Internal carotid artery stenosis is one of the high risk factors in the causation of transient ischemic attack and brain infarction. Recently this disorder (disease) has been increasing in Japan as well as in western countries.
We treated a 65-year-old man with soft palate carcinoma, taking anticoagulant therapy and scheduled for stenting for severe internal carotid artery stenosis. High risk of difficulty in attainment of hemostasis was suspeculated in addition to possible postoperative ischemic complications to various organs due to decrease in blood pressure and resulting in high risk for cerebral. Therefore, surgical treatment under general anesthesia was performed with strict general management. Postoperatively, he showed considerable recovery and was discharged from the hospital.

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We herein describe a case of herpes zoster localized to the oral mucosa of an odontogenic infection patient with ulcerative colitis. A 21-year-old man with ulcerative colitis was referred to the Department of Dentistry and Oral Surgery at Toho Hospital for complications of pyrexia and swelling of the right cheek. Antibiotics were instilled for the diagnosis of the cheek phlegmon originating in the pericoronitis of the right mandibular wisdom tooth. On the third day, multiple erosions appeared in hard palate and buccal mucosa but no erosion and bleb were identified in the facial epidermis in the buccal region and anterior to the ear. Intravenous drip of antiviral drug (acyclovir) was commenced though the examination result for the varicella-zoster virus (VZV) antibody was negative. On the 11th day, inflammation and erosions in the oral cavity resolved completely and he was discharge. At the time of discharge, complement fixation reaction for the VZV antibody examination was revealed to be 256 times greater than norm.

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As previously reported in our first study in 2004, by utilizing the stepwise logistic regression analysis, we revealed that the factors which influence postoperative bleeding in patients taking warfarin^® were PT-INR level, the number of tooth extraction per treatment and the method of management for warfarin^® therapy.
In this report, to evaluate the course and prognosis following tooth extraction, we examined a total of 84 patients, who visited our clinic for tooth extraction from January 2003 to May 2005: 43 patients who were taking warfarin^® (warfarin^® group: 19 males, 24 females) and 41 patients who had no bleeding factor (control group: 11 males, 30 females).
Using a test paper for salivary occult blood detection (salivastar^®), we compared the level of salivary occult blood immediately prior to, one day after, and one week following tooth extraction between both groups. The Mann-Whiney U test was utilized for analysis of the test results, the results revealed that the one day after and one week following tooth extraction in the warfarin^® group had significantly (at 5% level) higher occult blood levels than those of the control group.
In addition, these two groups were classified into 2 subgroups in reference to the location of tooth extraction: one subgroup was defined as the free-end edentulous subgroup while the other subgroup was defined as the bounded edentulous subgroup. The Wilcoxon Signed Ranks test revealed that in the warfarin^® group, salivary occult blood level at one week following tooth extraction in the free-end edentulous subgroup was significantly higher than that prior to extraction. This difference did not appear in the other subgroups. These results suggested that patients taking warfarin^® tend to have occult bleeding for about one week following tooth extraction. It also indicated that for patients taking warfarin^®, the factor of pressure to the surgical site as a form of surgical trauma would affect local hemostatic management.
Through this study, utilization of test paper for salivary occult blood detection has proven its usefulness as a tool for prognosis and course evaluation following tooth extraction. In conclusion, to establish criteria for assessment of risk factors for surgery and preoperative planning for tooth extraction in patients taking warfarin^® is necessary.

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We herein report a case of pneumocystis pneumonia development following radiation therapy and chemotherapy for metastatic lesions to the neck and pulmonary regions originating as a head and neck carcinoma. Pneumocystis pneumonia is an opportunistic disease which occurs in immunocompromised patients. The patient, a 75-year-old male, had been under radiation therapy since January 1997 for squamous cell carcinoma of the left oropharynx. The patient has undergone several resections and radiation therapies for recurrences and the progress had been under strict observation. He was hospitalized on July 7th, 2003, for metastasis to the left cervical lymph node. Although pulmonary metastasis was identified, pulmonary metastatectomy was not performed. Neck dissection was performed on July 14th with preservation of the left accessory nerve. Radiation therapy was conducted along with two sessions of chemotherapy following surgery. From September 16th, one week after the second chemotherapy, the patient complained of high-grade fever of 39°C or greater with decrease in neutrophilic leukocyte count. Chest radiograph examination taken on September 25th revealed interstitial shadows. Since pneumocystis pneumonia was suspected, trimethoprim-sulfamethoxazole and steroid were orally administered from that day. Subsequently, the indication values improved rapidly and returned to normal values on October 6th. Thereafter, the patient had shortperiod hospitalizations on several occasions for chemotherapy. However, he died on April 3rd, 2005. He was under a home healthcare program and his ADL was preserved until his last hospitalization.

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We experienced a case of right internal jugular vein thrombosis following surgery for left mandibular gingival carcinoma and right thyroid gland carcinoma. The patient was a 66-year-old male and consulted our department for left mandibular gingival carcinom. He underwent surgical resection of the gingiva and marginal resection of the mandible, resection of the right thyroid gland and neck dissection with preservation of the right internal jugular vein. He had atelectasis, prior to awaking from general anesthesia, therefore he was transferred to the intensive care unit for observation and care. Since metastasis to the submandibular lymph nodes was identified in the postoperative pathologic examination, we scheduled the patient to undergo additional left radical neck dissection. However, CT of the neck prior to surgery identified right internal jugular vein thrombosis. The surgery was postponed and he underwent thrombolytic therapy. After we confirmed that the thrombus had resolved completely, he underwent left radical neck dissection. He was administered preventive anticoagulant therapy from the day following surgery for 11 days. He underwent postoperative radiation therapy totaling 63Gy and received 3 adjuvant chemotherapies with CDDP+5-FU. We herein report a case with internal jugular vein thrombosis.

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An 87-year-old female patient had been diagnosed with left mandibular gingival cancer. Under general anesthesia she underwent partial excision of the mandible, resection of the superior cervical lymph nodes and palatal reconstruction. Her history revealed left facial palsy and goiter, but no specific treatment had been previously administered for these conditions.
Preoperatively atropine sulfate and midazolam were administered intramuscularly. Anesthesia was introduced by m-NLA and included nitrous oxide, oxygen, midazolam and pentazocine. Anesthesia was subsequently maintained with nitrous oxide, oxygen and sevoflurane. The course of surgery was uneventful and was completed in 7 hours and 25 minutes. The patient regained her consciousness uneventfully.
Approximately three hours after returning to the ward, she began to show signs of unrest. She was heavily sedated with an intramuscular dose of midazolam (5mg). However, about 7 hours after returning to the ward, airway obstruction developed, apparently due to edema and bleeding from the site of surgery, making it impossible for her to breathe spontaneously. An emergency tracheotomy was performed, and spontaneous ventilation resumed. Later, she again showed signs of unrest. Despite four additional doses of midazolam (10mg in total), adequate sedation was not achieved. At that time, we considered possible disorders of the brain related to hypoxia caused by disturbed spontaneous ventilation and therefore commenced (thus started) low-dose drip infusion of thiamylal sodium (about 2mg/min). The infusion lasted for about 18 hours (2000mg thiamylal sodium in total). During this infusion, her condition was well controlled. Her mental state was clear about 9 hours after completion of infusion. Thereafter, she showed no noteworthy symptoms. The brain-protective effect of thiamylal sodium is remarkable and no other drug exerting such comparable effect is available at present. Our experience with this case again emphasizes the beneficial effect of thiamylal sodium and its usefulness in sedation of postoperative patients.

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Idiopathic thrombocytopenia purpura (ITP) is caused by production of autoantibodies against the platelet. Therefore, hemostatic control is considerably important in oral surgical treatments or any surgery involving ITP patients.
We herein report a case of hemangioma of the cheek in a 72-year-old female patient with ITP. The preoperative laboratory data revealed a low platelet count of 29, 000/μl. She received a preoperative high-dose γ-globulin therapy (400 mg/kg/day) for 4 days. On the day of surgery, her platelet count had increased to 81, 000/μl. After surgery, abnormal bleeding did not occur and the postoperative course was uneventful. We are able to conclude that surgery could be performed safely and successfully for patients with ITP as demonstrated by this case.
For oral surgical treatment of patients with ITP, high-dose γ-globulin therapy has demonstrated its usefulness in increasing the platelet count immediately prior to surgery.

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We experienced a case of concomitant (concurrent) acute hepatitis with a dental focal infection. The patient consulted two dental offices and an internist where both dentists and the physician diagnosed that his medical condition such as tiredness and fever was caused by the dental focal infection. Therefore, diagnosis of latent acute hepatitis was delayed.

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We herein report our experience with anesthetic management of a schizophrenic patient with a medical history of neuroleptic malignant syndrome (NMS).
A 48-yr-old man with an old (chronic) bilateral luxation of the temporomandiblar joints was scheduled for bilateral eminoplasty. He had been diagnosed with schizophrenia at the age of 42, and suffered NMS twice during psychotropic drug therapy. Each time he was treated by terminating his psychotropic drugs, hypothermic therapy and administration of bromocriptine mesilate, leading to a recovery from NMS within two to three weeks. He demonstrated involuntary bilateral finger movement, dorsiflexion of soma and retroflexion of the collum, but no hallucination and phantasm preoperatively. The results of laboratory tests were unremarkable. Medication administered to the patient preoperatively was continued until the day of surgery. No other pre-medication was used.
Anesthesia was induced with 100mg of propofol and 8mg of vecuronium bromide to facilitate nasotracheal intubation, and maintained with sevoflurane, nitrous oxide and oxygen. Barbiturates were avoided as an induction agent due to their potentiality in the causation of circulatory depression from drug interactions with psychotropic drugs. Succinylcholine was avoided as a muscle relaxant for possible risk of causing malignant hyperthermia; i. e. a condition similar to that observed in neuroleptic malignant syndrome (NMS). A radial arterial catheter and a subclavian venous catheter were inserted and the direct arterial pressure and central venous pressure were monitored with a standard anesthetic monitor. The anesthetic course was uneventful (SpO₂: 96-98%; rectal temperature: 36.8-37.9°C; heart rate: 70-92 beats/min; systolic blood pressure: 98-115mmHg; diastolic pressure: 55-70mmHg). The record is shown in Figure 1. One mg of atropine sulphate and 2.5mg of vagostigmin were administered after confirmation of spontaneous respiration. The patient was extubated after awakening, which was confirmed by opening of the eyes and movement of the extremities. The amount of blood loss (quantity of bleeding) was 64g, surgical time was 2 hours 38 minutes, and the anesthesia time was 5 hours. After surgery, the blood pressure, heart rate, SpO₂ and body temperature were monitored every four hours for 72 hours.
We were able to manage this patient without complications and occurrence of neuroleptic malignant syndrome (NMS) during the perioperative period.

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