Patients with malignant and nonmalignant respiratory diseases often suffer from dyspnea during end-of-life care. Terminal suffering of patients with nonmalignant diseases, such as chronic obstructive pulmonary disease, is comparable with or sometimes surpasses the patients with lung cancer.. There are several studies on palliative care for malignant diseases, but very few studies have investigated palliative care for nonmalignant diseases. We focused on the last stage of terminal care and evaluated the status and challenges of palliative care for patients with respiratory diseases at our hospital. We aimed to identify the areas that are lacking in the treatment and palliative care and understand the problems encountered in the patients with malignant and nonmalignant respiratory diseases. We included 90 patients who had died of malignant or nonmalignant respiratory diseases from January 1, 2018, to January 31, 2019 at the Department of Respiratory and Allergy Medicine, Showa University Hospital and compared the actual conditions between the two groups. The number of patients with malignant and nonmalignant diseases was 31 and 59, respectively. We observed that opioids were used significantly less frequently for nonmalignant diseases than for malignant diseases. Furthermore, rehabilitation was performed significantly less frequently in patients with malignant diseases. Although end-of-life care for malignant and nonmalignant diseases differs in many aspects, the results suggest an overlap in terms of opioid administration and rehabilitation. Thus, additional interventions should be considered. During end-of-life care, irrespective of whether the disease is malignant or nonmalignant, it is necessary to determine whether adequate palliative care interventions are provided.

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We present three cases diagnosed with central vertigo following referrals from other departments with suspected peripheral vertigo. The first case included a 33-year-old man who visited the emergency department due to severe vertigo, nausea, and neck pain the day before. The computed tomography （CT） scans revealed no abnormalities. The patient was referred to the otorhinolaryngology department on suspicion of benign paroxysmal positional vertigo （BPPV）. However, a vertical nystagmus was observed and the magnetic resonance imaging （MRI） scan of the head led to the diagnosis of Wallenberg syndrome. The second case included a 46-year-old woman who visited the gastroenterology department complaining of dizziness and hiccups following the treatment for acute gastroenteritis. The patient was referred to the otorhinolaryngology department on suspicion of Meniere’s disease, but vertical nystagmus and dysphagia were observed and the MRI scan of the head revealed brainstem inflammation, leading to the diagnosis of neuromyelitis optica at the neurology department. The third case included a 55-year-old woman undergoing chemotherapy for breast cancer who visited the breast oncology department owing to the onset of vertigo and headache during treatment. She was referred to the otorhinolaryngology department on suspicion of BPPV, but a CT scan of the head revealed breast cancer metastasis to the brain. The different imaging techniques were useful for the diagnosis in all three cases.

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Ossifying fibroma （OF） is a benign tumor composed of fibrous connective tissue with cementum and bone-like tissue formation. Juvenile OF （JOF） is a rare, rapidly growing OF that occurs in patients aged＜15 years. We present a case of maxillary large JOF in a 12-year-old Japanese boy who presented with worsening gum swelling in the left maxillary canine region. After his initial visit to our hospital, the painless swelling extended to his right cheek and buccal and palatal gingiva, reaching the maxillary first premolar and maxillary central incisor. Panoramic X-ray imaging and computed tomography revealed a well-circumscribed radiolucent mass with irregularly structured hard tissue scattered internally from the right maxillary first molar to the left maxillary canine. He was diagnosed with a benign maxillary tumor and underwent surgical enucleation and curettage. Histopathologically, the lesion primarily comprised fibrous tissue with intricate thick collagen bundles and contained scattered cement-like calcified pellets and small clusters of bone-like calcified material, which led to the diagnosis of OF. The final diagnosis was JOF, and the tumor grew rapidly. No signs of recurrence were noted 2 years after the surgery. Given the high recurrence rate of this tumor, careful follow-up was continued.

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Lymph nodes are considered a rare site for endometriosis. Its involvement in endometriosis is frequent in the pelvic lymph nodes, where it is largely associated with deep pelvic endometriosis. Herein, we report a case of para-aortic lymph node endometriosis without deep-pelvic endometriosis. A 44-year-old patient was referred to our department because of anemia due to excessive menstruation. A magnetic resonance imaging scan revealed adenomyosis and a uterine myoma of 8.7cm, with a mildly high signal on diffusion-weighted imaging and a partially low signal on the ADCmap. Therefore, malignancy could not be ruled out. Contrast-enhanced computerized tomography was performed for a systemic search, which revealed multiple pulmonary artery thrombi, left inferior vein thrombi, and a cystic right para-aortic lymph node with a size of 12×25mm. Total abdominal hysterectomy, bilateral oophorectomy, and biopsy of the right para-aortic lymph node were performed after anticoagulation therapy and inferior vena cava filter placement. Intraoperative findings revealed no pelvic or abdominal cavity endometriotic lesions. Postoperative pathology revealed uterine myoma and adenomyosis with no malignant findings. The enlarged lymph nodes have endometriotic lesions. Endometriosis can develop in isolated lymph nodes, as endometrial cells can appear in extra-pelvic organs via lymphatic and blood vessels. This case was incidentally discovered when cystic enlargement of lymph node lesions is observed, but lymph node endometriosis should be considered in addition to lymph node metastasis due to malignant disease.

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Dentigerous cysts are relatively common odontogenic cysts that typically occur in the mandibular wisdom teeth and maxillary canines but rarely attach to the orbital floor. Herein, we report a case of a dentigerous cyst that filled the maxillary sinus and was attached to the orbital floor in a 25-year-old woman. The patient’s initial visit was scheduled for extraction of the left mandibular wisdom tooth. Panoramic radiographic examination revealed impaction of both the left mandibular and maxillary wisdom teeth, with the latter being located in the maxillary sinus. Computed tomography showed a 34×32×21mm opaque lesion extending from the maxillary sinus floor to the orbital floor, including the impacted wisdom tooth. The patient underwent impacted wisdom tooth extraction and jawbone cystectomy under general anesthesia, with a clinical diagnosis of impacted wisdom teeth in the left upper and lower jaw and a left mandibular tooth bearing a cyst. Histopathological analysis confirmed the diagnosis of a dentigerous cyst. The patient experienced an uneventful postoperative course in the oral and ophthalmologic regions.

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