Article JOMP - Korea Science

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pISSN 2288-9272 eISSN 2383-8493

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


(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


(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.


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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


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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.


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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.

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