Hyoid Bone Syndrome: A Comprehensive Medical Review

Compiled from Peer-Reviewed Medical Literature by Asian Pain Academy

Abstract

Hyoid Bone Syndrome (HBS) is a poorly recognized but clinically significant cause of chronic anterolateral neck pain, throat discomfort, and referred orofacial pain. First described by Brown in 1954, the syndrome arises from degenerative and inflammatory changes at the greater cornu of the hyoid bone, particularly at the insertion of the stylohyoid ligament and the middle pharyngeal constrictor muscle. Patients typically present with deep-seated, unilateral throat pain aggravated by swallowing, speaking, head rotation, and palpation of the greater hyoid cornu. Because of its nonspecific symptoms, HBS is frequently misdiagnosed or overlooked, leading to unnecessary investigations and delayed treatment. Diagnosis is clinical, supported by imaging, and confirmed through a diagnostic local anesthetic injection. Treatment ranges from conservative NSAIDs and corticosteroid injections to surgical resection of the affected greater cornu. This article synthesizes evidence from the current peer-reviewed literature to provide clinicians with a thorough understanding of the epidemiology, anatomy, pathophysiology, clinical features, diagnostic approach, and management of this condition.

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1. Introduction

Hyoid Bone Syndrome (HBS) is an often-missed clinical entity characterized by pain arising from the region of the greater cornu of the hyoid bone. Despite being recognized in the medical literature for over seven decades, it remains underdiagnosed in both primary care and specialist settings. The syndrome can cause significant physical suffering and psychological distress, and patients frequently endure prolonged diagnostic workups before receiving an accurate diagnosis.

The hyoid bone occupies a unique anatomical position: it is the only bone in the human body that does not directly articulate with any other bone. This U-shaped bone, situated between the root of the tongue and the thyroid cartilage, is held in place entirely by muscles and ligaments. Its constant motion during breathing, swallowing, speaking, and head movement renders it susceptible to degenerative stress at its ligamentous and muscular attachments.

HBS was first formally described by Brown in 1954 as a complex of neck and throat pain on swallowing and neck movement, accompanied by tenderness at the tip of the greater hyoid cornu. Subsequently, Steinmann (1968), Kopstein, Lim, and Ernest further characterized the syndrome. Steinmann defined it as a form of insertion tendinosis — a degenerative and inflammatory phenomenon resulting from the repetitive mechanical stress imposed on the hyoid's attachments.

Greater recognition of this condition is essential to avoid unnecessary investigations, prevent inappropriate surgical interventions, and ensure timely, effective treatment for affected patients.

2. Anatomy and Biomechanics of the Hyoid Bone

2.1 Structure

The hyoid bone is a U-shaped (horseshoe-shaped) structure located at the level of the C3 vertebra, between the floor of the mouth superiorly and the thyroid cartilage inferiorly. It consists of a central body, two lesser cornua (superior horns), and two greater cornua (inferior horns). The greater cornua are the primary site of pathology in HBS.

2.2 Muscular and Ligamentous Attachments

Nine muscles attach to the hyoid bone, providing elevation, depression, protraction, and retraction. Key attachments relevant to HBS include:

•       Middle pharyngeal constrictor muscle: inserts onto the greater cornu; identified as the primary site of degenerative injury in HBS.

•       Stylohyoid ligament: connects the styloid process of the temporal bone to the lesser cornu of the hyoid; its degeneration and/or calcification is a key etiological factor.

•       Digastric muscle: inserts centrally and acts as a biomechanical fulcrum during hyoid motion.

•       Other muscles: mylohyoid, hyoglossus, thyrohyoid, sternohyoid, omohyoid, and geniohyoid also attach to the hyoid.

The hyoid rises with expiration and falls with inspiration, and it moves anterosuperiorly during swallowing. This constant biomechanical cycling places repetitive stress on all its attachments, predisposing the greater cornu to degenerative tendinosis over time.

2.3 Proximity to Neurovascular Structures

The greater cornua of the hyoid lie in close proximity to the internal carotid artery, jugular vein, glossopharyngeal nerve, and branches of the cervical plexus. This anatomical relationship explains the wide radiation pattern of pain reported by patients and the potential for rare vascular complications.

3. Etiology and Pathophysiology of Hyoid Bone Syndrome

3.1 Primary Pathology

The underlying pathological process in HBS is degenerative insertion tendinosis at the greater cornu of the hyoid bone. Ernest and Salter provided histopathological confirmation of this mechanism, demonstrating focal degenerative injury of the middle pharyngeal constrictor muscle (MPCM) at its insertion onto the greater cornu — consistent with microscopic findings of insertion tendinosis.

The stylohyoid ligament, which attaches to the styloid process superiorly and the hyoid bone inferiorly, is also subject to degenerative change and/or elongation. In some cases, an abnormally elongated or calcified stylohyoid ligament can impinge on adjacent structures, contributing to symptoms. This overlaps pathophysiologically with Eagle's syndrome, from which HBS must be distinguished.

3.2 Predisposing Factors

Several factors have been identified as predisposing patients to HBS:

•       Repetitive mechanical stress from constant hyoid motion during swallowing and phonation

•       Congenital anatomical variants, including an elongated hyoid bone or abnormal stylohyoid ligament

•       Trauma (e.g., whiplash injuries, direct neck trauma)

•       Excessive muscular strain (e.g., prolonged speaking or singing)

•       Age-related degeneration

3.3 Etiological Theories (Historical)

Various etiological theories have been proposed historically, including pain from stimulation of vasomotor fibers, stimulation of the cervical sympathetic trunk, or a variant of glossopharyngeal neuralgia. The current consensus, supported by histopathological evidence, favors a degenerative tendinosis model.

4. Clinical Features of Hyoid Bone Syndrome

4.1 Cardinal Symptoms of Hyoid Bone Syndrome

The hallmark of HBS is unilateral, deep-seated, dull, aching throat pain located at the anterolateral neck, typically below the angle of the mandible. The pain is characteristically provoked or worsened by:

•       Swallowing (dysphagia or odynophagia)

•       Speaking and phonation

•       Yawning

•       Chewing

•       Turning or inclining the head to the affected side

•       Direct palpation of the tip of the greater hyoid cornu

4.2 Radiation Pattern

Pain radiates in a predictable pattern. Superiorly and anteriorly, it may extend to the throat, mandible, mandibular molar teeth, zygomatic arch, temporomandibular condyle, face, ear, and temple. Inferiorly, it may radiate to the neck, clavicle, upper chest, shoulder, arm, and across to the scapula on the same side.

4.3 Associated Symptoms

Patients may also report:

•       A foreign body or globus sensation in the throat

•       A clicking sound or sensation in the throat (clicking larynx) during movement

•       Dysphonia (altered voice quality)

•       Dysphagia (difficulty swallowing)

•       In rare cases, intermittent ulceration or bleeding at the tongue base

4.4 Laterality

In the cohort studied by Stern, Jackson-Menaldi, and Rubin (2013), 63% of 84 patients presented with unilateral tenderness, while 38% had bilateral involvement of the greater cornua.

4.5 Psychological Impact

The chronic, poorly localized nature of symptoms, combined with frequent diagnostic delay, can produce significant psychological distress. Patients may experience anxiety, depression, and reduced quality of life.

5. Diagnosis

5.1 Clinical History

A careful history focusing on the character, location, radiation, and provocation of pain is the cornerstone of diagnosis. The clinician should inquire specifically about pain on swallowing, head movement, and palpation of the neck.

5.2 Physical Examination

The key examination finding is point tenderness at the tip of the greater hyoid cornu, which is palpable just below the angle of the mandible. Passive accessory motion testing — applying lateral pressure on the greater cornua with the thumb and index finger on opposite sides — may reproduce the pain or foreign body sensation. Protrusion of the tongue or tilting of the head may also elicit symptoms.

5.3 Diagnostic Injection

A diagnostic local anesthetic injection (e.g., lidocaine 1%) into the attachment of the stylohyoid ligament to the greater cornu of the hyoid provides both diagnostic confirmation and temporary therapeutic relief. Abolition of pain following injection strongly supports the diagnosis of HBS. Corticosteroid (e.g., triamcinolone acetonide 40 mg/mL) may be co-administered for additional therapeutic effect. Ultrasound guidance improves injection accuracy and reduces the risk of inadvertent vascular puncture.

5.4 Imaging

Computed tomography (CT) is the preferred imaging modality to evaluate the hyoid bone morphology, identify elongation, calcification, or degeneration of the stylohyoid ligament, and exclude other structural causes of neck pain. Magnetic resonance imaging (MRI) can assess soft tissue inflammation and rule out masses. Fiberoptic laryngoscopy is used to exclude other laryngeal and pharyngeal pathology.

5.5 Diagnosis of Exclusion

HBS is fundamentally a diagnosis of exclusion. Malignant tumors of the neck, hypopharynx, and lung apex must be excluded before the diagnosis is established. Additional conditions to rule out include:

•       Eagle's syndrome (elongated styloid process)

•       Carotidynia

•       Glossopharyngeal neuralgia

•       Temporomandibular joint (TMJ) disorders

•       Cervicogenic headache

•       Inflammatory arthritis

•       Laryngopharyngeal reflux

•       Hyoid bone fracture or neoplasm

6. Treatment for Hyoid Bone Syndrome

6.1 Conservative Management

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): A study by Beltran-Alacreu et al. and a primary study published in the European Archives of Oto-Rhino-Laryngology demonstrated that oral NSAIDs and topical NSAID ointment provided symptomatic relief in approximately 66–71% of patients. Notably, relief was achieved in 91% of patients when symptom duration was less than 6 weeks. NSAIDs are therefore recommended as the first-line treatment, particularly in patients with a recent onset of symptoms.

Current evidence supports attempting a 4–6 week course of NSAID therapy before proceeding to more invasive interventions.

6.2 Corticosteroid Injection

Injection of triamcinolone acetonide (40 mg/mL) into the affected greater cornu is the most evidence-supported intervention for HBS. In the largest published retrospective series (Stern, Jackson-Menaldi & Rubin, 2013; n=84):

•       74% of patients achieved complete resolution of symptoms

•       54% achieved complete response after a single injection

•       A further 14% required two injections for complete response

•       15% had a partial response

•       10% had no response

A positive response to the corticosteroid injection may negate the need for further diagnostic testing and invasive procedures. Ultrasound guidance is recommended to optimize needle placement and minimize risk.

6.3 Surgical Management

Surgical resection of the greater hyoid cornu is reserved for patients who have failed conservative management and corticosteroid injections. Multiple case series have reported excellent outcomes with surgical excision, including immediate and complete relief of symptoms with no postoperative complications in appropriately selected patients.

A retrospective surgical series from the University Hospital of Antwerp (UZA), published in 2024, reported outcomes in 17 patients (2 bilateral) who underwent surgical hyoid bone resection. Pre- and post-operative pain scores demonstrated significant improvement, supporting surgery as an effective option in refractory cases.

The case series by Chen Li et al. (2022) reported four of five patients responding well to surgical resection of the abnormal hyoid bone, with immediate and complete relief of symptoms and no postoperative complications.

6.4 Treatment Algorithm Summary

Based on the available evidence, the following stepwise approach is recommended:

•       Step 1: NSAID therapy (oral or topical) for 4–6 weeks, especially effective if symptom duration is less than 6 weeks

•       Step 2: If NSAIDs fail, diagnostic/therapeutic local anesthetic and corticosteroid injection into the affected greater cornu

•       Step 3: If injections fail or symptoms recur repeatedly, surgical resection of the greater hyoid cornu

7. Epidemiology and Demographics

HBS can affect both males and females across a wide age range. The case series by Chen Li et al. (2022) included three females and two males with a mean age of 37.2 years (range 21–57). The condition is described as relatively uncommon but likely underdiagnosed due to poor recognition. In a primary ENT clinic setting, hyoid bone syndrome has been recognized as a cause of nonspecific cervical pain, which itself is a common presenting complaint.

The condition has been observed in patients who use their voice professionally (e.g., singers and public speakers), and trauma is a recognized precipitating factor. Due to the frequent diagnostic delay, many patients present with symptoms lasting months to years before a correct diagnosis is established.

8. Differential Diagnosis

The differential diagnosis of HBS is broad, reflecting the nonspecific nature of the symptoms. Key conditions to distinguish include:

•       Eagle's Syndrome: caused by an elongated styloid process; pain is triggered by swallowing and turning the head, similar to HBS. Distinguished by CT imaging showing styloid elongation and palpation superior to the hyoid at the styloid tip.

•       Carotidynia: tenderness along the carotid artery; may mimic HBS but is characterized by tenderness over the carotid bifurcation rather than the hyoid cornu.

•       Glossopharyngeal Neuralgia: paroxysmal shooting pains similar to trigeminal neuralgia; unrelated to jaw movement or hyoid motion.

•       TMJ Disorder: pain in the preauricular region, often with clicking of the jaw; distinguished by tenderness at the TMJ rather than the hyoid cornu.

•       Cervicogenic Headache: neck-origin headache; typically associated with upper cervical joint dysfunction.

•       Laryngopharyngeal Reflux: globus and throat irritation without localized bony tenderness.

•       Neck Neoplasms: tumors of the hypopharynx, neck, or lung apex; must be excluded with appropriate imaging and endoscopy.

9. Complications and Special Considerations

9.1 Diagnostic Complications of Injection

Injection into the hyoid region carries risks due to proximity to important neurovascular structures. Potential complications include injury to the brachial plexus, phrenic nerve, recurrent laryngeal nerve, internal carotid artery, and jugular vein. Inadvertent intravascular injection of local anesthetic can cause systemic toxicity and seizures. Pneumothorax and inadvertent spinal injection are also possible. Ultrasound guidance significantly reduces these risks.

9.2 Vascular Complications

Rare cases of cerebrovascular ischemia have been described in association with injury to the carotid artery in the region of the hyoid bone. Sympathetic symptoms have also been reported in isolated cases.

9.3 Obstructive Sleep Apnea

The hyoid bone's position and its muscular connections to the pharyngeal airway are relevant to obstructive sleep apnea (OSA). During sleep, relaxation of the pharyngeal muscles allows the hyoid and its attached structures to fall posteriorly, potentially obstructing the airway. Hyoid suspension procedures are sometimes employed as a surgical adjunct in the management of OSA.

10. Historical Perspective

Hyoid Bone Syndrome was first described in 1954 by Brown, who characterized it as a complex of neck and throat pain on swallowing and neck movement with tenderness at the tip of the greater hyoid cornu. Subsequent contributions by Steinmann (1968), who framed HBS as insertion tendinosis; Kopstein and Lim, who reported surgical cures; and Ernest and Salter, who provided histopathological validation of the condition, progressively solidified HBS as a distinct clinical entity.

Despite this body of work, HBS has remained poorly recognized, partly because of the diffuse and seemingly unrelated radiation of symptoms and partly because early reports lacked objective histopathological evidence. The provision of photomicroscopic evidence by Ernest and Salter was a pivotal step in establishing the biological validity of HBS.

11. Conclusion

Hyoid Bone Syndrome is a real, clinically significant, and treatable cause of chronic neck and throat pain that is frequently misdiagnosed or overlooked. A thorough understanding of the unique anatomy and biomechanics of the hyoid bone, combined with awareness of the characteristic clinical presentation, allows clinicians to make an accurate diagnosis and implement effective treatment.

Clinicians — including otolaryngologists, oral and maxillofacial surgeons, neurologists, dentists, and primary care physicians — should include HBS in the differential diagnosis of unexplained anterolateral neck pain, odynophagia, and globus sensation, particularly when direct palpation of the greater hyoid cornu reproduces the patient's pain.

The stepwise treatment approach — beginning with NSAIDs, progressing to corticosteroid injections, and reserving surgical resection for refractory cases — is supported by published evidence and results in excellent outcomes for the majority of patients. Increased awareness and recognition of this syndrome will reduce diagnostic delay, spare patients from unnecessary investigations, and improve quality of life.

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