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Clinical Policy Bulletin:
Ernest or Eagle's Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis
Number: 0400


Aetna considers radiofrequency (RF) thermoneurolysis (also known as RF ablation, RF neurolysis, RF thermoablation) experimental and investigational for the treatment of Ernest or Eagle's syndrome because the effectiveness of this procedure in treating this condition has not been established.

See also CPB 0028 - Temporomandibular Disorders (noting that RF thermoneurolysis is considered experimental and investigational for treatment of TMD/TMJ syndrome).


Ernest or Eagle's syndrome, a problem similar to temporo-mandibular joint pain, involves the stylomandibular ligament, a structure that connects the styloid process at base of the skull with the hyoid bone.  Symptoms of Ernest syndrome, in decreasing order of occurrence, are: temporo-mandibular joint and temporal pain, ear and mandibular pain, posterior tooth sensitivity, eye pain, and throat pain (especially when swallowing).  Treatment of Ernest syndrome, which is successful about 80 % of the time, includes a soft diet, use of an intra-oral splint, physiotherapy, medication and injections of local anesthetics at the insertion of the ligament.

There are anecdotal reports that radiofrequency thermoneurolysis is effective in treating symptoms of Ernest syndrome.  However, these studies lack scientific rigor and the claims of effectiveness have not been validated in the peer-reviewed medical literature.

Surgical treatment of Eagle's syndrome includes styloidectomy (removal of the elongated portion of the styloid process). Mupparapu and Robinson (2005) stated that Eagle's syndrome refers to pain and discomfort in the cervico-facial region resulting specifically from the elongated styloid process.  Surgical shortening may be the only treatment that will alleviate the patient's symptoms.

CPT Codes / HCPCS Codes / ICD-9 Codes
There are no specific codes for radiofrequency thermoneurolysis (also known as radiofrequency ablation, radiofrequency neurolysis, radiofrequency thermoablation):
Other CPT codes related to the CPB:
Other ICD-9 codes related to the CPB:
379.91 Pain in or around eye
388.70 - 388.72 Otalgia
521.89 Other specific diseases of hard tissues of teeth (sensitive dentin)
524.60 - 524.69 Temporomandibular joint disorders [TMJ]
526.81 - 526.89 Other specified diseases of the jaw
728.0 - 728.9 Disorders of muscle, ligament, and facsia
784.1 Throat pain
733.99 Other disorders of bone and cartilage
784.92 Jaw pain

The above policy is based on the following references:
  1. Shankland WE 2nd. Ernest syndrome as a consequence of stylomandibular ligament injury: A report of 68 patients. J Prosthet Dent. 1987;57(4):501-506.
  2. Wilk SJ. Surgical management of refractory craniomandibular pain using radiofrequency thermolysis: A report of thirty patients. Cranio. 1994;12(2):93-99.
  3. Brown CR. Ernest syndrome: Insertion tendinosis of the stylomandibular ligament. Pract Periodontics Aesthet Dent. 1996;8(8):762.
  4. DuPont JS Jr. Panoramic imaging of the stylohyoid complex in patients with suspected Ernest or Eagle's syndrome. Cranio. 1998;16(1):60-63.
  5. Mupparapu M, Robinson MD. The mineralized and elongated styloid process: A review of current diagnostic criteria and evaluation strategies. Gen Dent. 2005;53(1):54-59.
  6. Piagkou M, Anagnostopoulou S, Kouladouros K, Piagkos G. Eagle's syndrome: A review of the literature. Clin Anat. 2009;22(5):545-558.
  7. Rinaldi V. Eagle syndrome. eMedicine Surgery. New York, NY: Medscape; updated April 27, 2012.
  8. Han MK, Kim do W, Yang JY. Non surgical treatment of Eagle's syndrome - A case report. Korean J Pain. 2013;26(2):169-172.

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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