Specialist article: jaw and head
Eagle syndromeWhy the long bone is rarely the cause
Pain in the throat, a foreign-body sensation when swallowing, and an X-ray showing a long styloid process? Here you will learn how common this finding is, why we usually consider Eagle syndrome a false conclusion and which warning signs matter.
Does this sound familiar?
Your throat hurts, and the X-ray shows a bone that is too long?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a second look. At least as important as the bone is how the muscles hold the head, hyoid bone and jaw. This muscular work can be trained.
How common the finding isWarning signsThe key points at a glance
- An elongated styloid process is not a rare finding. In large analyses of X-ray and CT images, roughly one in four to one in three people have it, most of them without symptoms.
- We therefore usually consider Eagle syndrome a false conclusion. In our view, what matters is how the head, hyoid bone and jaw are held by the muscles, i.e. head balance, the swallowing pattern and the tongue reference position.
- Styloidectomy has its place, above all in the rare vascular form. For pain without warning signs, we consider it premature as long as head balance and the swallowing sequence have not been put in order. Dizziness or visual disturbances when turning the head, suddenly severe difficulty swallowing or a one-sided swelling of the neck should be clarified by a doctor immediately.
Video
Cervical spine and neck: why the hyoid muscles carry head balance
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Assessment
Eagle syndrome: a common finding, a rare explanation
Eagle syndrome is named after the American ENT surgeon Watt Eagle. It refers to pain in the neck and head area that is attributed to an overly long bony process at the base of the skull.
The styloid process is generally considered elongated from three centimetres. A review from Athens analysed 104 studies with a total of 136,010 sides of the neck. On average the bone was 28.9 millimetres long, just below this threshold2. Even small differences in measurement therefore decide whether a finding is considered abnormal.
What would you guess: how many people have an elongated styloid process?
of the people examined showed an elongated styloid process, analysed in 39 studies with 50,655 participants1
of the 136,010 sides of the neck in the Athens review had an elongated process. The authors therefore do not call it a rare variant2
were analysed in Istanbul. Length, angle and shape of the process were not related to the symptoms3
A finding that so many people have without symptoms cannot simply explain the symptoms. We therefore usually consider the diagnosis of Eagle syndrome a false conclusion. That does not mean the pain is imagined. It is real. It is just that, in our view, its cause usually lies somewhere other than in the length of the bone.
The diagnosis of Eagle syndrome looks only at the shape of a bone. We look first at the muscles that hold the head, hyoid bone and jaw, because they determine the pull that arrives at this bone. We therefore see the elongated styloid process more as an accompanying finding of this pull than as the cause of the complaints.
Symptoms
Typical symptoms and what the length says about them
The symptoms attributed to Eagle syndrome are varied. That makes the diagnosis difficult.
Foreign-body sensation
When swallowing, something seems to be stuck in the throat, often on one side.
Throat pain
A pulling or stabbing pain in the throat, at the angle of the jaw or below the ear.
Ear pain
The pain radiates to the ear, but nothing is found at the ear itself.
Neck and head
Tension in the neck, headaches, discomfort when turning the head.
Jaw
Clicking or pain at the jaw joint.
We also know almost all of these symptoms from TMD, from neck pain and from disturbed swallowing patterns. Anyone who has them and shows a long styloid process on an X-ray is easily given this one explanation. The fact that the finding also occurs in many people without symptoms is overlooked. You can read more about the related conditions under TMD and jaw joint and under Neck pain.
longer on average was the process on the painful side, 33.6 versus 31.1 millimetres in 35 patients. Five of them also had a palpable process on the symptom-free side4
were surveyed in Sharjah. The symptoms were related more to the angle of the process than to its length5
So some studies find a slightly longer bone on the painful side, others find no relationship. The Istanbul authors conclude that the diagnosis should be based on the examination, not on the X-ray alone3.
Anatomy
The styloid process is an anchor point
To understand why the length explains little, it is worth looking at what is attached to the styloid process.
Three muscles attach to the styloid process. The styloglossus pulls the tongue backwards and upwards. The stylohyoid runs to the hyoid bone. The stylopharyngeus raises the throat when you swallow. In addition, there is the ligament to the hyoid bone.
The hyoid bone is a small, horseshoe-shaped bone above the larynx. It is the only bone in the body without a joint. It is held solely by muscles and ligaments, from above, from below and from behind.
The bone does not pull. It is being pulled on.The styloid process is a suspension point. How much pull reaches it depends on how the tongue, hyoid bone and head are held.
An animal experiment from Chicago shows how strongly head balance contributes. When the head was flexed, the hyoid bone shifted forwards and the length of the stylohyoid muscle changed9. Transferring this to humans is a hypothesis of the authors, but it fits the anatomy.
Our view
Not the length, but the constant pull
If not the bone, then what? In our view, the chain usually begins with the basic functions of breathing, swallowing and head balance.
If the head moves forwards, for example at a screen, the neck muscles have to catch it constantly. The lines of pull between the base of the skull, hyoid bone and ribcage shift.
If the tongue lies low instead of against the palate in its tongue reference position, the hyoid bone lacks guidance from above. When swallowing, other muscles then join in, and this happens many hundreds to a thousand times a day.
The basic function deviates
The head moves forwards, the tongue lies low, swallowing relies on accessory muscles.
The body compensates
Neck and floor-of-mouth muscles take on holding work that is not theirs.
Constant pull develops
Muscles and ligaments around the styloid process and hyoid bone are under constant tension.
The symptom appears
Foreign-body sensation, throat pain, ear pain. If an X-ray shows a long process, it quickly becomes the explanation.
This is our explanatory model, not an established fact. It does, however, explain why so many people with a long styloid process never develop symptoms. In them, head balance and swallowing pattern are right. You will find more on this connection under Swallowing and swallowing disorders and under unstable upper cervical joints.
Surgery and warning signs
Styloidectomy: when it has its place
When the bone is shortened, specialists speak of a styloidectomy. The operation is an established procedure, and the studies report good results.
in 12 case series were analysed in a Paris review. 84% were symptom-free after the external approach and 74% after the approach through the mouth6
of the 497 cases in a Copenhagen review had the vascular form, in which the bone presses on blood vessels7
The figures should be classified as follows. The data come from case series and case reports without randomised comparative studies, and case reports tend to include courses that ended well. After the external approach, complications occurred in 16 % in the case reports6. The operation shortens the bone, but in our view the pattern of head balance and swallowing remains as it is. For pain without warning signs, we therefore consider it premature as long as head balance and the swallowing sequence have not been put in order.
The vascular form must be taken seriously. Here, the process presses on the carotid artery or a large neck vein, often triggered by turning the head7. A review from Bordeaux describes 231 such cases; with pressure on an artery, stroke was the most common consequence8. According to this review, surgery is the treatment of choice here. This form is rare, but you should still know its signs.
Have the following medically assessed immediately: dizziness, visual disturbances or a feeling of fainting when turning your head, suddenly severe swallowing difficulties, one-sided swelling of the neck. In the event of paralysis, numbness on one side of the body or sudden speech disturbances, call the emergency number 112. Do not stop prescribed medication on your own initiative.
Training
What you can do yourself: train the pattern
If there are no warning signs, our approach starts where, in our view, the cause lies: with breathing, swallowing and head balance.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. In the basic exercise you close your lips, bite down briefly and swallow. In doing so, the tongue settles against the palate and, in our view, the hyoid bone regains its guidance from above.
A few minutes three times a day are enough to start with. You begin with the FaceFormer ZERO and switch to the ONE after a few weeks. It is the same size, just made of firmer material.
Later, the pull exercise and the head balance rotation are added. In the latter, you turn your head slowly while maintaining lip closure and the tongue reference position.
In this way, the nervous system practises balancing the head from the muscles at the front of the neck. A new pattern develops through repetition over months.
Head over the body
Set up your screen and seat so that your head is balanced upright and does not drift forwards.
Tongue to the palate
The tip of the tongue rests on the small ridge behind the upper front teeth, and the lips rest loosely together.
Increase gradually
If the throat pain increases while practising, reduce the repetitions and build up again slowly.
After surgery
Only start again once everything has healed.
Questions
Frequently asked
What is Eagle syndrome?
This is the name given to pain in the throat, the angle of the jaw or the ear that is attributed to an elongated styloid process or a calcified ligament to the hyoid bone. The finding is common and usually causes no symptoms. We therefore usually consider the diagnosis a false conclusion.
What are the symptoms of Eagle syndrome?
Described symptoms include a foreign-body sensation when swallowing, one-sided throat pain, and ear, neck and headaches. The same complaints also occur with craniomandibular dysfunction (TMD), neck problems and a disturbed swallowing pattern.
Is Eagle syndrome dangerous?
The rare vascular form, in which the bone presses on a blood vessel, must be taken seriously. You should therefore have dizziness or visual disturbances when turning your head, suddenly severe swallowing difficulties or one-sided swelling of the neck medically assessed immediately.
What does the cervical spine have to do with Eagle syndrome?
The cervical spine carries the head, and the muscles at the front of the neck keep it in balance. If the head moves forwards, the lines of pull between the base of the skull, hyoid bone and ribcage change. In our view, this constant pull explains the symptoms more often than the length of the bone.
Does an elongated styloid process have to be operated on?
In the vascular form, styloidectomy is considered the treatment of choice; have its warning signs clarified by a doctor immediately. For pain without warning signs, we consider surgery premature as long as head balance and the swallowing sequence have not been put in order. In our view, a long styloid process on an X-ray does not support the diagnosis: in an analysis of 945 CT scans, length, angle and shape were not associated with the complaints.
Can I train with the FaceFormer if I have Eagle syndrome?
Yes, provided there are no warning signs. You start with the basic exercise and the FaceFormer ZERO and build up carefully. After surgery, only once everything has healed.
More articles from the knowledge section
Where to go next
Sources
- Nogueira-Reis F, de Oliveira Reis L, Fontenele RC, Freitas DQ, Tabchoury CPM (2022). Prevalence and features of elongated styloid process on imaging studies: a systematic review and meta-analysis. Clinical Oral Investigations 26(2):1199-1215. PMID 34800204. Source
- Triantafyllou G, Paschopoulos I, Duparc F, Tsakotos G, Papadopoulos-Manolarakis P, Piagkou M (2025). The Anatomy of the Stylohyoid Chain: A Systematic Review with Meta-Analysis. Diagnostics 15(7):925. PMID 40218275. Source
- Yaşar S, Erdim İ, Bilir AB (2025). Is There a Relationship Between Styloid Process Morphology and Symptoms Associated With Eagle Syndrome? Annals of Otology, Rhinology and Laryngology 134(11):848-853. PMID 40539859. Source
- Singh R, Sharma R, Sharma VK, Prajapati N, Rana AK (2022). Styloid Process; Correlation Between Symptoms, Palpability and Measurements on Three Dimensional Computed Tomography. Indian Journal of Otolaryngology and Head and Neck Surgery 74(Suppl 3):5556-5561. PMID 36742646. Source
- Al-Amad SH, Al Bayatti S, Alshamsi HA (2021). The effect of styloid process medial angulation on Eagle’s syndrome’s self-reported symptoms: A preliminary cross-sectional study. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 132(1):52-56. PMID 33867305. Source
- Lisan Q, Rubin F, Werner A, Guiquerro S, Bonfils P, Laccourreye O (2019). Management of stylohyoid syndrome: A systematic review following PRISMA guidelines. European Annals of Otorhinolaryngology, Head and Neck Diseases 136(4):281-287. PMID 31126893. Source
- Hassani M, Grønlund EW, Albrechtsen SS, Kondziella D (2024). Neurological phenotypes and treatment outcomes in Eagle syndrome: systematic review and meta-analysis. PeerJ 12:e17423. PMID 38948209. Source
- Thielen A, Brizzi V, Majoufre C, Nicot R, Schlund M (2025). Eagle syndrome and vascular complications, a systematic review. International Journal of Oral and Maxillofacial Surgery 54(1):31-42. PMID 39406633. Source
- Li P, Ross CF, Luo ZX, Gidmark NJ (2023). Head posture impacts mammalian hyoid position and suprahyoid muscle length: implication for swallowing biomechanics. Philosophical Transactions of the Royal Society B 378(1891):20220552. PMID 37839446. Source
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FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
