Beyond Eagle's Syndrome: Enlarged Styloid Process Inducing Facial Nerve Paralysis

Background: Facial nerve paralysis is most commonly idiopathic (Bell’s palsy), traumatic, infectious, or neoplastic in origin. Elongation and ossification of the styloid process, known as Eagle syndrome, rarely presents with facial paralysis. Compression of the facial nerve at the stylomastoid foramen by an elongated styloid process is an uncommon but clinically significant etiology requiring high suspicion and multidisciplinary management. Case Presentation: We report the case of a 56-year-old female who developed acute left neck swelling, throat pain, dysphagia, and otalgia. Initial treatment with antibiotics and steroids did not provide relief. Within one week, she developed progressive left facial paralysis, initially of the lower division and subsequently complete paralysis. She denied hearing loss or prior otologic surgery. CT scans of the temporal bones and neck showed enlargement and elongation of the left styloid process forming a pseudoarthrosis with the hyoid bone, near the stylomastoid foramen, with soft tissue thickening and enhancement. The contralateral styloid process was mildly elongated. No masses, middle ear pathology, or other intracranial abnormalities were identified. Fig. 1 Axial computed tomography scan showing enlarged styloid at stylomastoid foramen Fig. 2 Coronal computed tomography scan showing enlarged styloid at stylomastoid foramen Management and Intervention: Given her progressive, complete paralysis and imaging findings, a combined surgical approach was planned. A left transparotid styloidectomy and inferolateral temporal bone resection were performed for facial nerve decompression. Intraoperatively, the facial nerve was intact but edematous, without stimulation throughout the procedure even at 2.0 mA. The facial nerve was decompressed along the mastoid segment up to the tympanic segment. The nerve was traced distally to the mastoid tip, and the mastoid tip was drilled until soft tissue was encountered. The elongated left styloid process was skeletonized and resected, with preservation of surrounding vascular and neural structures. A 4.5 cm specimen was excised. The nerve sheath and vascularity were preserved. Fig. 3 Styloid process exposure prior to resection Fig. 4 Excised styloid process specimen Outcome: The patient recovered well postoperatively and was clinically stable for discharge with appropriate followup on postoperative day one. At the time of discharge, there was no noted improvement in facial nerve function. Long-term follow-up is ongoing to assess functional improvement. Conclusion: We present a rare case presentation of facial nerve paralysis from an elongated styloid process at the stylomastoid foramen. Imaging was required to make the diagnosis and rule out idiopathic Bell’s palsy and other causes. Combined facial nerve decompression with styloidectomy provided definitive management, with preservation of neural structures and safe postoperative recovery. Clinicians should consider Eagle syndrome variants in patients with atypical or refractory facial paralysis, especially when imaging reveals elongated styloid processes abutting the facial nerve. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany