J O U R N A L O F

CLINICAL
FORENSIC
MEDICINE
Journal of Clinical Forensic Medicine 13 (2006) 268270
www.elsevier.com/locate/jcfm

Original communication

Overview of the ossied stylohyoid ligament based in more than

1200 forensic autopsies
Theodore Vougiouklakis *

University of Ioannina, Department of Forensic Medicine and Toxicology, University Campus, 451 10 Ioannina, Greece

Received 25 May 2005; received in revised form 10 August 2005; accepted 28 September 2005
Available online 25 January 2006

Abstract

The human stylohyoid chain presents considerable anatomic variability. In a personal series of 1215 forensic autopsies, eleven cases of
complete ossication of the stylohyoid ligament have been revealed. Nine cases were bilateral and two cases were unilateral ossications.
A fractured ossied stylohyoid ligament was found in one case. The embryology and clinical signicance of this condition has been men-
tioned briey.
2005 Elsevier Ltd and AFP. All rights reserved.

Keywords: Stylohyoid; Ossication; Forensic; Autopsy; Incidence; Fracture

1. Introduction 2. Methodology Results

The human stylohyoid chain includes the styloid pro-
cess (SP), the stylohyoid ligament (SHL), and the lesser
cornu of the hyoid bone. The stylohyoid chain is derived
from the second branchial arch and is sub-divided into
four parts: the segment known as tympanohyale, the sty-
lohyale, the ceratohyale, and the hypohyale.1 The SHL is
a connective tissue band originating from the apex of the
SP and is attached to the lesser horn of the hyoid bone.
For no obvious reason it occasionally ossies and forms
a solid structure. Various degrees of ossication may be
observed in SHL because of the cartilaginous content of
the ligament. Although the partial ossication of the sty-
lohyoid ligament is not uncommon, the complete ossica-
tion is rare.2 Variable radiographic appearances may be
present due to variations in ossication and fusion of
elements.3
To our knowledge this is the rst report about ossied
SHL presented in the forensic literature.
*
Tel.: +30 2651 097614; fax: +30 2651 097857.
E-mail address: tvujuk@cc.uoi.gr.
In a series of 1215 forensic autopsies performed in our
department a careful dissection of the neck structures com-
plex was done by 1 investigator. Only a macroscopic exam-
ination of the stylohyoid chain was carried out;
radiographs and histological slices were not regularly
made. Therefore only a completely ossication of the
SHL could be detectable; for example, the extent of ossi-
cation could not be considered with this simple method.
Ossications of the SHL were found in 11 cases (0.9%).
Males were 7/11 cases and females were 4/11 cases (male/
female ratio: 1.75). Age distribution of the diseased
showed: 2 cases in the 2nd decade, 5 cases in the 3rd dec-
ade, 3 cases in the 4th decade and 1case in the 6th decade
of life. Nine out of the eleven cases were bilateral and 2/11
cases were unilateral ossications in the left side (Fig. 1). In
one case was found a fractured ossied SHL. The case con-
cerned a 23-year-old man who was involved in a fatal road
incident as the passenger of a bus. Autopsy revealed several
injuries on the left side of the neck consequence of blunt
impact. Dissection of the neck structures revealed bilateral
completely ossied stylohyoid ligaments. The left ligament
was recently fractured in the middle.

1353-1131/$ - see front matter 2005 Elsevier Ltd and AFP. All rights reserved.
doi:10.1016/j.jcfm.2005.09.006
 T. Vougiouklakis / Journal of Clinical Forensic Medicine 13 (2006) 268270
Fig. 1. The gure nicely illustrates the stylohyoid ligament that ossied
from the skull base all the way to the hyoid bone.
3. Discussion
The presence of the ossied stylohyoid ligament and
elongated styloid has been noted both, with and without
symptoms, by various authors in the late nineteenth and
early twentieth centuries.4 The reported incidence of
radiographic stylohyoid ossication varied from 1.4%5 to
84.4%6, most probably due to dierent denitions used to
describe this phenomenon. The condition is usually bilateral,
but it has been reported to occur unilaterally. Although the
term calcication has been originally used, this terminology
is considered erroneous.7 The denition as ossication is
considered more precise, since histologically the specimen
will exhibit either hyperplasia of the styloid process or
metaplasia of stylohyoid ligament into bone (Fig. 2).
Dierent suggestions have been put forward regarding
the extent of ossication versus age. Previous studies have
Fig. 2. Histological appearance of osseous metaplasia in stylohyoid
ligament (H&H X200).
269
suggested that the vast majority of ossied sites in the
stylohyoid ligaments are established during childhood
and adolescence. The mean length of these sites has shown
a rapid, linear increase with age until the end of adoles-
cence; any further increase has been not linear and has
occurred at a much slower rate.8
Fractures of an ossied SHL are an uncommon and
unusual entity that could be seen incidentally during
autopsy. Generalisations on the fractures of ossied SHL
are impossible because of the limited reported
cases in the literature. The inciting cause may be as mild
as yawning but more often blunt trauma of a serious
nature, like in our case, is the cause.9,10 In cases without
ossication, specimens often remained macroscopically
uninjured.
Symptoms are non-specic and rarely occur before the
age of 40. An elongated SHL or SL process is considered
to be the source of craniofacial and cervical pain com-
monly known as Eagles syndrome.11
An ossied SHL has been implicated as a cause of unan-
ticipated diculty in tracheal intubation. An immobile lar-
ynx, as direct result of SHL ossication and the elevation
of the epiglottis due to forward traction of the hyoid bone
would render direct laryngoscopy dicult. If not well man-
aged, there may be serious traumatic consequences and
possible risk of regurgitation and aspiration especially in
emergency situation.1214
Moreover, a simultaneous occurrence of an ossied
SHL and anomalies in the atlantic section of the vertebral
artery has been also reported.15 The discovery of an ossi-
ed SHL seems to be a warning for potential arterial
anomalies. These subjects may be more susceptible to a
variety of head and neck insults resulting to disturbance
in blood ow. Consequently, such anomalies should be
recorded during autopsy in subjects who die as a result of
fatal vertebral artery injuries.16,17 This consideration may
have clinical and medico legal implications for therapists
who perform spinal manipulation in the cervical region.
It is important for the therapist to identify patients at risk
of complications from minor trauma and in the presence of
any signs of vertebrobasilar insuciency such manipula-
tion should be avoided.
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