Ernest or Eagle's Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis

Number: 0400

Policy

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).

Background

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.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

Radiofrequency thermoneurolysis (also known as radiofrequency ablation, radiofrequency neurolysis, radiofrequency thermoablation):
No specific code

Other CPT codes related to the CPB:
64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch

The above policy is based on the following references:

  1. Baba A, Okuyama Y, Ojiri H, Nakajima T. Eagle syndrome. Clin Case Rep. 2017;5(2):201-202.
  2. Brown CR. Ernest syndrome: Insertion tendinosis of the stylomandibular ligament. Pract Periodontics Aesthet Dent. 1996;8(8):762.
  3. Dominguez J, Bornhardt T, Wen S, Iturriaga V. Ernest syndrome: A systematic review of the literature. J Oral Facial Pain Headache. 2020;34(2):167-173.
  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. Elimairi I, Baur DA, Altay MA, et al. Eagle's syndrome. Head Neck Pathol. 2015;9(4):492-495.
  6. 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.
  7. Jose A, Rawat A, Nagori SA. Insertion tendinosis of stylomandibular ligament: Ernest syndrome. J Craniofac Surg. 2020 Sep 1 [Online ahead of print].
  8. Kumai Y, Hamasaki T, Yumoto E. Surgical management of Eagle's syndrome: An approach to shooting craniofacial pain. Eur Arch Otorhinolaryngol. 2016;273(10):3421-3427.
  9. Malik JN, Monga S, Sharma AP, et al. Stylalgia revisited: Clinical profile and management. Iran J Otorhinolaryngol. 2018;30(101):335-340.
  10. 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.
  11. Piagkou M, Anagnostopoulou S, Kouladouros K, Piagkos G. Eagle's syndrome: A review of the literature. Clin Anat. 2009;22(5):545-558.
  12. Rinaldi V. Eagle syndrome. eMedicine Surgery. New York, NY: Medscape; updated April 27, 2012.
  13. 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.
  14. Taheri A, Firouzi-Marani S, Khoshbin M. Nonsurgical treatment of stylohyoid (Eagle) syndrome: A case report. J Korean Assoc Oral Maxillofac Surg. 2014;40(5):246-249.
  15. Wilk SJ. Surgical management of refractory craniomandibular pain using radiofrequency thermolysis: A report of thirty patients. Cranio. 1994;12(2):93-99.