Alexander disease is an extremely rare and intractable neurodegenerative disease caused by mutations in the GFAP gene. Symptoms include convulsions, macrocephaly, psychomotor retardation, limb muscle weakness, spastic paralysis, limb and trunk ataxia, dysarthria, dysphonia, dysphagia, and other medullary and spinal cord symptoms, as well as cerebellar symptoms. We report our experience providing general anesthesia management during dental treatment in a child with Alexander disease. The patient was a 5-year and 1-month-old girl with a height of 89.6 cm and a weight of 12 kg. Dental treatment under general anesthesia was scheduled for the treatment of multiple dental caries. Her symptoms included epilepsy, autism, and dysphagia. Her epilepsy symptoms were stable and were being managed with the ongoing administration of regular medications. Regarding her autism, we were able to avoid non-cooperation at the time of induction by providing a prior explanation. Anesthesia was slowly induced with oxygen and sevoflurane. After securing a venous route, rocuronium bromide was administered ; nasotracheal intubation was then performed. The anesthesia was maintained using oxygen, nitrous oxide, and desflurane. Approximately 30 minutes after the start of anesthesia, spontaneous breathing occurred, and the anesthesia was maintained with assisted ventilation until the end of the operation. In consideration of postoperative respiratory depression, no opioids were administered intraoperatively. The operation time was 1 hour and 50 minutes, and the anesthesia time was 2 hours and 50 minutes. No complications were observed during or after the general anesthesia, and the patient was discharged from the hospital on the second postoperative day. This case suggests that the selection of anesthetic agents capable of preventing postoperative respiratory depression and neuromuscular blockade monitoring are both important for providing safe anesthesia in patients with Alexander disease.

  We report a case in which tracheal stenosis was incidentally found during endotracheal intubation in a patient receiving general anesthesia for dental treatment.

  A 19-year-old woman with Down syndrome was scheduled to undergo dental treatment under general anesthesia because of multiple dental caries. The patient had undergone a patent ductus arteriosus repair at the age of 18 months.

  General anesthesia was initiated by a slow induction, and endotracheal intubation was attempted using a tracheal spiral tube with an inner diameter (I. D.) of 7.0 mm and an outer diameter (O. D.) of 9.7 mm. Resistance was encountered while attempting to advance the endotracheal tube. Subsequent observation of the inside of the trachea using an endoscope revealed an apparent tracheal stenosis, which was thought to have been the cause of the resistance. The tracheal tube was changed to one with an I. D. of 5.0 mm (O. D., 6.9 mm), and the endotracheal intubation was completed. Normal artificial respiration was obtained, and the operation was completed without any complications. Prior to a subsequent second general anesthesia, we performed a 3D chest computed tomography (CT) examination to evaluate the morphology of the tracheal stenosis, and we selected a strategy that would enable airway management without advancing an endotracheal tube through the stenotic area.

  Tracheal stenosis without clinical symptoms can be detected incidentally during intubation under general anesthesia. As patients with Down syndrome are more likely to have tracheal stenosis, careful attention is needed when performing endotracheal intubation.

  We performed anesthetic management with remimazolam during dental treatment in a 15-year-old male adolescent patient (height, 146.5 cm ; weight, 35.5 kg) with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS), who had elected to undergo tooth extraction for carious teeth that were not preservable. He had been diagnosed as having MELAS at the age of seven years, following a convulsive seizure, and he also had mental retardation. He was unable to remain calm without the company of his parents, had difficulty communicating, and was aggressive toward medical personnel. Consents for the off-label use of remimazolam (which is indicated for adults only) and the publication of this article were obtained from the patient’s parents. Lacoamide, perampanel hydrate, and ubidecarenone were being used as routine oral medications. Remimazolam was started at 12 mg/kg/h through a peripheral venous route that was secured prior to entering the operation theater, and the patient was sedated without any problems. During surgery, remimazolam (0.8-1.0 mg/kg/h) was administered along with a continuous remifentanil infusion (0.15-0.2 μg/kg/min), and a sedation monitor was observed continuously. The patient’s lactate level was 2.2 mmol/L at the start of the first hour of surgery. The surgical and anesthetic times were 107 min and 193 min, respectively. There were no problems with the patient’s progress after leaving the operating theater, and he was discharged safely the next day.

  In conclusion, anesthesia using remimazolam seemed to be useful in an adolescent patient with MELAS.

  A gag reflex is a condition in which the gag reflex is significantly enhanced because of anatomical abnormalities of the oral and nasal cavity or unpleasant memories of past dental treatment. The patient in the present case was a 31-year-old male who had been referred to our clinic because of difficulty undergoing normal dental treatment as a result of a severe gag reflex, the onset of which had occurred at around the age of 20 years. Based on the results of an oral examination, a long-term treatment plan to be performed under intravenous sedation was developed. We first attempted to manage him with deep sedation using propofol and midazolam, but he had difficulty controlling his reflexes and also vomited during the dental treatment. In this case, we considered that peripheral input from stimulation of the oral mucosa and input from the cerebral cortex, such as past discomfort and fear, had been responsible for inducing vomiting, and we tried a new approach to suppress the gag reflex. We decided to use the histamine H₁ receptor-antagonist hydroxyzine hydrochloride for direct inhibition of the vomiting center, pentazocine for analgesia against nociception, and famotidine, which antagonizes histamine H₂ receptors and inhibits gastric acid. As a result, the patient’s gag reflex was sufficiently suppressed, and the dental treatments were performed without difficulty. Although various reports of patients with severe gag reflexes have been made, various management methods that are appropriate to the patient’s background, treatment, and the facility environment in which the anesthesia management is being performed should be considered, so that the best method can be selected for each patient.

  A 79-year-old man who presented with a persistent allodynia of the left face and had been diagnosed as having postherpetic neuralgia underwent a stellate ganglion block and drug therapy. The patient had a history of alcoholic hepatitis and hepatic dysfunction. The patient complained of bilateral chest lumps after the oral administration of 10 mg/day of amitriptyline hydrochloride for 9 months. Two 40 mm×40 mm swollen areas were observed, one beneath each nipple, and CT images showed two enlargements of the mammary tissue, each 15 mm×35 mm in size, with one on each side. The patient was diagnosed as having gynecomastia, and the amitriptyline hydrochloride was immediately discontinued. The gynecomastia disappeared 6 months after the discontinuation of the oral medication.

  Gynecomastia is the benign proliferation of glandular breast tissue in men and can occur physiologically or as a disease symptom. In both cases, it occurs when female hormones become absolutely and/or relatively dominant over male hormones. The secretion of prolactin, a hormone that regulates mammary gland differentiation and development, is regulated by prolactin inhibiting and prolactin releasing factor (PRF). Tricyclic antidepressants can increase the relative amount of PRF, which can in turn accelerate prolactin secretion. Estrogen, a female hormone, is metabolized by conjugation in the liver, but this patient had a history of alcoholic hepatitis and impaired liver function. Aging can also cause breast enlargement. During old age, the synthesis of androgen is decreased, and the activity of aromatase, which is an enzyme that biosynthesizes estrogen from androgens, is increased. In this case, the combination of aging, liver dysfunction, and the use of amitriptyline hydrochloride may have caused a relative dominance of female hormones, resulting in gynecomastia.

  Oculodentodigital dysplasia (ODDD) is an autosomal dominant syndrome in which multiple malformations of the face, eyes, fingers, and teeth are observed. Although Hallermann-Streiff syndrome is similar to this disease, the pathology is different. ODDD can be discriminated by the identification of specific genes and syndactyly. Here, we report a 4-year-old boy with ODDD who underwent dental treatment under general anesthesia.

  Lateral cranial X-rays showed micrognathia and the tonsillar enlargement. Anesthesia management was conducted via slow induction and was maintained using remifentanil and propofol. A tracheal tube was placed through the nasal cavity using a fiberscope because of the anticipated difficulty of tracheal intubation. The patient’s vital signs were stable throughout the operation. He recovered well and was discharged on the next day. In the presently reported patient with ODDD, a specific risk of general anesthesia was the difficulty in airway management. For patients with suspected micrognathia, lateral head X-rays are likely to be useful for assessing the difficulty of airway management in children and/or patients with intellectual disability, since such images are relatively easy to obtain and provide useful information.

  Conversion disorder consists of changes in motor or sensory function that cannot be explained by other diseases, and its symptoms cannot be explained physiologically or anatomically. We herein report a case of disturbed consciousness that was suspected of having been caused by conversion disorder arising after various painful treatments.

  A 33-year-old woman had received stellate ganglion blocks for the relief of her right myofascial pain and neuropathic pain in the right lower molar region. After completing the stellate ganglion block and intravenous injection, we performed professional mechanical tooth cleaning (PMTC) as requested by the patient. Five minutes after the end of the PMTC, however, the patient suddenly lost consciousness. Her electrocardiogram (ECG) was normal, her heart rate was 60 beats per minute, her blood pressure was 85/46 mmHg, and her pulse oximetry was 99%. Approximately 10 minutes later, she recovered briefly. However, approximately 20 minutes thereafter, she once lost consciousness once again. Her heart rate was 75 beats per minute, her blood pressure was 127/83 mmHg, and her pulse oximetry was 100%. Her symptoms persisted for 90 min, at which time she was rushed to an emergency hospital. A head CT and blood tests performed at the emergency hospital showed no abnormalities. Approximately 180 minutes later, her condition resolved and she was discharged home.

  The clinical findings in this case allowed commonly occurring complications to be ruled out. The patient’s loss of consciousness was diagnosed as conversion disorder by a psychiatrist. Severe pain and emotional distress occurring during the PMTC procedure were thought to have been the cause. The present case suggests that patients with chronic pain should be treated with greater caution when performing procedures that may cause pain.