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Keywords:

  • Neck pain;
  • neck strain;
  • thyrohyoid ligament;
  • steroid injection

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

A lateralized pain in the neck is a common symptom encountered by the otolaryngologist. This complaint, frequently caused by lateral thyrohyoid ligament syndrome, is often misdiagnosed. The pathophysiology of this syndrome may relate to overuse and inflammation. [change made here after initial online publication]. Typically, patients present with chronic unilateral neck pain often associated with odynophagia. The point of maximum tenderness localizes over the axis of the lateral thyrohyoid ligament. We present a series of 15 patients, in whom treatment with depot steroid and local anesthetic injection (n = 14) improved symptoms in 12 (86%), with complete resolution in nine (64%) patients. Laryngoscope, 124:116–118, 2014


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

Lateralized cervical pain is not an infrequent presentation in the otolaryngologist's clinic. A thorough history, head and neck examination, and appropriate investigation often rules out any specific etiopathology. To explain such nonspecific, lateral cervical pain, a variety of causative syndromes has been reported, based on the underlying bony or cartilaginous structures. These include hyoid,[1] styloid,[2] stylohyoid,[3] and complex of thyroid and cricoid cartilage syndromes.[4]

In our practice, we observed patients presenting with cervical pain, in whom the clinical features were suggestive of lateral thyrohyoid ligament syndrome. Pain was often accompanied by odynophagia, sometimes a globus sensation, and less commonly, voice changes. The pain typically localized over the axis of the lateral thyrohyoid ligament. The point of maximum tenderness varied on this axis, but most commonly was located at the superior cornu of thyroid cartilage or the greater cornu of hyoid bone. A trial with depot steroid injection in the affected region attenuated pain in most patients. We consider this entity different from the well-defined hyoid syndrome due to its distinctive pain localization.[1] Description of thyrohyoid ligament syndrome is scarce, and our search revealed only one published reference in the oral–maxillofacial surgery literature.[5] It is therefore not unusual for these patients to receive a battery of investigations, prolonged medical treatment with analgesics and/or antireflux agents, and even surgical intervention such as tonsillectomy with no symptomatic relief. For better and timely recognition, we reviewed cases in which a thorough history and focused physical examination identified the source of the lateral neck pain along the axis and/or insertions of the thyrohyoid ligament.

CASE SERIES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

An institutional review board-approved retrospective review was performed for 15 consecutive cases of patients presenting with lateralized cervical pain in the senior author's (b.h.h.) practice. The cases were identified from billing records using the diagnostic code for throat pain (2011 International Classification of Diseases, 9th Revision, Clinical Modification code 784.1). Information about the history of symptoms and the impact of treatment on relief of neck pain was collected through the medical records. All information was verified with patients via phone calls. Phone interviews included a structured questionnaire incorporating all relevant data points and the 11-point Numeric Rating Scale (NRS-11)[6] for patient's self-reporting of pain (0 = no pain, 1–3 = mild, 4–6 = moderate, and 7–10 = severe). Patients were asked to rate the pain intensity at the time of presentation and following treatment.

History and Physical Examination

There were nine females and six males, with a median age of 57 years (minimum–maximum, 39–80 years). At the time of presentation, nine had cervical pain for ≥1 year, three for 6 to 12 months, and three for <6 months. Cervical pain was associated with odynophagia in eight patients, foreign body sensation in five, hoarseness in three, cough in two, otalgia in three, facial pain in one, and painful neck movement in three patients. No definite precipitating factor was identified in 12 of 15 patients. One patient reported onset following severe cough from an upper respiratory tract infection, another following excessive voice use, and the third after strenuous activities of rowing and skiing. Past medical history was significant for musculoskeletal problems (e.g., bone or joint pain) in eight patients. Eight patients had smoking history.

Eight patients had seen two or more providers before consulting the senior author. Four patients had undergone radiological imaging including sialography, barium swallow, computed tomography; one had comprehensive testing for reflux. Six patients were on analgesics varying from nonsteroidal anti-inflammatory drugs to narcotic opioid-containing formulae, with little or no improvement. Five patients were treated with antireflux medication as their neck pain was attributed to gastroesophageal reflux. Four patients underwent surgical intervention, including tonsillectomy, glossopharyngeal and partial vagal neurectomy for suspected neuralgia, dental extraction, and sinus surgery for presumed association with facial pain in one each.

At presentation, all patients underwent complete head and neck examination and an office fiber optic laryngoscopy that ruled out any specific pathology. Tenderness over the lateral thyrohyoid ligament axis was elicited in all 15 patients, usually accompanied by wincing and withdrawal on palpation, which led to the diagnosis of lateral thyrohyoid ligament syndrome. The point of maximum tenderness was localized along the lateral thyrohyoid ligament in all 15 cases. It extended superiorly up to the greater cornu of hyoid in three and inferiorly to the superior cornu of thyroid in an additional three. With the exception of one patient with bilateral pain, all patients had unilaterally localized pain (four on the right, 10 on the left).

Treatment

After the diagnosis was established, patients were counseled regarding options of no treatment versus a trial injection of depot steroid and local anesthetic. Once consented, an injection using 2 mL of Kenalog-40 (triamcinolone acetonide injectable suspension, United States Pharmacopoeia) with 1% lidocaine is freshly assembled. Kenalog-40 injection is used because of its extended effect sustained over a period of several weeks. The point of maximum tenderness is localized on the thyrohyoid ligament. After manually stabilizing the laryngeal skeleton, the needle is targeted toward that point through the skin, until it reaches the ligament or thyroid cartilage (Fig. 1). The needle is then gently withdrawn by a few millimeters, and the injection administered slowly after determination of safe tip positioning by a slight pull of the plunger.

image

Figure 1. Posterolateral view of the anatomical structures. Target points for injection in lateral thyrohyoid ligament syndrome are shown by the arrow and circle. 1 = greater cornu of hyoid; 2 = cartilago triticea; 3 = superior cornu of thyroid; 4 = thyrohyoid membrane; 5 = lateral thyrohyoid ligament).

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TREATMENT RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

Using the NRS-11, the distribution of pain severity rating at the time of presentation was mild pain in one patient, moderate in six patients, and severe in seven patients. Rating could not be assessed for one patient. Following the first steroid injection in 14 patients (one refused), 11 (78.6%) patients reported improvement. The time from injection to any perceptible improvement was at least 1 week and up to 3 weeks. Long-term symptomatic improvement was achieved in seven patients. Symptoms recurred in four patients (after 2 months in two patients, 9 months in one patient, and 2 years in one patient). The patient who refused injection experienced significant reduction in pain after refraining from strenuous activities. The details of patients receiving injection are illustrated in Table 1. One diabetic patient experienced worsening of hyperglycemia requiring insulin injections. The remaining 13 patients had no adverse effects.

Table 1. Comparison of Pre- and Postinjection (1–3 weeks) Pain Severity Using Numeric Rating Scale, NRS-11 (n = 13/15a).
Serial No.Preinjection NRS-11 scorePostinjection NRS-11 ScoreNo. of Repeat InjectionsFollow-up, moStatus at Last Follow-up
  1. a

    One patient refused injection and one could not be scored.

  2. b

    Received bilateral injections .

131179.8Improved but present
263258.5Improved but present
361077Resolved
45009Resolved
550165.4Resolved
6500220Resolved
760053Resolved
866255No improvement
9b70085.3Resolved
1074123.6Resolved after second injection
1171291.5Resolved
1270065Resolved
1377010No improvement

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

The diagnosis of lateral thyrohyoid ligament syndrome is made in patients with acute or chronic cervical pain, where tenderness is localized over the lateral thyrohyoid ligament axis and/or its insertion points on the thyroid or hyoid, and in whom sinister pathology has been excluded. This pain is distinct from the pharyngeal pain of Eagle's syndrome.

The lateral thyrohyoid ligament is a rounded, fibroelastic cord at the posterolateral edge of the thyrohyoid membrane (Fig. 1). A small cartilaginous nodule, the cartilago triticea, is frequently found in it. Another less recognized structure in the region is the retro- or subhyoid Boyer's bursa, located usually in the midline but can lie to the right or the left of the greater cornu of hyoid.[7] Inflammation of the ligamentous, cartilaginous, or bursa-related anatomical structures may contribute to the etiology of the lateral thyrohyoid ligament syndrome.

Persistent strain or inflammation of the lateral thyrohyoid ligament can be caused by overuse or factors such as cough, voice abuse, or strenuous neck and upper limb movements. Though a definite precipitating factor could be identified in only three patients, the symptoms could have possibly been related to similar factors that were not recognized or reported by the patients. Smoking is known to inhibit ligamentous healing,[8] and 57% of our patients were smokers. Laryngeal movements during deglutition may be diminished due to the strain causing discomfort and pain. Odynophagia and foreign body sensation were present in more than two-thirds of our patients. Frank dysphagia was not a symptom that we detected.

The diagnosis of lateral thyrohyoid ligament syndrome requires only a physical examination but can be easily missed if clinicians are not aware of it. The symptoms of lateral thyrohyoid ligament strain may be present over acute, subacute, or a more prolonged chronic time course, and once the diagnosis is established, treatment may be offered at any time. The pathognomonic feature is point tenderness with deep palpation along the axis of the lateral thyrohyoid ligament. There are no specific radiological findings. If underlying activities are identified, patients are advised to first try a “cease and desist” approach for such aggravations. A majority of the patients achieve satisfactory symptomatic improvement with the steroid and local anesthetic injection. We acknowledge the lack of a control group, but support this management based on our clinical experience and reported benefit with steroid injection in a few reports for similar conditions.[1, 4, 5] Depot steroid is widely and effectively used in other somatic/musculoskeletal or ligamentous inflammatory conditions. The injection can be repeated with minimal adverse effect unless steroids are contraindicated, which should be ruled out prior to the administration. A lower dose of 1 mL of Kenalog-10 can be offered in patients with relative contraindications such as brittle diabetics. Application of platelet-rich plasma or bone marrow cell concentrate injections,[9] currently under investigation by orthopedic specialists for chronic ligament strain, are other options that may in the future become available for patients not responding to steroid injection.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY

Lateral thyrohyoid ligament syndrome is a condition that must be considered by otolaryngologists during their evaluation of patients with lateralized neck pain. If aerodigestive tract pathology is ruled out, elicitation of the characteristic localized tenderness over the lateral thyrohyoid ligament axis confirms the diagnosis.

BIBLIOGRAPHY

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE SERIES
  5. TREATMENT RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. BIBLIOGRAPHY
  • 1
    Stern N, Jackson-Menaldi C, Rubin AD. Hyoid bone syndrome: a retrospective review of 84 patients treated with triamcinolone acetonide injections. Ann Otol Rhinol Laryngol 2013;122:159162.
  • 2
    Eagle WW. Elongated styloid process; further observations and a new syndrome. Arch Otolaryngol 1948;47:630640.
  • 3
    Gossman JR Jr, Tarsitano JJ. The styloid-stylohyoid syndrome. J Oral Surg 1977;35:555560.
  • 4
    Kunachak S. Anterior cervical pain syndromes: hyoid, thyroid and cricoid cartilage syndromes and their treatment with triamcinolone acetonide. J Laryngol Otol 1995;109:4952.
  • 5
    Kunjur J, Brennan P, Ilankovan V. The use of triamcinolone in thyrohyoid syndrome. Br J Oral Maxillofac Surg 2002;40:450451.
  • 6
    McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. Baltimore, MD: V. V. Mosby Company; 1993.
  • 7
    Sellars I. An anatomical study of the subhyoid bursa. J Laryngol Otol 1981;95:487491.
  • 8
    Gill CS, Sandell LJ, El-Zawawy HB, Wright RW. Effects of cigarette smoking on early medial collateral ligament healing in a mouse model. J Orthop Res 2006;24:21412149.
  • 9
    Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009;37:22592272.