S4535 Temporomandibular Joint Dislocation: A Rare Complication of Esophagogastroduodenoscopy

Introduction: Anterior temporomandibular joint (TMJ) dislocation is a rare but recognized complication of upper endoscopic procedures. It occurs when the mandibular condyle moves anteriorly out of the glenoid fossa, often due to excessive mouth opening, muscle relaxation from sedation, or anatomical predisposition. Symptoms include inability to close the mouth, jaw pain, and malocclusion. TMJ dislocation has been associated with the use of inflexible mouthpieces and sedatives. Though uncommon, awareness and early recognition are crucial for appropriate management. Case Description/Methods: A 30-year-old man with an undisclosed and remote past medical history of TMJ dysfunction underwent an elective esophagogastroduodenoscopy (EGD) for evaluation of dysphagia. The sedation for the procedure included lidocaine, propofol, midazolam, and fentanyl. The procedure was uncomplicated; however, upon emergence from sedation and removal of the bite block, the patient was unable to close his mouth. His physical exam revealed jaw tenderness, malocclusion, visible dislocation, and inability to tolerate his secretions. Patient has no history of connective tissue disorders or facial trauma. Patient was found to have anterior TMJ dislocation. Initial reduction attempts in the endoscopy suite were unsuccessful, and the patient was transferred to the emergency department where maxillofacial computed tomography revealed no fractures or acute abnormalities. Under procedural sedation with propofol, bilateral TMJ reduction was successfully performed. However, upon oscitation (yawn), it recurred. TMJ reduction was then successfully performed with ketamine. Discussion: This case highlights the importance of recognizing TMJ dislocation as a rare complication of upper endoscopy, especially in patients with a history of jaw dislocations. Sedatives like propofol reduce muscle tone and trigger oscitation, contributing to dislocation, particularly when paired with rigid mouthpieces. Preventative measures may include pre-procedural screening for TMJ instability as most case reports mention patients that have had history of TMJ dislocations in the past prior to the EGD, using smaller (<1.8 cm in diameter) or flexible mouthguards, minimizing procedure duration to less than 40 minutes, and minimizing the risk of oscitation, such as alternatives to propofol and utilizing lighter sedation techniques. Imaging may be required to exclude fractures. Prompt diagnosis and reduction can prevent complications, such as aspiration, muscle spasms or chronic dislocation.