Risk of Jaw Dislocation With Prolonged Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

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To the Editor:
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is generally a safe procedure with very rare complications including bleeding, pneumothorax, pneumomediastinum, mediastinitis, and respiratory failure. We report a rare, unrecognized complication of EBUS-TBNA that, once recognized, is treatable by prompt action.
A 74-year-old gentleman recently diagnosed with left upper lobe squamous cell carcinoma underwent elective EBUS-TBNA for sampling of subcarinal lymph node, and thus staging the malignancy. Past medical history included chronic obstructive pulmonary disease (COPD), bronchiectasis, rheumatoid arthritis, and hypertension. The oropharynx was sprayed with a topical local anesthetic (50 mg of Lidocaine) and he was sedated with Propofol and Remifentanyl. An BF-UC260FW Olympus EBUS-TBNA scope was passed through oral cavity via a mouth guard (medgic medical devices, disposable bite block). The patient had persistent cough during the procedure. Four samples were taken from station 7 lymph nodes and the procedure was stopped thereafter. Total duration of procedure was 22 minutes. Overall, the procedure was uneventful and the mouth guard was removed. The patient woke up 20 minutes after the procedure in the recovery suite. He complained of jaw pain, inability to close his mouth and could not talk secondary to incomplete mouth closure. He was seen by the Oral and Maxillofacial surgery team and clinical diagnosis of bilateral anterior temporomandibular joint (TMJ) dislocation was made. As he was still under the effect of sedation, manual relocation of mandible was performed, which led to immediate relief of symptoms.
Dislocation of TMJ is a common complication associated with endotraheal intubation and anesthesia and has rarely been described secondary to gastroscopy, bronchoscopy, trans-esophageal echocardiogram, otolaryngology, and dentistry procedures.1–8 However, to the best of our knowledge TMJ dislocation has never been reported secondary to EBUS-TBNA. Several factors have been identified as potential sources for increasing the risk of jaw dislocation which include previous joint dislocation, prolonged procedure time, increased age, and relaxation of the musculature caused by sedating medications.1–3 When patients suffer from TMJ dislocation, they will often be unable to close their mouth and have drooling and garbled speech along with pain.5 The diagnosis of TMJ dislocation is based upon clinical examination. Delayed reduction increases the risk of development of muscular spasms making the reduction of the dislocation more challenging.6 Although Propofol and Remifentanyl was used for sedation in our patient, jaw dislocation has been reported with use of midazolam alone.8 EBUS-TBNA often requires deeper sedation and prolonged intubation compared with conventional flexible bronchoscopy. While jaw dislocation is a very rare complication of EBUS-TBNA, it is important for bronchoscopists to be aware of this possibility, recognize it in the recovery area and seek urgent treatment. Patients with a history of TMJ subluxation are at a high risk for this complication during any bronchoscopic procedure. Early recognition of this unusual complication of EBUS-TBNA enables prompt, effective treatment, and reduces further morbidity.

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