling and pain in her right cheek that extended to her ears. She had been taking antibiotics for the previous 3 months. The patient had a history of hypertension and was prescribed candesartan and amlodipine. During extraoral examination, the right side of the face exhibited asymmetry and tenderness upon palpation. Intraoral examinations did not significantly contribute to this study. The patient was considered to have soft tissue lesions extending to the condyle. The initial clinical diagnosis indicated a possible case of parotitis, with differential diagnoses including primary lymphadenopathy.The patient teeth were positioned edge-to-edge for a 10.4-second exposure, which was performed with a Vatech PaX-I Insight (United States) dental panoramic machine that was set to an exposure of 60 to 99 kV and 4 to 10 mA. Examination revealed the root of tooth #35 and multiple edentulous areas in the maxilla and mandible. Additionally, a unilaterally elongated SP was identified as an anomaly on the right side ([Fig. 1]). Informed consent was obtained from the patient for being included in this case report.

Fig. 1 Elongation of the styloid process is visible on the right side of the panoramic radiograph (the white arrow).

In this case, the elongated SP appeared to consist of three bone segments. EzDent-i software (Vatech, Republic of Korea) was used for precise measurement of SP length. This measurement was performed at the junction of the base of the temporal bone and tip of the SP. On [Fig. 2], the SP appears to have extended to a total length of 65.06 mm, comprising three parts that measure 24.15, 9.67, and 31.24 mm, sequentially. The ends of fragment III overlapped with the inferior border of the jaw, whereas fragments I and II appeared parallel to the mandibular axis. Discontinuity in the head of the condyle suggested a right condyle fracture.

Fig. 2 Measurements of the length of each styloid process fragment is shown using the red lines: (I) 24.1 mm, (II) 9.67 mm, (III) 31.24 mm. A radiolucent line resembling a right head condyle fracture (yellow) is visible.

The patient was referred to the UGM Academic Hospital for fine-needle aspiration biopsy (FNAB) and computed tomography (CT). FNAB results of the right parotid revealed disseminated histiocytes, macrophages, and dominant lymphocytes. No malignant cells were detected. Actinomycosis was found along with persistent suppurative inflammation (abscess), which was negative for cancer. The results of the head CT scan were obtained without the use of contrast material and provided axial, coronal, and sagittal views, which indicated that right's parotid gland was enlarged, with fat stranding around it and extending into the buccal region ([Fig. 3]). A radiodiagnosis of suspected parotitis was made, accompanied by a buccal space-extending abscess.

Fig. 3 Computed tomography assessment in coronal (A) and sagittal (B) planes reveals hypertrophy in the buccal region, particularly within the right parotid gland (indicated by an arrow).

The short review conducted in this study aimed to identify case reports in the literature published from 2020 to 2024 that discuss SP elongation. We searched the PubMed database using the search queries “Eagle's syndrome,” “elongated styloid process,” “styloid process,” and “case report” using the Boolean operators—AND and OR. The detailed keywords and search queries are presented in the [Supplementary Material 2] (available in the online version only). Study selection criteria for selected articles are publication of case reports between 2020 and 2024 written in English. In addition, the articles must be supplemented by imaging examination to enhance the precise classification of the SP through images. Review articles and original research are excluded from the screening process. A systematic search of the PubMed database applying the predetermined query generated 169 manuscripts, which were screened for titles and abstracts by two independent reviewers. EndNote, a software reference manager, automatically performed full-text searches, yielding 30 case reports, which are presented in [Table 1]. Data on age, sex, laterality, length, and type of morphological classification were extracted from the articles presented in [Supplementary Table S1].

Table 1 Data extraction was performed from case reports related to the elongation of the SP that were published between 2020 and 2024

No.	Author	Year	Age	Sex	Laterality	Length (mm)	Langlais classification
1	Halalmeh et al7	2024	20	Male	Bilateral	R 35.4/L 33.4	Type I
2	Berrada et al2	2024	40	Male	Bilateral	R 40/L 38	Type II
3	DiLosa et al3	2024	48	Male	Bilateral	60	Type II
4	Sayed et al4	2024	22	Male	Left	–	Type I
5	Hayashi et al5	2023	69	Male	Left	32	Type I
6	Hamamin et al6	2023	39	Male	Bilateral	R 35/L 41	Type I
7	Amir et al7	2023	65	Male	Left	–	–
8	Xu et al8	2023	59	Male	Bilateral	L 57.1	Type III[a]
9	Sun et al9	2023	54	Male	Bilateral	R 36/L 44	Type I
10	Alsoghier21	2023	52	Male	Bilateral	R 35.9/L 38.8	Type I
11	Sarwar et al11	2023	57	Male	Left	45.3	Type I
12	Mann et al12	2023	48	Male	Bilateral	32	–
13	Lakner and Savšek13	2023	38	Male	Bilateral	R 45/L 50	Type I
14	Breda et al20	2023	33	Male	Bilateral	R 38.8/L 43.2	–
15	Ortiz Sánchez et al15	2023	67	Female	Bilateral	–	Type III[a]
16	Aravindan et al22	2023	35	Female	Bilateral	–	Type II
			28	Male	Bilateral	–	Type II
17	Angelou et al17	2023	43	Male	Left	90	Type I
18	Albayat et al9	2023	58	Male	Left	149	Type III[a]
19	Tanenbaum et al19	2022	10	Female	Bilateral	R 24/L 25	–
20	Nunes et al20	2022	62	Female	Right	–	–
21	Pradhan and Adhikari21	2022	33	Male	Bilateral	R 42.7/L 41.5	Type I
22	Loroch et al22	2022	66	Male	Right	10	Type II
23	Dey and Mukherji23	2022	19	Female	Right	–	Type III[a]
24	Cartwright and Moreno24	2022	35	Female	Bilateral	29.2	–
25	Boucher et al25	2022	51	Female	Bilateral	37.3	Type II
26	Wolińska et al26	2021	39	Male	Bilateral	R 41/L 57	Type I
27	Wakoh et al27	2021	49	Male	Right	64	Type I
28	Tanaka et al28	2021	27	Male	Left	–	Type I
29	Priyamvada et al29	2021	34	Female	Bilateral	R 45/ L 48	Type I
30	Worden et al30	2020	50	Male	Left	–	Type I

Abbreviations: L, left; R, right.

^a Type III Langlais classification.

In 1986, Langlais classified the elongation patterns of the SP into three types, according to the extent of elongation.[8] In summary, the distinct classifications of SPs that undergo elongation are outlined in [Table 2]. For clarity, [Fig. 4] illustrates the classification of elongation patterns of the SPs using BioRender.com.

Table 2 Summary of the styloid process classification according to Langlais[8] [10]

Type	Classification	Definition
I	Elongated	Styloid process lengths exceeding 30 mm with continuous integrity
II	Pseudo-articulated	Styloid process is connected to the mineralized stylomandibular or stylohyoid ligament through a single pseudo-articulation; it is not segmented
III	Segmented	Styloid process segmented, contains several pseudo-articulations

Fig. 4 Schematic image of the classification of styloid process elongation based on Langlais classification: types I (A), II (B), and III (C). Created with BioRender.com.

Extracted articles revealed that the most frequently reported elongated SP classification was type I, with 15 cases, followed by type II and III, with six and four cases, respectively. The type of SP elongation in five cases could not be identified because the SP could not be observed on the attached radiograph. Twenty-two cases were reported in men, compared with only 8 in women, with an average patient age of 43.5 years. Regarding laterality, there were 19 cases of bilateral SP elongation and 11 unilateral cases. As shown in [Table 1], Albayat et al reported the longest SP (a total length of 149 mm) in a 58-year-old patient with a type III unilateral classification.[9]

 

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Discussion

The SP of the temporal bone is a pointed bone that is located anterior to the stylomastoid foramen, anterior and inferior to the external auditory canal, and anterior and medial to the mastoid process. The stylohyal portion develops after birth, forming the trunk at the tip of the SP and proximal portion of the stylohyoid ligament. The SP provides the origin attachment for three muscles and two ligaments, which are crucial for speech, swallowing, and mastication.[10] The stylohyoid muscle, one of the three muscles, inserts on the larger horn of the hyoid bone after passing forward and downward. One of the suprahyoid muscles—the styloglossus muscle—inserts into the lateral portion of the tongue by passing forward and downward. When entering the pharynx, the stylopharyngeus muscle crosses medially and inferiorly through the space between the superior and inferior constrictors. Furthermore, the stylomandibular and stylohyoid ligaments are the two ligaments attached to the SP.[11]

The SP was considered to be elongated if its length exceeds 30 mm. The normal SP exhibits numerous variations, necessitating a classification to characterize its radiographic appearance.[12] Langlais et al classified elongated and mineralized stylohyoid ligament complexes into three types based on their radiographic appearance. Additionally, Langlais et al also differentiated them based on the appearance of the types of calcifications, namely, type A calcified outlines, type B partially calcified, type C nodular, and type D completely calcified.[8] Based on the short review, the majority of SP elongations were classified as type I in men with an average age of 43.5 years. This is in line with the research conducted by Alwanni et al, Assiri et al, and Alzarea regarding the prevalence of SP types, predominantly type I, followed by types II and III.[3] [13] [14] Researchers have also found a significant correlation between age and SP length. In a study conducted by Chen et al, SP length was found to progressively increase with age.[5] Further, research conducted by Assiri et al and Vieira et al concluded that SP elongation has a higher prevalence in women than in men.[13] [15] In this case report, we describe a type III unilateral elongated SP with a completely calcified total length of 65.06 mm, found in a 61-year-old female patient. Type III is rare; therefore, the SP elongation described in this case report is also rare.

The abnormal length of the SP allows the compression of the surrounding blood vessels and nerves, causing complaints. Some symptoms that may be encountered, including neck pain, dysphagia, headache, sore throat, ear pain, and mandibular dysfunction, clinically framed in Eagle's syndrome.[6] Based on our short review, the longest SP was 14 cm long (unilateral) reported in a 58-year-old male patient who complained of difficulty in swallowing for 2 years. The CT scan showed elongation of the SP anterolaterally and caudally toward the hyoid bone.[9] However, the association between the abnormal length of the SP and Eagle's syndrome is not always present, and many cases are asymptomatic.[6] Eagle's syndrome is rarely suspected in clinical practice, and the visualization of an elongated SP is often an incidental finding. Radiographic studies are usually advised to visualize other, more frequent diseases.[2] In this case report, SP elongation was discovered incidentally and did not cause any symptoms.

In this case report, the patient sought medical care due to complaints of facial asymmetry and was finally diagnosed with parotitis after undergoing several examinations. Suspicion of malignancy was denied in this case because the findings from the FNAB revealed an absence of cellular indicators suggestive of neoplastic activity. The diagnosis of parotitis is also supported by a CT scan, which reveals hypertrophy in the parotid gland on the affected side. Parotitis is a pathological condition characterized by the inflammation of the parotid glands, which may arise as a consequence of bacterial infections, viral agents, or other factors such as sialoliths. The anatomical proximity to the parotid gland and other neck structures could potentially lead to misdiagnosis or confusion with parotitis symptoms. Indirectly, there exists a correlation between the phenomena of inflammation and swelling in parotitis; specifically, the swelling and edema resulting from infection can exert additional pressure on the elongated SP, potentially leading to exacerbated pain and any other clinical symptoms.[16]

The diagnosis of SP elongation can be made based on clinical examination with palpation in the ipsilateral tonsillar fossa region, which can then be confirmed by radiographic imaging examination.[17] Panoramic radiography is the most useful clinical examination for diagnosing bone disorders related to facial structures, such as the maxillary, mandibular, and temporomandibular joint (TMJ) areas, including the elongation of the SP.[5] Other conventional radiographic techniques that can be used include the anteroposterior view to evaluate the laterality and skull lateral radiographs to measure the length of the SP.[18] In advanced dental imaging, CBCT also provides a reliable visualization of the orientation of the medial and lateral directions and dimensions of the styloid apparatus in 3D imaging.[5]

CBCT has demonstrated superior efficacy in identifying anatomical variations in the SP compared with conventional imaging modalities, such as panoramic radiographs, thereby facilitating the detection of elongated SP. This capacity is crucial to ensure accurate diagnostic results, especially in individuals presenting with clinical manifestations associated with elongated SP, potentially leading to better surgical outcomes. These technological advancements highlight the need for the use of contemporary imaging techniques in the clinical setting for careful evaluation and management of associated clinical symptoms. Unfortunately, in this case report, a CBCT assessment was not conducted. This omission may be attributed to the patient's primary complaint being localized cheek swelling, a condition that is well recognized by standard CT scanning.[19] A CT scan can provide excellent visualization of the position of the elongated SP relative to the surrounding neurovascular structures, if necessary.[20]

Based on a short review, Alsoghier, Breda et al, and Aravindan et al used panoramic radiography as an initial examination for complaints.[20] [21] [22] Panoramic radiography is commonly used in dental practice and provides an efficient and simple method for examining the maxillofacial area. They are also valuable tools for measuring the length of the SP.[23] Panoramic radiography provides several advantages over CT, including affordability, lower radiation exposure, and simple interpretation. However, care should also be taken to avoid image distortion and magnification, as well as superimposition of images between teeth and bones.[15] The position of the patient's head is important because if the anatomical structure is outside the focal point, the SP can appear blurred and distorted, and even the image can become too wide or too narrow.[24] In this report, the interpretation and determination of suspected radiodiagnosis were performed by a dentomaxillofacial radiologist.

Treatment planning for styloid elongation is refined to the patient's symptomatic or asymptomatic condition. A surgical intervention is preferred in symptomatic patients, while asymptomatic patients may not necessitate immediate treatment unless symptoms emerge. The extraoral surgical technique permits better visibility and exposure, while in the intraoral approach, the styloid is accessed via the oral cavity. Although the results of the intraoral approach can prevent external scars, access to the styloid is limited, and there is a high risk of infection.[25] Considerations such as the surgeon's preferences, duration of the surgical procedure, patient's existing comorbidities, and mouth opening should be integrated into the decision-making process regarding the surgical method for styloidectomy.[22] In cases with extreme styloid length, surgical procedure is performed with an extraoral approach, even though the results of intraoral surgery do not cause external scars aesthetically.[9]

In the maxillofacial area, the relevant differential diagnoses for SP elongation include odontogenic pain, headache, glossitis, carotidynia, vertigo, salivary gland sialolithiasis, sialadenitis, and head and neck tumors.[21] Alsoghier reported a case of an elongated SP that mimicked TMJ disorders in which the patient complained of a disturbing sound around the jaw, which was interpreted as a popping sound.[21] According to Halalmeh et al, in cases of trauma, displacement of a fragment of the elongated SP can injure the carotid artery or other vital anatomical structures, causing the onset of Eagle's syndrome. In contrast to this previous case report, in our case, SP elongation was incidentally detected on a panoramic radiograph in the patient who presented with discomfort and swelling in the right cheek.[7] In such situations, even if the CT scan and FNAB test confirm the diagnosis of parotitis, dentists should still be able to identify normal anatomical alterations, such as elongation of the SP.

 

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Conclusion

Panoramic radiography can be used to detect SP elongation and determine its classification. Type III SP can be interpreted as an elongated radiopaque line segmented into three parts. Dentists should consider the involvement of these anatomical variations if a patient exhibits complaints in the cheek area, TMJ, or around the neck, as confirmed by panoramic radiography. Dentists should be aware that SP elongation is an incidental finding that might be observed in patients during regular dental examinations using panoramic radiograph.

 

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Conflict of Interest

None declared.

Acknowledgments

None.

Authors' Contributions

S.F.D.: conception and design, data collection, drafting the manuscript, and final approval.

R.D.Y.: conception and design, data collection, analysis and interpreting data.

D.I.: data collection, analysis and interpreting data.

A.L.A.V.: data collection and drafting the manuscript.

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Publication History

Article published online:
13 August 2025