Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and frequent comorbid obesity. We present the safe perioperative management of a patient with narcolepsy who required mandibular surgery. A 22-year-old man (weight, 69.8 kg ; height, 160.8 cm ; BMI, 27.2) was scheduled to undergo a sagittal splitting ramus osteotomy. He was diagnosed as having narcolepsy at the age of 15 years, of having obstructive sleep apnea syndrome (OSAS) at the age of 20 years, and experienced drowsiness while driving at the age of 21 years (weight, 48 kg ; height, 156 cm ; BMI, 19.7) ; he was prescribed modafinil (200 mg) at this time. After taking his daily dose of modafinil (100 mg) on the morning of the surgery, general anesthesia was induced and maintained with air-oxygen-sevoflurane, remifentanil, and rocuronium to maintain his BIS value between 40 and 60. Following the osteotomy, his mandible was fixed using a 7-mm setback. After surgery, he emerged from anesthesia within 10 min at a BIS value of 92 and was extubated. His intraoperative course was uneventful, with no hemodynamic instability occurring. Postoperative hypertension required a reoperation for hemostasis with intravenous sedation under SpO₂ monitoring and capnography. Six months later, he was referred to a hospital for a reevaluation of his OSAS. His AHI (apnea hypopnea index) was exacerbated from 17.2/h to 26.0/h as a result of him being overweight (21.8 kg), rather than the downward position of the hyoid bone caused by the setback of the mandibular bone. BIS monitoring of the sevoflurane and remifentanil anesthesia during the surgery was useful for preventing postoperative oversedation in this narcoleptic patient. Modafinil is a central neurological stimulant (a non-amphetamine, wake-promoting compound used for excessive daytime sleepiness). Its reported side effects include postoperative hemodynamic instability. Further studies examining the perioperative risk when anesthetics and central neurological stimulants are combined in narcolepsy patients with OSAS are needed.

  The patient was a 56-year-old female who complained of a burning pain on her tongue. The pain was continuous except eating and sleeping time and was accompanied by dry mouth and headache. We diagnosed her as having burning mouth syndrome (BMS) based on the exclusion of any local factors (e.g., candidiasis, hyposalivation, mucosal lesions, trauma) or systemic conditions (e.g., vitamin deficiency, diabetes, hypothyroidism, side effect of medications, autoimmune disorders). Only a psychometric test yielded high scores.

  Since the patient had not only tongue pain but additional sign and symptoms such as edema and scalloped tongue, dry mouth and headache, we planned to use lidocaine and goreisan, which is a kampo medicine, based on the results of a numerical rating scale (NRS). A referral to a psychiatrist was considered. However, 3 years have passed since her initial visit, and her condition has been successfully managed using only goreisan.

  The etiology of BMS is unclear, but psychological factors often trigger pain in many cases. Recent evidence shows neuropathic mechanisms involving both the peripheral and central nervous systems in the etiology of BMS. If BMS is approached as a neuropathic pain condition, the use of lidocaine is reasonable as both a diagnostic tool and an initial therapy for BMS. Kampo medicine can be useful as a complementary alternative medicine.

  Here, we introduce a case of BMS with dry mouth that was successfully managed using goreisan.

  The incidence of postoperative nausea and vomiting (PONV) after oral and maxillofacial surgery is high, and the prevention of PONV is important for patient comfort after surgery. Droperidol and metoclopramide hydrochloride, two dopamine receptor antagonists, are widely used for the prevention and treatment of PONV. However, one of the adverse effects of these drugs is extrapyramidal symptoms (EPS). We report a case of EPS after the administration of droperidol and metoclopramide hydrochloride following orthognathic surgery.

  A 19-year-old woman underwent orthognathic surgery under general anesthesia. Dexamethasone sodium phosphate (6.6 mg) was administered prior to the start of surgery, and droperidol (1.25 mg) was administered at the end of surgery for the prevention of PONV. After the completion of the surgery, an intravenous patient-controlled analgesia (IV-PCA) device was used for postoperative analgesia (contents : fentanyl citrate, 20 ml [1 mg] and droperidol, 2 ml [5 mg] diluted with saline [28 ml]). Immediately after returning to the ward, metoclopramide hydrochloride (10 mg) was administered because the patient developed nausea. Fourteen hours and 30 minutes after the end of surgery, the patient noticed sursumvergence and torticollis. Since the patient’s consciousness was clear and her vital signs were stable, the use of droperidol in combination with metoclopramide hydrochloride was suspected of having caused the EPS. Thus, IV-PCA was discontinued, and her symptoms resolved after 2 hours.

  In the present case, the EPS were likely attributable to the inclusion of droperidol in the IV-PCA. Therefore, we believe that EPS should be prevented by reducing the dose of droperidol or administering serotonin receptor antagonists (ondansetron and granisetron) as alternatives.

  A multimodal analgesia approach that combines acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and local anesthesia is commonly used for postoperative pain management in head and neck surgery. However, the risk of complications should be considered when using NSAIDs and opioids. Reducing the amounts of these agents as much as possible reduces the risk of developing postoperative complications, leading to early postoperative recovery and improved patient prognosis. If a patient’s preoperative assessment suggests an increased risk of postoperative complications, anesthesia management should be planned to prevent such complications, leading to a good patient prognosis. Ultrasound-guided nerve blocks are considered an effective approach to reduce the required doses of NSAIDs and opioids. In addition, ultrasound-guided techniques also provide real-time confirmation of deep anatomy and the spread of local anesthesia from the needle tip. In the presently reported case, an ultrasound-guided maxillary nerve block and superficial cervical plexus block were performed in a patient with a high risk of postoperative complications who was scheduled to undergo a right partial maxillary resection and right neck dissection under general anesthesia. As a result, we were able to provide a good analgesic effect after surgery. An analgesic approach using a head and neck nerve block is not yet a common procedure, but it has the potential to provide effective postoperative analgesia as well as safe long-term analgesia for many maxillofacial surgical procedures.

  Chronic myofascial pain (CMP) of the masticatory muscles is a common chronic pain disorder in the orofacial region. CMP is characterized by a trigger point (TP) on a myofascial taut band, the palpation of which induces reproducible pain. Trigger point injection (TPI) and fascia hydrorelease (FHR), in which local anesthetics are injected into a trigger point and adhesions of fascia, are often performed for CMP because of the high therapeutic effect on pain relief. CMP is caused by abnormal sympathetic nerve excitement that leads to a vicious cycle of reflexes by vasoconstriction of the arterioles in muscles. Therefore, an agent with vasoconstrictive action has not been previously used for TPI and FHR. We report two cases in which TPI and FHR was performed using local anesthetics with vasoconstrictive actions, providing successful pain relief. TPI and FHR were performed using NeoVitacain^® injection (dibucaine hydrochloride, sodium salicylate, calcium bromide) as a general procedure in our department. Both patients complained of an unsatisfactory effect on pain relief, and the duration was not long enough. Consequently, the agents were switched from NeoVitacain^® to lidocaine with adrenaline and ropivacaine, respectively. As a result, sufficient pain relief was obtained in both cases. Adrenaline, a vasoconstrictor, was added to the local anesthetic to prolong the anesthetic effect. Ropivacaine has a long anesthetic effect because of its strong protein binding and unique vasoconstrictive action at concentrations used clinically. The pain relief obtained in the present two cases of CMP might have arisen from the vasoconstrictive actions of these two agents.