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J Oral Med Pain 2018;43(3):77-83
https://doi.org/10.14476/jomp.2018.43.3.77
The Association of Ponticulus Posticus & Elongated Styloid Process with Headaches
Shivani Sharma1, Rakesh Nagaraju2, Shweta Sharma3
1Department of Oral Medicine and Radiology, Army Dental Corps, New Delhi, India
2Department of Oral Medicine and Radiology, M. S. Ramaiah Dental College and Hospital, Karnataka, India 3Department of Opthalmology, Government Medical College, Jammu, Jammu & Kashmir, India
Received February 8, 2018
Revised March 15, 2018
Accepted March 23, 2018
Purpose: The present study was designed to investigate the association of ponticulus posticus (PP) and elongated styloid process (ESP) with headaches.
Methods: Analysis of head and neck cone beam computed tomography samples from the ar-chives of the Department of Oral Radiology was done for the presence of partial or complete PP and ESP length, type, thickness, mediolateral angulation, anterioposterior angulation (hori-zontal & vertical), lateral or medial curvature. This was followed by personal & telephonic questionnaires to the subjects for the evaluation of the presence of headaches & other associ-ated symptoms.
Results: Among 134 subjects, 62 subjects (46.3%) presented with headache and 72 subjects (53.7%) did not have any headache. On further analysing the total 62 subjects with headache, it was found out that 31 subjects (50.0%) of them had ESP and PP both, 16 subjects (25.8%) had only ESP, and 15 subjects (24.2%) had only PP. A strong association was present between headache and presence of PP & ESP individually and together.
Conclusions: All health care professionals dealing with the head and neck pain disorders should also consider the presence of ESP & PP during diagnosis and treatment.
Key Words: Cone beam computed tomography; Elongated styloid process; Headache; Ponticu-lus posticus; Surveys and questionnaires
Correspondence to:
Shivani Sharma
Department of Oral Medicine and
Radiology, Army Dental Corps, New
Delhi 110011, India
Tel: +91-94-1918-7170
Fax: +91-11-2619-2356
E-mail: [email protected]
OriginalArticle
JOMP Journal of Oral Medicine and Pain
Copyright Ⓒ 2018 Korean Academy of Orofacial Pain and Oral Medicine. All rights reserved.
CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Headaches are highly prevalent and disabling disorders
throughout the world but are largely not diagnosed and
treated properly. World Health Organisation’s recent re-
search on the leading causes of disabling conditions lists
headache as 12th for women and 19th for men worldwide.1)
The fact that the data of the prevalence of headache disor-
ders has been gathered predominantly from the high-in-
come countries leaving vast geographical areas of underde-
veloped and developing countries including India leads to
a lack of knowledge of the prevalence and burden attribut-
able to headache disorders among such a large population.2)
Minority of people with headache disorders are profession-
ally diagnosed, about 50% of people are estimated to be
primarily self-treating worldwide.3) The primary headache
disorders account for approximately 95% of all headache
complaints. Headache also occurs as a typical symptom
of a range of other health conditions, called ‘secondary
headaches’.4)
The ponticulus posticus (PP) is a bridge of bone some-
times found on the atlas vertebra surrounding various ner-
vous and vascular structures and is generally regarded as a
simple anatomical variant. It can have varied presentations
namely complete, incomplete, unilateral or bilateral. The
prevalence of PP has been reported to be 5.14%-37.83% in
78 J Oral Med Pain Vol. 43 No. 3, September 2018
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the western population.5) Among Indian population, com-
plete PP was found in 4.3% of the subjects with a male
(5.33%) predominance over female (3.76%).6) Due to the
compression of the structures passing through the foramen,
symptoms such as cervical migraine, neurosensory-type
hearing loss, neck pain, vertigo, shoulder-arm pain and,
vertebrobasilar insufficiency may occur. Severe headache is
present in 56%-90% of subjects.7)
The stylohyoid complex (SHC) consists of the styloid pro-
cess (SP), the stylohyoid ligament (SHL) and the lesser horn
of the hyoid bone. The SP is a cylindrical, long cartilagi-
nous bone located on the temporal bone with many adja-
cent nerves and vessels. The normal SP length is approxi-
mately 20-30 mm and is considered elongated if either the
SP or adjacent SHL ossification shows an overall length
in excess of 30 mm.8) The the compression of the adjacent
neural and vascular structures by the elongated styloid pro-
cess (ESP) leads to the symptoms of headache, dizziness and
reversible cerebral ischemia.9)
Sekerci et al.7) has confirmed a significant correlation be-
tween the presence of PP and ESP. In the present study, our
aim was to investigate the association of PP & ESP with
headaches. To our knowledge, this is the first study in liter-
ature investigating this association.
MATERIALS AND METHODS
We designed a retrospective study composed of the cone
beam computed tomography (CBCT, Carestream 9300;
Carestream Health, Rochester, NY, USA) scans of patients
who presented to the Department of Oral Medicine and
Radiology, M.S. Ramaiah Dental College, Bangalore. All
the patients had been referred for diagnosis and treatment
planning for different problems involving the maxillofacial
region.
CBCT scans were retrieved from the archives and exam-
ined for PP and ESP. Exclusion criteria included inadequate
picture quality (artifacts, low resolution, patient movement
during imaging), patients presenting with congenital and
systemic abnormalities involving the craniofacial region.
All medical data were obtained from the records. 4500 full
skull CBCT scans (field of view 17×13.5 cm) from the ar-
chives of Department of Oral Radiology were examined.
1. Evaluation of the ImagesThe CBCT scans were analysed using a 32-in. Dell liquid
crystal dysplay screen with a resolution of 1,280×1,024 pix-
els. The contrast and brightness of the images were adjusted
using the image processing tool in the software to ensure
optimal visualization. The images were reconstructed into
three-dimensional images and carefully inspected for the
presence of PP and ESP. Out of 4500 full skull CBCT scans,
150 scans showing the presence of ESP (≥30 mm) and/or
PP were retrieved and analysed. All the CBCT images were
evaluated by two observes. To eliminate any error, 100 ran-
domly selected images were re-examined separately by the
same two experts 1 month after initial examination. There
was complete agreement between the two authors and the
two examinations.
1) Evaluation of the PP
The direct visual method of examination under adequate
A B C
Fig. 1. (A) Absent PP. (B) Partial PP. (C) Complete PP. PP, ponticulus posticus; AVG, arteriovenous graft; MIP, maximum intensity projection.
79Shivani Sharma et al. The Association of PP & ESP with Headaches
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illumination was used to analyse whether PP was complete
or partial (Fig. 1). Complete type was defined as a clear
bony bridge between the superior articular process and the
posterior arch of the atlas in 3-D CBCT images. Partial type
was considered as a distinct bony spicule extending from
the superior articular facet overhanging the dorsal arch (ad-
opted from Sekerci et al.7)).
2) Evaluation of the ESP
SP was evaluated on axial, coronal and sagittal planes.
SP was analysed for length, type, thickness, mediolateral
angulation, anterioposterior angulation (horizontal & verti-
cal), lateral or medial curvature (Fig. 2).
(1) Length: The distance between the base of the SP and
the tip of the ossified SHC. If segmental ossification of the
stylohyoid ligament was observed, the measurement was
made including the non-ossified part in-between (adopted
from Ramadan et al.10)).
(2) Type: The SHC ossification was evaluated to be con-
tinuous or partial (segmented or pseudo articulated) (adopted
from Ramadan et al.10)).
(3) Thickness: The maximum thickness of SHC ossifica-
tion (adopted from Ramadan et al.10)).
(4) Mediolateral angulation: Measured by the angle of in-
tersection of the line connecting both bases of the SP and
the longitudinal axis SHC on anteroposterior view (adopted
from Ramadan et al.10)).
(5) Horizontal anteroposterior angulation: A vertical line
was passed from the cranial base of the process, which was
vertical to Frankfort plane (a line passing horizontally from
the superior border of external auditory meatus to the in-
ferior border of the orbital rim). Anterior angulation was
measured as the angle between this vertical line on lat-
eral skull X-ray and the body of the process (adopted from
48.0 mm 48.9 mm
4.3 mm
66
67
20
111.9 mm
70.9 mm
75.5 mm
68
B
D
F
A
C
E
Fig. 2. Elongated styloid process (A)
length, (B) type, (C) thickness, (D) me-
diolateral angulation, (E) anteroposte-
rior angulation (horizontal & vertical),
and (F) lateral or medial curvature. MIP,
maximum intensity projection; AVG, ar-
teriovenous graft.
80 J Oral Med Pain Vol. 43 No. 3, September 2018
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Yavuz et al.11)).
(6) Vertical anteroposterior angulation: Ante roposterior
angle was defined as the vertical line passing from the cra-
nial base of the process, which was vertical to the Frankfort
plane (a line passing horizontally from the superior border
of the external auditory meatus to the inferior border of the
orbital rim) on the lateral view. The angle between this ver-
tical line and the body of the process was measured (adopted
from İlgüy et al.12)).
(7) Lateral or medial curvature: The angle between the
base of the SP and the tip of the SHC at the level of the
bending point on skull base views (adopted from Ramadan
et al.10)).
2. Questionnaire The analysis was followed by structured close ended
questionnaire consisting of 96 entities (adapted from refer-
ences13,14)) to the subjects for the evaluation of the presence
of headaches & other associated symptoms. Out of 150
subjects, 134 responded to the questionnaire (personal and
telephonic interviews). The questionnaire had good reliabil-
ity (0.859) by personal and telephonic interviews on assess-
ment with cronbach alpha test.
Informed consent was obtained from all the subjects.
Statistical analysis was conducted using Statistical
Package for the Social Sciences (SPSS) 16.0 for Windows
(SPSS Inc., Chicago, IL, USA). Data was analysed for these
134 subjects by the Pearson chi-square test. Statistical sig-
nificance was considered at p<0.05.
RESULTS
The study group comprised 134 subjects including 86
males (64.2%) and 48 females (35.8%) with an age range of
15 to 86 years. Out of 134 subjects, 114 had the presence of
ESP (102 bilateral & 12 unilateral ESP) and 48 had PP (27
bilateral & 21 unilateral PP). Further among these 134 sub-
jects, 86 had only ESP, 20 had only PP and 28 had PP with
ESP.
Among 134 subjects, 62 subjects (46.3%) presented with
headache and 72 subjects (53.7%) did not have any head-
ache. Out of 114 ESP subjects, 47 subjects (41.2%) presented
with headache and 67 subjects (58.8%) did not. Among 48
subjects with PP, 46 subjects (95.8%) had headache and 2
subjects (4.2%) did not. The p-value was 0.001, thus sug-
gesting a positive association between headache and PP &
ESP individually.
On analysing the individual ESP parameters, there was no
association between headache and length, type, thickness,
mediolateral angulation, anterioposterior angulation (hori-
zontal & vertical), lateral or medial curvature (Tables 1-3).
On further analysing the total 62 subjects with headache,
it was found out that 31 subjects (50.0%) of them had ESP
and PP both, 16 subjects (25.8%) had only ESP, and 15 sub-
jects (24.2%) had only PP. The p-value of 0.009 suggested a
strong association between headache and presence of PP &
ESP together (Table 4).
DISCUSSION
Ponticulus posticus also known as Kimmerle’s variant,
foramen retroarticulare superior, canalis vertebralis, retro-
articular vertebral artery ring, retroarticular canal and ret-
rocondylar vertebral artery ring.15) Conflicting theories have
been put forward by various authors for the origin of this
anomaly. The theories suggested congenital characteristic;
genetic trait; ossification due to ageing; external mechani-
cal factors; acquired ossification of ligaments induced by
the pulsation of the vertebral artery or activation of exist-
ing special osteogenetic potency in the region of the cra-
niovertebral junction.16) These ponticuli in extreme cases
compromise the calibre of the vertebral artery. Ercegovac
and Davidović17) alleviated the symptoms of vertebrobasilar
insufficiency by surgical removal of the bony ring in 8 cas-
es thus confirming their predisposition to a peripheral com-
pression syndrome. Finale et al.18) reported a case of drop
attacks on head rotation and hyperextension in an adoles-
cent having PP.
Wight et al.19) investigated the relationship of PP and
headache symptoms, a significant association was found
between PP and migraine without aura. PP is intimately at-
tached to the atlanto-occipital membrane which is further
attached to the dura. Thus any mechanical dysfunction at
the atlanto-occipital joint could result in traction on the
dura, initiating the onset of unilateral headache prevalent in
migraine. The treatment modalities available for PP include
81Shivani Sharma et al. The Association of PP & ESP with Headaches
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surgical and spinal manipulative therapy (SMT) to the cra-
niovertebral articulation.
The ESP and its clinical symptoms were first described
by Eagle. Therefore, it is also known as Eagle’s syndrome
(ES).20,21) The incidence of the ESP ranges between 1.4% and
54% in the literature,22,23) whereas incidence of the ES (1%-
5%) is much lower. Steinmann anticipated diverse theories
to explain the ossification of SHC. These were theory of re-
active hyperplasia, reactive metaplasia and anatomic vari-
ance.24) Langlais et al.25) have classified the radiographic
appearance of elongated and mineralized stylohyoid liga-
ments based on the types of elongation and the pattern of
calcification.
Two types of syndrome were described by Eagle. ‘Classic
styloid syndrome’ characterized by dysphagia, odynopha-
gia, increased salivation and a sensation of a foreign body
in the pharynx, sometimes accompanied by vocal changes.
Second type ‘stylocarotid syndrome’ caused by the SHC ex-
erting pressure on the internal and external carotid arteries
thus stimulating the sympathetic nerve plexus around the
vessels causing orbital pain, parietal headache, vision dis-
turbance and syncopal attacks.26) Chuang et al.27) reported
Table 1. Association of headache with ESP length, thickness, mediolateral angulation, anterioposterior angulation (horizontal & vertical), lat-
eral or medial curvature
ESP parameter Headache Mean Std. deviation Std. error mean p-value
Right ESP length (mm) Present 37.58 13.99 2.04 0.33
Absent 38.83 15.60 1.85
Left ESP length (mm) Present 35.97 13.51 1.99 0.34
Absent 38.70 15.44 1.83
Right ESP thickness (mm) Present 3.79 1.43 0.20 0.42
Absent 4.11 1.27 0.15
Left ESP thickness (mm) Present 4.04 1.88 0.27 0.19
Absent 4.07 1.27 0.15
Right ESP ant vertical angle (o) Present 30.87 7.10 1.03 0.73
Absent 31.54 7.58 0.89
Right ESP ant horizontal angle (o) Present 62.60 5.67 0.83 0.96
Absent 61.70 6.02 0.71
Left ESP ant vertical angle (o) Present 31.14 6.76 0.98 0.89
Absent 31.19 7.35 0.87
Left ESP ant horizontal angle (o) Present 62.65 6.14 0.90 0.65
Absent 62.40 5.95 0.70
Right ESP medial angle (o) Present 66.51 5.22 0.76 0.79
Absent 65.63 5.27 0.62
Left ESP medial angle (o) Present 69.06 4.54 0.66 0.28
Absent 66.92 8.93 1.06
ESP, elongated styloid process; Std., standard.
Table 2. Association of headache with left ESP type
HeadacheLeft ESP type
TotalContinuous Partial
Absent 32 35 67
Present 28 19 47
Total 60 54 114
ESP, elongated styloid process.
p-value=1.5.
Table 3. Association of headache with right ESP type
HeadacheRight ESP type
TotalContinuous Partial
Absent 27 40 67
Present 26 21 47
Total 53 61 114
ESP, elongated styloid process.
p-value=1.2.
Table 4. Association of 62 headache subjects with PP & ESP
ESPPP
TotalAbsent Present
Absent 0 15 15
Present 16 31 47
Total 16 46 62
PP, ponticulus posticus; ESP, elongated styloid process.
p-value=0.009.
82 J Oral Med Pain Vol. 43 No. 3, September 2018
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a case of left hemispheric ischemia within 15 seconds of
turning head to the left which was completely reversible
on returning the head to the neutral position. The findings
were correlated with computed tomography angiography
and surgery. Öztunç et al.28) analysed the SP among 208 pa-
tients with orofacial pain and concluded that patients suf-
fering from orofacial pain, who also had elongated SP, had
increased rate of corresponding neurological complaints
compared with non-elongated ones.
The treatment of ES is primarily surgical through an in-
traoral or extraoral approach.29) Nonsurgical treatments in-
clude reassurance, non-steroidal anti-inflammatory medica-
tions, analgesics, anticonvulsants, antidepressants, and lo-
cal infiltrations with steroids or anesthetic agents.30) Patients
who fail to get relief from medical therapy may benefit
from surgical removal of the elongated portion of the SP.29)
In conclusion, headache is one of the most common dis-
orders worldwide causing substantial levels of disability and
lost productivity through missed workdays. Health care for
headache needs to be improved by education. According to
our study, there is a positive association of headache with
PP & ESP. Therefore, ESP & PP could be major etiologic
factors responsible for headaches and should be taken into
consideration while diagnosing and managing headache
disorders. The clinicians, radiologists, surgeons, dentists and
chiropractors, should be aware of these anatomical varia-
tions and their various clinical features. We recommend
further research to determine the type of headaches associ-
ated with ESP and PP.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article
was reported.
REFERENCES
1. House of Commons. Headache Disorders - not respected, not re-sourced: a report of the all-party parliamentary group on primary headache disorders (APPGPHD). London: House of Commons; 2008-2009.
2. Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Head-ache disorders and public ill-health in India: prevalence estimates in Karnataka State. J Headache Pain 2015;16:67.
3. World Health Organization. Atlas of headache disorders and re-sources in the world 2011: a collaborative project of world health organization and lifting the burden. Geneva: World Health Orga-nization; 2011.
4. Mateen FJ, Dua T, Steiner T, Saxena S. Headache disorders in developing countries: research over the past decade. Cephalalgia 2008;28:1107-1114.
5. Chitroda PK, Katti G, Baba IA, et al. Ponticulus posticus on the posterior arch of atlas, prevalence analysis in symptomatic and asymptomatic patients of gulbarga population. J Clin Diagn Res 2013;7:3044-3047.
6. Sharma V, Chaudhary D, Mitra R. Prevalence of ponticulus pos-ticus in Indian orthodontic patients. Dentomaxillofac Radiol 2010;39:277-283.
7. Sekerci AE, Soylu E, Arikan MP, Aglarci OS. Is there a relation-ship between the presence of ponticulus posticus and elongated styloid process? Clin Imaging 2015;39:220-224.
8. Prasad KC, Kamath MP, Reddy KJ, Raju K, Agarwal S. Elongated styloid process (Eagle’s syndrome): a clinical study. J Oral Maxil-lofac Surg 2002;60:171-175.
9. Başekim CC, Mutlu H, Güngör A, et al. Evaluation of styloid process by three-dimensional computed tomography. Eur Radiol 2005;15:134-139.
10. Ramadan SU, Gokharman D, Tunçbilek I, Kacar M, Koşar P, Kosar U. Assessment of the stylohoid chain by 3D-CT. Surg Radiol Anat 2007;29:583-588.
11. Yavuz H, Caylakli F, Yildirim T, Ozluoglu LN. Angulation of the styloid process in Eagle’s syndrome. Eur Arch Otorhinolaryngol 2008;265:1393-1396.
12. İlgüy D, İlgüy M, Fişekçioğlu E, Dölekoğlu S. Assessment of the stylohyoid complex with cone beam computed tomography. Iran J Radiol 2013;10:21-26.
13. Fritsche G, Hueppe M, Kukava M, et al. Validation of a german language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias. Headache 2007;47:546-551.
14. Hong JP, Lai CH, Lin YC, Chou SW. Clinical assessment of pa-tients with cervicogenic headache: a preliminary study. Chang Gung Med J 2010;33:58-66.
15. Schilling J, Schilling A, Suazo Galdames I. Ponticulus posticus on the posterior arch of Atlas, prevalence analysis in asymptomatic patients. Int J Morphol 2010;28:317-322.
16. Hasan M, Shukla S, Siddiqui MS, Singh D. Posterolateral tunnels and ponticuli in human atlas vertebrae. J Anat 2001;199:339-343.
17. Ercegovac N, Davidović R. Foramen arcuale atlantis as the etio-logical factor of vertebrobasilar insufficiency–decompression of the vertebral artery. Vojnosanit Pregl 1970;27:435-441.
18. Finale E, Martinetti M, Rocca FL, Guccione F, Guala A. Kimmerle anomaly and drop attacks in adolescent. Am J Med Case Rep 2015;3:255-256.
19. Wight S, Osborne N, Breen AC. Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache. J Manipula-tive Physiol Ther 1999;22:15-20.
20. Eagle WW. Elongated styloid process. Report of two cases. Arch
83Shivani Sharma et al. The Association of PP & ESP with Headaches
www.journalomp.org
Otolaryngol 1937;25:548-587.21. Murtagh RD, Caracciolo JT, Fernandez G. CT findings associated
with Eagle syndrome. AJNR Am J Neuroradiol 2001;22:1401-1402.
22. Anbiaee N, Javadzadeh A. Elongated styloid process: is it a pathologic condition? Indian J Dent Res 2011;22:673-677.
23. Matsumoto F, Kase K, Kasai M, Komatsu H, Okizaki T, Ikeda K. Endoscopy-assisted transoral resection of the styloid process in Eagle’s syndrome. Case report. Head Face Med 2012;8:21.
24. Steinmann EP. Styloid syndrome in absence of an elongated pro-cess. Acta Otolaryngol 1968;66:347-356.
25. Langlais RP, Miles DA, Van Dis ML. Elongated and mineral-ized stylohyoid ligament complex: a proposed classification and report of a case of Eagle’s syndrome. Oral Surg Oral Med Oral Pathol 1986;61:527-532.
26. Patil S, Ghosh S, Vasudeva N. Morphometric study of the styloid process of temporal bone. J Clin Diagn Res 2014;8:AC04-AC06.
27. Chuang WC, Short JH, McKinney AM, Anker L, Knoll B, McKin-ney ZJ. Reversible left hemispheric ischemia secondary to carotid compression in Eagle syndrome: surgical and CT angiographic correlation. AJNR Am J Neuroradiol 2007;28:143-145.
28. Öztunç H, Evlice B, Tatli U, Evlice A. Cone-beam computed to-mographic evaluation of styloid process: a retrospective study of 208 patients with orofacial pain. Head Face Med 2014;10:5.
29. Mayrink G, Figueiredo EP, Sato FR, Moreira RW. Cervicofacial pain associated with Eagle’s syndrome misdiagnosed as trigemi-nal neuralgia. Oral Maxillofac Surg 2012;16:207-210.
30. Split W, Sawrasewicz-Rybak M. Character of headache in Kim-merle anomaly. Headache 2002;42:911-916.