Mædica - a Journal of Clinical Medicine C ASE
MAEDICA – a Journal of Clinical Medicine 2014; 9(3): 272-274
REPORTS
Anatomical Variation of Hyoid Bone: a Case Report Nursel Türkmen INANIRa,b; Bülent ERENb; Selçuk ÇETINa; Filiz ERENb; Ümit Naci GÜNDOĞMUŞc a
Department of Forensic Medicine, Medical Faculty, Uludag University, Bursa, Turkey Department of Bursa Morgue, Council of Forensic Medicine of Turkey, Bursa, Turkey c İstanbul University, Institute of Forensic Medicine, Council of Forensic Medicine of Turkey, İstanbul, Turkey b
ABSTRACT Hyoid bone is a solitary bone localized at the level of cervical 3 vertebrae, connected to the adjacent bone structures with muscles and tendons. Anatomical variations of hyoid bone can cause difficulties in the application of forensic medicine together with clinical and surgical problems. We present a case of a 81-year-old woman, reported to got sick, who died at home. In the autopsy, the neck dissection revealed prolonged right and left greater horns of hyoid bone measured 11 cm and 7 cm respectively. We aimed to present a case with long hyoid bone horns and discuss recent literature. Keywords: autopsy, hyoid bone, variation
INTRODUCTION
H
yoid bone is a horseshoe-shaped, solitary bone localized at the level of the third cervical vertebrae in front of the neck, just above thyroid cartilage, in the midline of neck. Unlike other bones, the hyoid bone is connected to the adjacent bone structures through muscles and tendons (1). Hyoid bone consists of the corpus, two greater horns and two lesser horns in total, both on the right and left sides. In embryological process, greater horns are developed in the second and lesser horns are developed in the third visceral arch.
The process of ossification of the hyoid bone takes place on six different points; at greater horns towards the end of pregnancy, on the body immediately after birth, in lesser horns ossification starts towards puberty, but ends of greater horns connected to the body maintaining the distinction of cartilage structure until the age of about 30 (2). The hyoid bone fractures have an important role in forensic medicine, especially a valuable finding in determining the cause and the manner of death concerning the neck region trauma. Abnormal sizes of hyoid bone and its horns and its anatomical variations can cause difficulties in the
Address for correspondence: Bülent Eren, Department of Bursa Morgue, Council of Forensic Medicine of Turkey, 16010, Bursa, Turkey. E-mail: [email protected]. Article received on the 14th of April 2014. Article accepted on the 21st of August 2014.
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Maedica
A Journal of Clinical Medicine, Volume 9 No.3 2014
ANATOMICAL VARIATION OF HYOID BONE: A CASE REPORT application of forensic medicine together with clinical and surgical problems. For this reason while making an assessment at neck dissection during autopsy if hyoid bone abnormalities and anatomic variations encountered it should require caution. Hyoid bone abnormalities can be found together with the different clinical situations such as Pierre Robin Syndrome, cleft lip and palate (3). The aim is to present a case with abnormally long hyoid bone horns and discuss in recent literature. CASE REPORT
W
e present the case of a 81-year-old female. She was reported to get sick and die at home. At external evaluation we noticed 17 cm of surgery scar on the lumbal vertebrae, 12-cm of horizontal course surgery scar which began under the xiphoid and extending to hub hole, 7 cm of surgery scar above the pubic region, and 2x1 cm of ecchymotic abrasion in the upper part of the right zygomatic region was observed. 10x3x5 cm-portion of the uterus was found prolapsed out of the vagina. At autopsy, the heart weighed 400 g and thrombus was detected in the first part of left coronary artery with atherosclerotic changes, narrowing the lumen on the arterial wall. Aortic and mitral valve surroundings were measured 9.5 and 10 cm respectively. In myocardial septum sections, 5x4 cm of scar tissue white discoloration due to previous myocardial infarct was observed macroscopically. At neck dissection, lengths of right and left greater horns of hyoid bone were measured 11 cm and 7 cm respectively (Figure 1-2). At histopathological examination of the samples taken from heart was revealed that expansion in cytoplasma of some myocytes, scarring area which composed mature connective tissue and eliminates myocardial tissue in heart samples. Destruction of alveolar walls, congestion and neutrophilic infiltration within the lumen of bronchioles were detected in lung samples. In samples prepared from the uterus, keratinized stratified squamous epithelium with subepithelial stroma tissue and congested vascular structures, erosion, ulceration, homogenization, necrotic changes and neutrophilic infiltration on the surface epithelium were observed. There was no significant finding at toxicological analysis. After autopsy the death was reported as cardiac failure.
DISCUSSION
A
natomical variations and anomalies of hyoid bone are defined in the literature beforehand and relationship of its morphological variations with different races and geographical locations are presented (2-8). Unur E at al. reported that hyoid bone lesser horns are longer than normal length and they found the lesser horns 2.2 cm, the greater horns 2 cm in their measurements in a 4-year-old girl who died as a result of carbon monoxide intoxication (2). Gök E at al. reported a case identified an anomaly of hyoid bone with an approximately 3.9 cm length extra bone structure connected to left side of corpus of the hyoid bone and no lesser horns (4). As a result of stiloid process’ being long or calcification of stilohyoid ligament (Eagle Syndrome) that is connected to stiloid proces and hyoid bone lesser horn, lower ends of calcific stilohyoid ligament can cause extension of lesser horns of hyoid bone (2,5). At our case bilateral greater horns are found longer than normal (right- 11 cm, left- 7 cm). In both genders and in different age groups, various differences are identified in vertebral levels localization and dimensions of hyoid bone by determining the hyoid bone developmental characteristics, localization, size and relationship between surrounding structures (6-8). The hyoid bone anomalies can be seen with findings such as cleft lip, cleft palate,
FIGURE 1. Right grater horn of hyoid bone was measured 11 cm. Left greater horn of hyoid bone was measured 7 cm.
Maedica
A Journal of Clinical Medicine, Volume 9 No.3 2014
273
ANATOMICAL VARIATION OF HYOID BONE: A CASE REPORT and micrognathia or associated with the disease Pierre Robin Syndrome (3). However, in our case no pharyngeal arch abnormalities associated with accompanying hyoid bone abnormalities were seen. Identification of hyoid bone abnormalities causing variety of clinical symptoms (9,10) and surgical and radiological problems (11) were reported previously, but in the presented case, there were not identified symptoms related with abnormal hyoid bone and cause of death. CONCLUSION
I FIGURE 2. Right grater horn of hyoid bone was measured 11 cm. Left greater horn of hyoid bone was measured 7 cm.
n forensic medical practice neck anatomy and findings, especially as their importance is known in strangulation cases and populationbased studies, are considered to provide important contributions to many fields about clinical and medico-legal approaches associated with it. Conflict of interests: none declared. Financial support: none declared.
REFERENCES 1. 2.
3.
4.
5.
Bibby RE, Preston CB – The hyoid triangle. Am J Orthod 1981;80:92-7 Unur E, Din H, Ülger H – The hyoid bone anomaly. Erciyes University Journal of Health Sciences 2003;12:62-64 El Amm CA, Denny A – Hyoid bone abnormalities in Pierre Robin patients. J Craniofac Surg. 2008;19:259-263 Gok E, Kafa IM, Fedakar R – Unusual variation of the hyoid bone: bilateral absence of lesser cornua and abnormal bone attachment to the corpus. Surg Radiol Anat. 2012;34:567-9 Rao PP, Menezes RG, Naik R, et al. – Bilateral calcified stylohyoid
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6.
7.
8.
ligament: an incidental autopsy finding with medicolegal significance. Leg Med (Tokyo) 2010;12:184-7 Mukhopadhyay PP – Morphometric features and sexual dimorphism of adult hyoid bone: a population specific study with forensic implications. J Forensic Leg Med. 2010;17:321-4 Shimizu Y, Kanetaka H, Kim YH, et al. – Age-related morphological changes in the human hyoid bone. Cells Tissues Organs 2005;180:185-92 Kanetaka H, Shimizu Y, Kano M, et al. – Synostosis of the joint between the
A Journal of Clinical Medicine, Volume 9 No.3 2014
body and greater cornu of the human hyoid bone. Clin Anat. 2011;24:837-42 9. Todo T, Alexander M, Stokol C, et al. – Eagle syndrome revisited: cerebrovascular complications. Ann Vasc Surg. 2012;26:729.e1-5 10. Baig S, Patil N, Considine N – An unusual cause of recurrent throat pain - calcified stylohyoid ligament. J Coll Physicians Surg Pak. 2012;22:258-60 11. Yetiser S, Gerek M, Ozkaptan Y – Elongated styloid process: diagnostic problems related to symptomatology. Cranio. 1997;15:236-41.
MAEDICA – a Journal of Clinical Medicine 2014; 9(3): 272-274
REPORTS
Anatomical Variation of Hyoid Bone: a Case Report Nursel Türkmen INANIRa,b; Bülent ERENb; Selçuk ÇETINa; Filiz ERENb; Ümit Naci GÜNDOĞMUŞc a
Department of Forensic Medicine, Medical Faculty, Uludag University, Bursa, Turkey Department of Bursa Morgue, Council of Forensic Medicine of Turkey, Bursa, Turkey c İstanbul University, Institute of Forensic Medicine, Council of Forensic Medicine of Turkey, İstanbul, Turkey b
ABSTRACT Hyoid bone is a solitary bone localized at the level of cervical 3 vertebrae, connected to the adjacent bone structures with muscles and tendons. Anatomical variations of hyoid bone can cause difficulties in the application of forensic medicine together with clinical and surgical problems. We present a case of a 81-year-old woman, reported to got sick, who died at home. In the autopsy, the neck dissection revealed prolonged right and left greater horns of hyoid bone measured 11 cm and 7 cm respectively. We aimed to present a case with long hyoid bone horns and discuss recent literature. Keywords: autopsy, hyoid bone, variation
INTRODUCTION
H
yoid bone is a horseshoe-shaped, solitary bone localized at the level of the third cervical vertebrae in front of the neck, just above thyroid cartilage, in the midline of neck. Unlike other bones, the hyoid bone is connected to the adjacent bone structures through muscles and tendons (1). Hyoid bone consists of the corpus, two greater horns and two lesser horns in total, both on the right and left sides. In embryological process, greater horns are developed in the second and lesser horns are developed in the third visceral arch.
The process of ossification of the hyoid bone takes place on six different points; at greater horns towards the end of pregnancy, on the body immediately after birth, in lesser horns ossification starts towards puberty, but ends of greater horns connected to the body maintaining the distinction of cartilage structure until the age of about 30 (2). The hyoid bone fractures have an important role in forensic medicine, especially a valuable finding in determining the cause and the manner of death concerning the neck region trauma. Abnormal sizes of hyoid bone and its horns and its anatomical variations can cause difficulties in the
Address for correspondence: Bülent Eren, Department of Bursa Morgue, Council of Forensic Medicine of Turkey, 16010, Bursa, Turkey. E-mail: [email protected]. Article received on the 14th of April 2014. Article accepted on the 21st of August 2014.
272
Maedica
A Journal of Clinical Medicine, Volume 9 No.3 2014
ANATOMICAL VARIATION OF HYOID BONE: A CASE REPORT application of forensic medicine together with clinical and surgical problems. For this reason while making an assessment at neck dissection during autopsy if hyoid bone abnormalities and anatomic variations encountered it should require caution. Hyoid bone abnormalities can be found together with the different clinical situations such as Pierre Robin Syndrome, cleft lip and palate (3). The aim is to present a case with abnormally long hyoid bone horns and discuss in recent literature. CASE REPORT
W
e present the case of a 81-year-old female. She was reported to get sick and die at home. At external evaluation we noticed 17 cm of surgery scar on the lumbal vertebrae, 12-cm of horizontal course surgery scar which began under the xiphoid and extending to hub hole, 7 cm of surgery scar above the pubic region, and 2x1 cm of ecchymotic abrasion in the upper part of the right zygomatic region was observed. 10x3x5 cm-portion of the uterus was found prolapsed out of the vagina. At autopsy, the heart weighed 400 g and thrombus was detected in the first part of left coronary artery with atherosclerotic changes, narrowing the lumen on the arterial wall. Aortic and mitral valve surroundings were measured 9.5 and 10 cm respectively. In myocardial septum sections, 5x4 cm of scar tissue white discoloration due to previous myocardial infarct was observed macroscopically. At neck dissection, lengths of right and left greater horns of hyoid bone were measured 11 cm and 7 cm respectively (Figure 1-2). At histopathological examination of the samples taken from heart was revealed that expansion in cytoplasma of some myocytes, scarring area which composed mature connective tissue and eliminates myocardial tissue in heart samples. Destruction of alveolar walls, congestion and neutrophilic infiltration within the lumen of bronchioles were detected in lung samples. In samples prepared from the uterus, keratinized stratified squamous epithelium with subepithelial stroma tissue and congested vascular structures, erosion, ulceration, homogenization, necrotic changes and neutrophilic infiltration on the surface epithelium were observed. There was no significant finding at toxicological analysis. After autopsy the death was reported as cardiac failure.
DISCUSSION
A
natomical variations and anomalies of hyoid bone are defined in the literature beforehand and relationship of its morphological variations with different races and geographical locations are presented (2-8). Unur E at al. reported that hyoid bone lesser horns are longer than normal length and they found the lesser horns 2.2 cm, the greater horns 2 cm in their measurements in a 4-year-old girl who died as a result of carbon monoxide intoxication (2). Gök E at al. reported a case identified an anomaly of hyoid bone with an approximately 3.9 cm length extra bone structure connected to left side of corpus of the hyoid bone and no lesser horns (4). As a result of stiloid process’ being long or calcification of stilohyoid ligament (Eagle Syndrome) that is connected to stiloid proces and hyoid bone lesser horn, lower ends of calcific stilohyoid ligament can cause extension of lesser horns of hyoid bone (2,5). At our case bilateral greater horns are found longer than normal (right- 11 cm, left- 7 cm). In both genders and in different age groups, various differences are identified in vertebral levels localization and dimensions of hyoid bone by determining the hyoid bone developmental characteristics, localization, size and relationship between surrounding structures (6-8). The hyoid bone anomalies can be seen with findings such as cleft lip, cleft palate,
FIGURE 1. Right grater horn of hyoid bone was measured 11 cm. Left greater horn of hyoid bone was measured 7 cm.
Maedica
A Journal of Clinical Medicine, Volume 9 No.3 2014
273
ANATOMICAL VARIATION OF HYOID BONE: A CASE REPORT and micrognathia or associated with the disease Pierre Robin Syndrome (3). However, in our case no pharyngeal arch abnormalities associated with accompanying hyoid bone abnormalities were seen. Identification of hyoid bone abnormalities causing variety of clinical symptoms (9,10) and surgical and radiological problems (11) were reported previously, but in the presented case, there were not identified symptoms related with abnormal hyoid bone and cause of death. CONCLUSION
I FIGURE 2. Right grater horn of hyoid bone was measured 11 cm. Left greater horn of hyoid bone was measured 7 cm.
n forensic medical practice neck anatomy and findings, especially as their importance is known in strangulation cases and populationbased studies, are considered to provide important contributions to many fields about clinical and medico-legal approaches associated with it. Conflict of interests: none declared. Financial support: none declared.
REFERENCES 1. 2.
3.
4.
5.
Bibby RE, Preston CB – The hyoid triangle. Am J Orthod 1981;80:92-7 Unur E, Din H, Ülger H – The hyoid bone anomaly. Erciyes University Journal of Health Sciences 2003;12:62-64 El Amm CA, Denny A – Hyoid bone abnormalities in Pierre Robin patients. J Craniofac Surg. 2008;19:259-263 Gok E, Kafa IM, Fedakar R – Unusual variation of the hyoid bone: bilateral absence of lesser cornua and abnormal bone attachment to the corpus. Surg Radiol Anat. 2012;34:567-9 Rao PP, Menezes RG, Naik R, et al. – Bilateral calcified stylohyoid
274
Maedica
6.
7.
8.
ligament: an incidental autopsy finding with medicolegal significance. Leg Med (Tokyo) 2010;12:184-7 Mukhopadhyay PP – Morphometric features and sexual dimorphism of adult hyoid bone: a population specific study with forensic implications. J Forensic Leg Med. 2010;17:321-4 Shimizu Y, Kanetaka H, Kim YH, et al. – Age-related morphological changes in the human hyoid bone. Cells Tissues Organs 2005;180:185-92 Kanetaka H, Shimizu Y, Kano M, et al. – Synostosis of the joint between the
A Journal of Clinical Medicine, Volume 9 No.3 2014
body and greater cornu of the human hyoid bone. Clin Anat. 2011;24:837-42 9. Todo T, Alexander M, Stokol C, et al. – Eagle syndrome revisited: cerebrovascular complications. Ann Vasc Surg. 2012;26:729.e1-5 10. Baig S, Patil N, Considine N – An unusual cause of recurrent throat pain - calcified stylohyoid ligament. J Coll Physicians Surg Pak. 2012;22:258-60 11. Yetiser S, Gerek M, Ozkaptan Y – Elongated styloid process: diagnostic problems related to symptomatology. Cranio. 1997;15:236-41.
