Artificial Intelligence: A Reliable Tool to Detect the Elongation of the Styloid Process

Background Eagle's syndrome is characterized by the anomalous elongation of the styloid process. This condition is usually identified through the manual evaluation of orthopantomogram (OPG) images, which is time-consuming and can have interobserver variability. The application of Artificial intelligence (AI) in radiology is gaining importance and interest in recent years. The application of AI in detecting styloid process elongation is less explored, advocating for research in the same arena. Aim and objectives The study aimed to evaluate the accuracy of artificial intelligence in detecting styloid process elongation in digital OPGs and to compare the performance of the three different AI algorithms with that of the manual radiographic evaluation by the radiologist. Materials and methods A total of 400 digital OPGs were screened, and linear measurements of the styloid process length (ImageJ software (National Institute of Health, Maryland, USA)) were done for the identification of styloid process elongation by a single calibrated observer to finally include a processed image dataset including 169 images of the elongated styloid process and 200 images of the normal styloid process. A machine learning approach was used to detect the styloid process elongation using the three different AI models: logistic regression, neural network, and Naïve Bayes algorithms in Orange software (University of Ljubljana, Slovenia). Performance evaluation was done using the accuracy, sensitivity, specificity, precision, recall, F1 score, and AUC-ROC (area under the receiver operating characteristic) curve. Results Logistic regression and neural network algorithms depicted the highest accuracy of 100% with no false positives or false negatives, securing a score of 1.000 for all the metrics. However, the Naïve Bayes model demonstrated a fairly considerable accuracy, classifying 49 false positive images and 59 false negative images with an AUC (area under the curve) score of 78 %. Nevertheless, it performed better than random guessing. Conclusion Logistic regression and neural network algorithms accurately detected styloid process elongation similar to that of manual radiographic evaluation. The Naïve Bayes algorithm did not perform an accurate classification yet performed better than random guessing. AI holds a promising scope for its application in automatically detecting styloid process elongation in digital OPGs.

Malignant Middle Cerebral Artery Infarct Caused by Eagle's Syndrome

Eagle's syndrome is characterised by elongation of the styloid process. The elongated styloid process can cause symptoms like dysphagia, facial or neck pain, syncope, visual changes, etc. In severe cases, it may cause a rupture or dissection of the carotid artery, which can lead to intracranial thrombo-embolism and ischemic stroke. We report a case of a 57-year-old male presenting with dysarthria and mild left-sided body weakness. An initial non-contrast computed tomography (CT) scan showed a possible right internal carotid artery thrombus. He developed worsening left-sided weakness and gaze palsy one day after the admission. Repeated CT brain and intracranial angiography were arranged, which showed significant oedema with mass effect and right internal carotid artery dissection with thrombus. He underwent decompressive craniectomy. An enlarged styloid process measuring 4.53 cm in close proximity to the cervical vasculature was also noted. He was not deemed an appropriate candidate for styloidectomy. Due to residual left-sided weakness, he had to take early retirement. He underwent extensive rehabilitation and was able to mobilize with the help of a quad stick after a period of nine months. At the five-year follow-up, there were no characteristic symptoms of Eagle's syndrome and he was mobilizing without support.

Dysphagia Due to an Extremely Long Styloid Process: A Case Report of Eagle Syndrome

Dysphagia is a relatively common condition in the general population and has a wide range of underlying etiologies. We present the case of a 58-year-old male who presented with a complaint of progressive difficulty swallowing for two years in duration associated with unintentional weight loss. He has been using a proton pump inhibitor therapy for more than one year, but he had only mild improvement in his symptoms. Recently, the patient started to experience neck pain during swallowing and he underwent a head and neck computed tomography scan, which demonstrated an extensive elongation of the left styloid process that measured 14.9 cm. The clinical and imaging findings were consistent with Eagle syndrome and the decision was made to perform a resection of the left styloid process. Excision of the left styloid process was made using the external cervical approach. At the follow-up visit, the patient reported a near-complete resolution of his complaints. Eagle syndrome is a very rare etiology of dysphagia. The case highlights an example of Eagle syndrome with an extremely long styloid process. This diagnosis should be considered when encountering a patient with dysphagia and neck pain.

Eagle Syndrome: A Rare Cause of Stroke in a Young Patient

Stroke is a common acute neurological injury that may develop due to arterial thrombosis or hemorrhage. However, it is uncommon in the young population. The etiologies of stroke in young patients are different compared with those for the elderly population. They include various non-atherosclerotic angiopathies, hematological conditions, and inflammatory disorders. We report the case of a 26-year-old man who presented to the emergency department because he noticed that his right hand had become clumsy. He first noticed this symptom five days before his presentation, but he noticed that his symptom had improved significantly since it began. He reported that he had episodes of neck pain and pain around the ear. He visited the family physician clinic several times for this complaint and was diagnosed as having a temporomandibular joint disorder. Neurological examination revealed decreased muscle strength in the right upper limb with a power of 4/5 along with a sensory deficit. The coordination was intact. No gait ataxia was noted. Considering the patient's age, the initial diagnosis was a demyelinating disorder such as multiple sclerosis. The patient underwent magnetic resonance imaging of the brain. It demonstrated an increased signal intensity in the territory of the left middle cerebral artery representing a left-sided infarction. Subsequently, the patient underwent computed tomography angiography of the head to rule out any structural malformation. The scan showed the presence of an elongated styloid process that appeared in close proximity to the neck vasculature. These radiological findings are consistent with Eagle syndrome. The patient underwent surgical resection of the styloid process. Eagle syndrome is a rare clinical condition that may have a myriad of clinical presentations. A high index of suspicion for this condition is vital to reach the diagnosis. Physicians should keep this condition in the differential diagnosis of stroke in the young population with no risk factors.

The Origin of the Variations of the Hyoid Apparatus in Human

Currently, theories based on acquired calcification of the stylohyoid ligament are believed to be a pathogenesis of syndromes associated with the hyoid apparatus (HA) and its variations. We studied the development of the HA from Reichert´s cartilage using serial sections of 25 human embryos and 45 fetuses. We ensured a fact that, at the initial stage, the HA appeared as two independent cartilage segments, that is, the cranial or styloid segment and the caudal or hyoid segment of Reichert's cartilage, those are connected by a mesenchymal structure. However, between 8 and 10 weeks of development, the mesenchymal connection was lost. We hypothesize that this disconnection is likely to be one of the major factors to make a descent of the hyoid bone in evolution. The stylohyoid ligament was not observed. The variations of the HA, should be considered variations of the development of Reicherts cartilage. If these variations are maintained in the adult, are likely to explain a major symptom associated with Eagle's syndrome.

Case report

Eagle's syndrome is often associated with elongated styloid process or ossified stylohyoid or stylomandibular ligament. Patients with this syndrome present with recurrent cervicofacial pain. Surgical removal of the elongated styloid process is a standard treatment and can be accomplished through either a transoral or extraoral approach. Both approaches have advantages and disadvantages, and the best surgical approach remains controversial. In our case, the elongated styloid process was removed by transoral approach assisted by endoscopy. Endoscopy provides clear surgical view thus lessen the chance of neurovascular injury and other intraoperative complications. Endoscopy-assisted transoral resection is an optional alternative surgical procedure for Eagle's syndrome.