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11 Articles in Volume 6, Issue #7
An Overview of Sleep Medications
Editor's Memo
Ernest Syndrome and Insertion of the SML at the Mandible
Low Level Laser Therapy – A Clinician’s View
Microcurrent Electrical Therapy (MET): A Tutorial
Observational Study of Dural Punctures
Pain as Disease and Illness: Part Two
Practice Patterns of Clinicians Treating Vulvar Pain
Share the Risk Model
Treating Sports-related Injury and Pain with Light Therapy
Using Topiramate in the Treatment of Migraine

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

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.

Parotid Gland Carcinoma. The symptoms of carcinoma of the parotid gland are very similar to Ernest Syndrome due to proximity and invasive sequellae. However, anesthetic block at the SML insertion in the presence of carcinoma is very painful and usually provides pain relief of 80-85% for about 20 minutes compared to 100% pain relief for two hours when the diagnosis is actually Ernest Syndrome.

Temporal Tendinitis. The insertion injury of the temporal tendon attachment at the mandibular coronoid process causes painful symptoms similar to Ernest Syndrome with the additional finding of maxillary molar teeth pain as part of the referral pattern. This author discovered temporal tendinitis in 1982 and coined the phrase “Temporal Tendinitis the Migraine Mimic”19,20 and, in 1991, provided photomicroscopic evidence of degenerative change (tendinosis) in the temporal tendon insertion at the mandibular coronoid process.42

Superior Pharyngeal Constrictor Muscle Pain. This painful syndrome, originating in the oral pharynx at the mandible, may be unilateral or bilateral in nature, and can result in limited mandibular opening due to the loss of muscle functionality resulting from the injury.44

This muscle has its origin at the lingual surface of the lower jaw medial to the third molar tooth area in the oro-pharynx. The muscle is found above the mylolhyoid muscle proper. The symptoms mimic the pattern of painful symptoms normally associated with Ernest Syndrome. Treatment may be non-surgical or surgical, depending on degree of injury. Trauma is a frequent initiating factor.

Materials and Methods

In confirming a diagnosis of Ernest Syndrome, local anesthetic is the primary test material. Treatment initially utilizes cortisone as the medication of choice for focal, micro injuries to insertion and origin fibers of muscles, tendons, and ligaments. If the medication fails to produce permanent pain relief, then radiofrequency thermoneurolysis (RFTN) surgery is used to “turn off” the damaged sensory nerve end organs in the tissue origin or insertion area. Following are case studies illustrating the non-surgical and surgical interventions, respectively.

Figure 1. Ernest Syndrome pain referral pattern. Figure 2. Stylomandibular ligament restraint displacing articular disc. Figure 3. Styloid Process.

Case Report #1 (Non-Surgical Intervention)

This report describes a 28-year-old female patient with a history of trauma to the head and neck as a result of an automobile accident four years prior. Initially, this patient was seen by an oral surgeon who did a temporomandibular joint articular disc repair on both right and left sides for chronic pain at the joint. Following the bilateral joint surgery, her recovery phase was marked by intense pain at each joint. The pain became less severe over the next few months but never went away. The following year, this author saw the patient for evaluation of her temporomandibular joint pain.

Examination revealed a patient with the expected limited mandibular range of motion in all excursions. The mandibular movements were noted to increase the pain reference areas consistent with Ernest Syndrome. At that point, digital palpation (see Figure 4) at the insertions of the right and left stylomandibular ligaments intensified her pain complex involving the ear, temple, jaw joint, lateral throat, lower molar teeth, cheek bone, and eye on both sides (see Figure 1).

Local anesthetic infiltration of 1 cc of local anesthetic at each stylomandibular ligament (see Figure 5) insertion stopped all pain of the head, face, jaw joint, molar teeth, and neck. After the elimination of the symptoms with the anesthetic injection, one quarter cc of synthetic cortisone was injected at each insertion for anti-inflammatory benefit. The patient was re-evaluated the following day, and was pain free with only minor tenderness at the injection site. This patient was found to be pain free three years later.

Figure 4. Digital palpation of ligament insertion Figure 6. Radiofrequency Needle Figure 5. Local anesthetic injection

Case Report #2 (Surgical Intervention)

This case history describes a 31-year-old female patient with a history of automobile accident trauma resulting in an onset of vague right hemifacial pain of five years duration. Repeated visits to otolaryngologists, neurologists, and dentists did not reveal any organic disorder. The absence of a physical finding responsible for her pain led her doctors to recommend psychiatric therapy. The patient participated in psychiatric therapy until the psychiatrist informed her that her problem was not mental in origin.

The next doctor to be seen was a dentist who diagnosed an internal derangement of the right temporomandibular joint. She was treated with acrylic splints and a jaw repositioning appliance, however she did not respond to that therapy. She was then referred to an oral surgeon who performed a disc repair four separate times over an approximate two year period on the right temporomandibular joint. After the fourth joint repair, the patient was referred to this author for evaluation of her persistent joint pain.

Examination of the patient revealed that the onset of her pain seemed particularly severe at the ear and then the area in front of the ear (TMJ) seemed to intensify as time progressed. My examination revealed a patient with pain manifested at the right gonial angle, mandibular teeth on the same side, ear pain and stuffiness, pharyngeal wall, temple, condyle, zygoma, and eye. Provocation testing such as rotation of the head to the left, and extension of the head on the neck precipitated the pain pattern. Additionally, left lateral and protrusive movements of the mandible also increased the pain intensity of the symptom complex. Manual palpation at the insertion of the stylomandibular ligament produced a radiation of severe pain to the specific areas previously mentioned.

Following manual palpation of the insertion area, one quarter cc of local anesthetic was injected into the insertion zone of the right stylomandibular ligament. Within one minute the patient experienced complete remission of all pain. She indicated this was the first time her pain had completely stopped since its onset five years earlier. At subsequent visits, a total of three local anesthetic blocks with cortisone were given, but she only experienced temporary relief of pain. With the failure of the blocks to maintain lasting pain relief, the patient accepted my recommendation of radiofrequency thermoneurolysis (RFTN) surgery as the treatment of choice, based on the only temporary benefits of the blocks. The patient was then operated the next day utilizing thermoneurolysis procedure and only had soreness at the surgery site the day following surgery. At the one year follow-up, she was pain free and the pain pattern of Ernest Syndrome was resolved.


This paper serves to emphasize for physicians and dentists that inclusion of Ernest Syndrome in the differential diagnosis of ear symptoms, TMJ pain, and other craniofacial pains will help to prevent unwarranted surgery of the TM Joint. Gregg45 and Farrar46 were the first dentists to report successful use of the radiofrequency generator for radiofrequency thermoneurolysis (RFTN) for treatment of dental related neuralgias. Farrar46 and Ernest5 also used RFTN to stabilize the posterior superior TMJ disc ligament and articular disc in select cases with great success. Ernest1,4 also reported using thermoneurolysis to denervate the articular nerve supplying the posterior TMJ for neuralgic pain with success. The proper use of RFTN for focal, degenerative painful tissue insertions and origins as well as dental neuralgias has a twenty-five year history in dental medicine with unqualified success. And, as in all cases, proper patient selection is necessary for a good outcome. Radiofrequency thermoneurolysis1-5,7-8,10-14,17-19,21,25-30 serves as a reasonable and preferred surgical choice when compared to the more invasive, higher risk and cost of scalpel surgery for Ernest Syndrome, temporal tendinitis, superior pharyngeal constrictor muscle pain, and similar conditions. n

Last updated on: January 30, 2012
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