In recalcitrant cases the greater hyoid cornu can be resected. The internal carotid artery is also nearby and injection of anaesthetic here can result in toxicity and seizures. There is also the potential for epidural, subdural, or subarachnoid injection.
If the needle is placed incorrectly then damage can occur to the brachial plexus, phrenic nerve, recurrent laryngeal nerve, and central neuroaxial structures. Ultrasound guidance can improve the accuracy of injection. Withdraw slightly out of the periosteum or calcified ligament. Advance until the hyoid bone is hit which should be 2.5-3cm deep. Insert the needle at this point perpendicular to the skin. Stabilise the hyoid bone with bidigital palpation of the greater cornua. The target point is 2-3cm inferior to the angle of the mandible. Use a 25-gauge needle with 40mg triamcinolone. There was a partial response in a further 15%, and no response in 10%. 54% had complete response after 1 injection, and a further 14% with 2 injections. A large cohort study found 74% had complete resolution with 1-5 injections.
If symptoms persist then corticosteroid injection of the inferior attachment of the stylohyoid ligament onto the greater cornu of the hyoid bone can be done. Tumours should in particular first be excluded. Hyoid syndrome is a diagnosis of exclusion. Corticosteroid can be added for an additional therapeutic effect. Abolition of pain supports the diagnosis. Injection of local anaesthetic into the attachment of the stylohyoid ligament to the greater cornu of the hyoid bone. Workup may include endoscopy and CT or MRI to exclude other causes. See Differential Diagnosis of Anterior Throat pain and article by Shankland for distinguishing some of these conditions. While in hyoid syndrome the pain occurs with movement. Glossopharyngeal neuralgia is characterised by paroxysms of shooting pains similar to trigeminal neuralgia, and is associated with cardiac bradyarrhythmias. Superior Pharyngeal Constrictor Syndrome.Tumours of the neck, hypopharynx, or lung apex.Occult cervical spine fracture or instability.Gastro-oesophageal reflux and laryngo-oesophageal reflux.
One study found focal degenerative changes of the middle constrictor muscle where it insert on the hyoid bone. It is thought to result from tendinitis or tendinosis of the muscles that insert onto the hyoid bone. Variations include an elongated styloid process, ossified stylohyoid ligament, and an elongated hyoid bone. The stylohyoid complex has much variability. With expiration the hyoid rises, and with inspiration it falls. The digastric muscle inserts centrally and acts as a fulcrum. With respiration, swallowing, and phonation is has a rocking motion. The stylohyoid ligament also attaches to the styloid process superiorly, and to the hyoid bone inferiorly. The middle pharyngeal constrictor muscle inserts onto the greater cornu. It is suspended by a total of 9 muscles that elevate, depress, protract, and retract it. It lies between the root of the tongue and thyroid cartilage. The hyoid bone is fixed only by ligaments and muscles and is the only bone that doesn't directly articulate with another bone (a tensegrity structure).
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