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Ernest Syndrome and Insertion of the SML at the Mandible

Characterized as a painful complex of symptoms related to the insertion of the stylomandibular ligament (SML) at the mandible, onset of this syndrome
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Ernest Syndrome is a painful complex of reproducible symptoms (see Figure 1) related to the insertion of the stylomandibular ligament (SML) at the mandible.1-21 The onset of Ernest Syndrome may be a consequence of auto accident, whiplash, blunt trauma, law enforcement submission techniques, general anesthesia, dental surgery, excessive yawning, and other etiologies. The disorder is not easily diagnosed due to the multiple areas of pain reference sites found distant from the insertion of the ligament. This article describes two cases having an ultimate diagnosis of Ernest Syndrome resulting from motor vehicular trauma but were inappropriately operated for TMJ arthroplasty.


Pain of the stylomandibular ligament with a referral pattern (see Figure 1) was first discovered by this author in 1981 and published in 1982.1 Sataloff,12,17 an otolaryngologist at Thomas Jefferson School of Medicine in 1983, was the second to report pain at the stylomandibular ligament insertion but made no mention of referred sites of pain. Sataloff noted that the pain was remitted following a mandibular saggital osteotomy procedure. Sataloff reported a restricted mandibular excursion prior to surgery which returned to normal following surgery. This finding is supported by other reports in the literature associating mandibular range of movement restriction with injury to the stylomandibular ligament.3

In some cases SML restraint causes posterior displacement of the mandible with the results of TMJ disc clicking and/or acute anterior dislocation of the TMJ articular disc. This particular joint complication can really confound the diagnostic picture (see Figure 2).

Since the initial discovery of Ernest Syndrome, many clinicians and researchers, including dentists1-6,8-11,13-14,15,16 otolaryngologists,7,12,17 plastic surgeons,22 orthopedists,23 neurologists,24 and neurosurgeons25-30 have reported on, or referenced Ernest Syndrome in the dental and medical literature. And many thousands of cases have been effectively diagnosed and treated by dentists and physicians internationally.8,15,25,31-33

Ligament Anatomy and Function

Gray34 described the stylomandibular ligament as a “specialized band of the cervical fascia, which extends from near the base of the styloid process of the temporal bone to the angle and posterior border of the ramus of the mandible. This ligament separates the parotid from the submaxillary gland, and from its deep surface some fibers of the styloglossus take origin.”

Shore35 reported that “the stylomandibular ligament runs from the styloid process of the temporal bone and inserts on the posterio-medial border of the mandible. It acts as a brake for the mandible, preventing excess anterior drift of the mandible during extreme opening.”

In fact, this author has observed—while treating one patient with the symptoms of Ernest Syndrome by open incision to reveal the Stylomandibular ligament attachment at the mandible—the insertion attachment of the ligament and noted on digital palpation that, in mandibular excursions, the stylomandibular ligament tensed very tightly. This observation confirmed Shore’s opinion that the stylomandibular ligament is not an accessory ligament, as some have reported but is, instead, a prime restraining ligament in mandibular function and, as a prime ligament, is subject to hyperextension injury as seen in other joints of the body. Since muscles are prime movers of joints, ligaments serve to protect the joint by checking the maximum range of motion.

Progression of Syndrome Development (See Figure 1)

The progression of symptoms of Ernest Syndrome typically presents as follows:

Early Stage

  1. Tenderness below lobe of the ear with discomfort
  2. Pressure simulating third molar trying to erupt

Later Stage

  1. Mandibular molar teeth on same side ache and throb
  2. Ear exhibits a sense of fullness and pain
  3. Throat soreness with lateral pharyngeal wall pain
  4. TMJ condyle pain
  5. Coronoid process and temporal tendon pain at zygomatic arch
  6. Temple headache
  7. Eye pain or pain near eye and photophobia

Differential Diagnosis

The multiple conditions and syndromes and structures capable of head, neck, face, and temporomandibular joint pain must be considered as potential factors in diffuse pain patterns. However, it is not the scope of this paper to attempt that task. For a comparative reference, only six are briefly mentioned as follows:

Eagle’s Syndrome. This syndrome is a constellation of symptoms associated with an elongated bony styloid process which impinges on the lateral pharyngeal wall with subsequent pain.36,37 Dr. Watt Eagle36 stated that in addition to ear, throat, and temple pain, “the elongated styloid process may also cause facial pain and headache as well as common pharyngeal pains, painful deglution and referred otalgia (ear pain).”

Hyoid Bone Syndrome. This syndrome was first described in 1954 by Brown38 as a “symptom complex of neck and throat pain on swallowing and neck movement. The pain may be referred to the ear on the same side.” Steinmann in 1968 and Lim39 in 1982 further reported Hyoid Bone Syndrome as a “symptom complex of chronic and recurrent local lancinating or dull pain in the carotid area at the level of the tip of the greater cornu of the Hyoid bone (see Figure 3). This is accompanied by associated radiating pain to the ipsilateral ear, temporal area, sternocleidomastoid muscle, posterior pharyngeal wall, and the supraclavicular area down to the middle of the breast marked by the areola. The pain is usually initiated and aggravated by swallowing and movement of the neck towards the affected side.” This author22,40 described referred pain from the hyoid bone to the temporomandibular joint (TMJ) on the same side and demonstrated with photomicroscopy that the injury was a tendinosis (degenerative cellular change at a narrow bony ridge) of the middle pharyngeal constrictor at the greater cornu, or horn of the hyoid.

Anterior Displacement. The dislocation of the temporomandibular joint disc41 and posterior displacement of the condyle may produce symptoms of ear pain, soreness of the throat, neck, temple pain and pain on movement of the mandible; suggesting an intra-articular problem as the primary etiology for vague pain of the head, neck and face. However, to be able to document an internal derangement of the temporomandibular joint, or osteochondritis, chondromalacia, or rhumatoid arthritis, or any number of orthopedic diseases at the TM joint does not establish a conclusive case for the joint being the source of pain. The joint “condition” may easily be a finding occurring simultaneously with one or more disorders. Not all pain at, or near, the temporomandibular joint is in fact originating with the temporomandibular joint. The burden lies with the clinician in ruling out the multiplicity of pain producing structures that may contribute to head and neck pain.

Last updated on: January 30, 2012
First published on: October 1, 2006