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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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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.

Last updated on: January 30, 2012