Ernest Syndrome – the answer to unresolved TMJ pain?

Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida

Ernest Syndrome – the missing diagnosis of unresolved TMJ pain

In the more than 27 years of helping patients with chronic pain, we often find that what people have been diagnosed with is not really the problem causing them their continued and chronic pain. Such is the case of people who were diagnosed with problems of TMJ and still have jaw pain and related issues.

In this article, we will focus on Ernest syndrome as the missing diagnosis in what is thought to be TMJ pain.

The problems of Ernest syndrome surrounds the damage and weakening of the stylomandibular ligament, a small but powerful ligament that connects the skull to the jaw by way of the styloid process of the temporal bone to the mandible. The missing diagnosis of Ernest Syndrome as the cause of TMJ related pain is found in that both TMJ and Ernest Syndrome have similar if not identical symptoms.

The accumulation of symptoms

In the many patients we see with cervical spine instability and ligament damage that is causing them significant and to some point “mysterious,” symptoms which I discuss below, we find that the symptoms are not usually isolated to one or two problems but have developed into many problems.

Patients come in and they discuss with us:

From our published research: Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction. Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Practical Pain Management. 2007; November/December:49-55.

Ernest syndrome

This myriad of confusion surrounding the displayed symptoms lead to the understanding that patients may be suffering from a yet unidentified syndrome.

Ernest syndrome was first identified by the dentist, Edwin A. Ernest, III, DMD, in 1981 and subsequently written up in the 1982 edition of the medical textbook An Orthopedic & Neurological Approach to Diagnosis and Management, 1st Ed. 1982. pp. 114. It would be best to let Dr. Ernest describe the syndrome named for him. This comes from the October 2006 issue of the medical journal Practical Pain Management. (1)

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

In the early stages patients may present with symptoms of:

  • Tenderness and discomfort below the ear lobe
  • Pressure simulating a new wisdom tooth trying to squeeze in.

In the later stages patients may present with symptoms of:

  • Molar teeth on same side ache and throb
  • Ear exhibits a sense of fullness and pain
  • Throat soreness
  • TMJ condyle pain
  • Coronoid process and temporal tendon pain at zygomatic arch. (The Coronoid process is where the jaw’s powerful temporal muscle attaches to the lower jaw. It attaches by way of the temporal tendon. If the temporal tendon is damaged, the muscle will not function correctly and the damage will cause pain at the zygomatic arch, more simply the cheekbone area.)
  • Temple headache
  • Eye pain or pain near eye and photophobia ( light sensitivity or intolerance to light).
  • Ernest Syndrome can occur with or be mistaken for including Barre-Lieou syndrome.

Ernest syndrome may not be so rare

Recently doctors at the University of Valencia in Spain wrote in the medical journal Neurología (2) that Ernest syndrome symptoms that they see:

  • the preauricular area (external ear)
  • mandibular angle (jaw),
  • pain radiating to the neck, shoulder, and eye on the same side.
  • palpation of the stylomandibular ligament, gently pressing on it, will cause pain.

Are common to the myriad of disorders that TMJ and cervical neck instability can  produce, including the tenderness on pressing into “the behind the ear area,” while implicating a problem of Ernest Syndrome, will still and often confuse clinicians that Ernest Syndrome is being caused by other types of orofacial pain including TMJ. Ernest Syndrome  the researchers conclude: “may, therefore, be more prevalent than the literature would indicate.”

Stylomandibular ligament damage and Ernest Syndrome

In our clinics, we are very aware of what damaged ligaments can do, so it is reassuring to us that medical research is documenting some of the same things that we have seen over the decades. In regard to Ernest Syndrome, this problem may be much more prevalent than doctors think, so maybe we should not call this a “rare,” disorder. Further, patients with unresolved TMJ and jaw pain should be examined for stylomandibular ligament damage.

Ross Hauser, MD, presents an overview of diagnosis and treatment for Ernest Syndrome and Eagle Syndrome.

Eagle Syndrome is is medically known as the elongation of the styloid process and stylohyoid ligament calcification. This typically occurs with aging, and often results in sharp, intermittent pain along the glossopharyngeal nerve that is located in the hypopharynx and at the base of the tongue. This is a stylohyoid ligament problem and is further explained in our accompanying article on Eagle Syndrome.

Summary video transcript

  • When we see patients with unresolved TMJ pain we think injury to the stylomandibular ligament. This injury can cause some incredible symptoms like those problems mentioned above with because of the impact this injury creates on the cranial nerves, specifically the glossopharyngeal nerve, the vagus nerve, and the Hypoglossal nerve (Cranial nerve XII).
  • The Styloid process. 
    • The styloid process is a small bone that projects out from the temporal bone at the base of the skull. Below the TMJ joint. It sits just below your ear. It is here that there a number of ligament and tendons attach themselves to provide movement for the jaw.
      • stylohyoid ligament
      • stylomandibular ligament
      • styloglossus muscle (tongue muscle which pulls up sides of tongue to form a scoop which aids in swallowing. It is innervated by the hypoglossal nerve.)
      • stylohyoid muscle (which helps elevate the tongue. It is innervated by the facial nerve Cranial nerve VII).
      • stylopharyngeus muscle (vital to the swallowing process. It is innervated by the glossopharyngeal nerve).

Focus on the stylomandibular ligament and development of bone spurs at the styloid process 

  • (0:56) Focus on the stylomandibular ligament
    • The stylomandibular ligament is a really important ligament even though it doesn’t get a lot of publicity. It is important, especially now, that we use cell phones and are in a constant head down position. The stylomandibular ligament  holds the mandible in place. When it is damaged, the mandible “floats,” and is unstable.
    • (3:18) Bone spurs. When the stylomandibular ligament is under constant pressure from instability of the mandible or pressure on the mandible exhibited in the head down position, it distributes this stress into the  styloid process. This stress causes the development of bone spurs. Formation of bone spurs at the styloid process can impinge on the vagus nerve, the glossopharyngeal nerve,  and the hypoglossal nerve. This impingement can be a leading culprit in the myriad of symptoms the patient suffers from.

Digital Motion X-Ray at 5:05 – the cervical spine instability connection is explored

  • Once a physical examination and palpation of the stylomandibular ligament reveals tenderness and pain. We will look at the patient’s cervical spine under digital motion x-ray and high definition ultrasound of the TMJ and cervical spine area. Many of the symptoms displayed in patients with suspected Ernest Syndrome are also symptoms of cervical spine instability. This connection is described further below.

Digital motion X-Ray C1 – C2

The digital motion x-ray is explained and demonstrated below

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
  • This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause the instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.

Treatments – Surgery or injections

In the October 2006 issue of Practical Pain Management, which I cited above, Dr. Ernest described two patients who were inappropriately operated on for TMJ. When TMJ issues did not resolve, the two patients were ultimately diagnosed with Ernest Syndrome resulting from motor vehicular trauma. Dr. Ernest summarized these case studies with this warning to doctors and dentists: “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.”

In 1987, Dr. WE Shankland II described a detailed clinical analysis of 68 patients diagnosed as suffering from Ernest syndrome. (3) This is an often-cited paper by researchers exploring the problems of treatment of Ernest Syndrome.

  • “Injury to the stylomandibular ligament is a real and frequent disorder causing craniomandibular pain.”
  • Of the patients in this study, 77.94% were treated successfully via nonsurgical management of their complaints. Resolution of this disorder is usually accomplished by a combination of a diagnostic injection of local anesthetic at the insertion of the ligament, localized injection of cortisone substitute, and placing the patient on a soft diet.

While we will agree that injection therapy will help the patients, we would prefer the injection of simple dextrose as opposed to cortisone. Cortisone acts and an anti-inflammatory and is not curative in nature. Dextrose injections or Prolotherapy is an injection that seeks to strengthen weakened ligaments by causing inflammatory repair.

Ernest Syndrome Dextrose Injections – Prolotherapy

The basic mechanism of Prolotherapy is simple.

  • Prolotherapy injections involve using a safe and simple base solution containing dextrose as the primary proliferant, along with an anesthetic (procaine), that is given into and around the entire painful/injured area. This basic Prolotherapy solution used for over 80 years includes the above mentioned hypertonic dextrose (1­2.5% concentration) along with an anesthetic.
  • Prolotherapy is a series of injections, in Ernest syndrome three to 8 treatments are recommended.


If you have a question about Ernest Syndrome, get help and information from our Caring Medical staff


1 Ernest EE. Ernest Syndrome and Insertion of the SML at the Mandible. PPM 2006 Volume 6, Issue #7
2 Peñarrocha-Oltra D, Ata-Ali J, Ata-Ali F, Peñarrocha-Diago MA, Peñarrocha M. Treatment of orofacial pain in patients with stylomandibular ligament syndrome (Ernest Syndrome). Neurologia. 2013 Jun;28(5):294-8. doi: 10.1016/j.nrl.2012.06.009. Epub 2012 Aug 14. [Google Scholar]
3 Shankland WE. Ernest syndrome as a consequence of stylomandibular ligament injury: a report of 68 patients. Journal of Prosthetic Dentistry. 1987 Apr 1;57(4):501-6. [Google Scholar]


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