A 61-year-old woman visited Prof. Soedomo Dental Hospital, Universitas Gadjah Mada, with what initially appeared to be an ordinary complaint: swelling and pain in the right cheek, with pain radiating toward the ear. She had been taking antibiotics for three months without significant improvement. No one expected that a routine panoramic radiograph taken to examine her dental condition would reveal a rare finding that is seldom encountered in dental practice.
On the radiograph, an elongated bony structure was clearly visible on the right side of the jaw—three sequential bone fragments forming a projection measuring 65.06 mm in total length. It was not a tooth, cyst, or tumor. It was an elongated styloid process extending far beyond the normal range.
A Small Bone That Can Become a Major Problem
The styloid process is a slender bony projection arising from the temporal bone at the base of the skull, extending downward and slightly forward. Under normal conditions, it measures approximately 2–2.5 cm in length. When it exceeds 3 cm, the condition is referred to as an elongated styloid process, and when accompanied by clinical symptoms such as throat pain, earache, or a foreign-body sensation in the throat, it is known as Eagle syndrome.
However, what makes this case remarkable is not simply its length. According to the Langlais classification—a classification system for elongated styloid processes that has been used since 1986—this projection was classified as Type III: segmented, consisting of several separate fragments connected by pseudo-articulations. This is the rarest type.
drg. Silviana Farrah Diba, Sp. RKG. Subsp. RP (K), a dental radiology specialist from the Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Universitas Gadjah Mada, and the lead author of the case report, together with the research team, documented that the three fragments measured 24.15 mm, 9.67 mm, and 31.24 mm, respectively. Measurements were performed using EzDent-i software with a Vatech PaX-I Insight panoramic machine. The tip of the third fragment even extended beyond the inferior border of the mandible—an unusual finding.
Parotitis, Not Eagle Syndrome
Ironically, the elongated styloid process was not responsible for the patient's symptoms. After being referred to Dr. Sardjito General Hospital for fine-needle aspiration biopsy (FNAB) and a head CT scan, the diagnosis instead pointed to parotitis—inflammation of the parotid gland caused by bacterial infection, accompanied by an abscess extending into the buccal space.
No malignant cells were detected. The CT scan confirmed enlargement of the right parotid gland with thickening of the surrounding fatty tissue. The elongated styloid process was an incidental finding: it was discovered accidentally and did not cause symptoms of Eagle syndrome.
Nevertheless, the finding cannot simply be ignored. The researchers noted that edema and pressure caused by the parotid infection could indirectly exacerbate symptoms if the elongated styloid process were compressed by swelling in the surrounding tissues. Although the relationship was not causal, it remains clinically relevant.
“Dentists should be aware that an elongated styloid process is an incidental finding that may be encountered in patients during routine dental examinations using panoramic radiography.”
Panoramic Imaging as an Often-Overlooked Window
A literature review conducted by the research team covering 30 case reports published between 2020 and 2024 revealed an interesting pattern. Most cases of elongated styloid processes—15 of the 30 cases—were classified as Type I (continuous elongation), followed by Type II (single pseudo-articulation) with six cases, while Type III accounted for only four cases. Twenty-two cases occurred in men, with a mean patient age of 43.5 years.
The longest case reported in the literature reached 149 mm—more than four times the normal length—in a 58-year-old man who had experienced difficulty swallowing for two years.
Although panoramic radiography has limitations compared with CBCT (cone-beam computed tomography) in terms of three-dimensional visualization, it remains the primary imaging modality used in many case reports. The reasons are simple: it is more affordable, involves lower radiation exposure, and is easier to interpret in conventional dental clinics. Yet precisely because it is so readily available, findings such as elongated styloid processes can easily go unnoticed.
Misdiagnosis is relatively common. An elongated styloid process may be mistaken for temporomandibular joint disorders, odontogenic pain, or even head and neck tumors. One patient reported in the literature even presented with a clicking sound in the jaw, which turned out not to be a joint problem but rather pressure caused by an elongated styloid process.
When a Bone Anomaly Becomes a Clinical Lesson
This case report from the Faculty of Dentistry, Universitas Gadjah Mada, published in the European Journal of General Dentistry in August 2025, is more than documentation of a rare finding. It carries a broader message for clinicians: panoramic radiographs contain more information than we often realize.
When patients present with cheek swelling, ear pain, or discomfort around the jaw joint, dentists should not limit their examination to the teeth and gums. The entire dentomaxillofacial region—including the bony structures surrounding the mandible—deserves careful attention.
The 65-mm styloid process may not have directly spoken to this patient. But it spoke loudly to anyone who examined her radiograph carefully.
Source DOI: DOI: 10.1055/s-0045-1809952
Authors: Anny Anggraini; drg. Achmad Zam Zam Aghasy, M.Kes.
Photo: Pexels