Fish bones can often get stuck in the tonsil or the root of the tongue, but rarely penetrate into the lingual tissue, and intraoperative identification of the location of the foreign body under general anesthesia can be quite difficult. In the present study, we experienced a case in which a fishbone penetrated into the tongue and was removed under general anesthesia by multiple needle punctures and intraoperative CT imaging.

A 73-year-old man ingested boiled fish at a drinking party and visited the otorhinolaryngology clinic seven days later because of persistent discomfort when swallowing. A CT scan showed a 1-centimetre linear hyperabsorptive area on the left side of the root of the tongue and a stuck fish bone was suspected. Intraoperative ultrasonography under general anaesthesia was used to confirm the location of the foreign body, but after the incision, it became difficult to identify the location. For survey, six needles were inserted into the tongue and intraoperative CT was performed. The fishbone foreign body was identified between the second and third needles posterior on the caudal side of the incision line. After removal of the other needles, the fish bone was identified and removed through a further incision in the lingual muscle layer using the needles as an indicator. We believe this approach is useful in cases in which intraoperative identification is difficult.

Traumatic facial nerve palsy generally has a good prognosis with conservative treatment alone. However, there are some cases in which paralysis is unexpectedly prolonged once decompression surgery has been ruled inadvisable, making it difficult to decide whether to perform surgery or not. Immediate and severe onset, with an electroneuronography (ENoG) value of less than 10%, is considered an absolute indication for decompression. In the present study, we describe a case of immediate traumatic facial nerve palsy in which decompression surgery with facial nerve monitoring was performed and a good prognosis was obtained. The patient was a 61-year-old male. Immediately after head injury, facial nerve palsy with a facial nerve paralysis score of 0 was observed, and CT image showed a fracture line extending into the fallopian canal. The ENoG value was 55%, 11 days after the injury, and conservative treatment was continued. However, the paralysis did not improve, and the ENoG value gradually worsened. During the surgery, facial nerve monitoring showed a response after removal of the bone fragments pressing on the facial nerve sheath, and it was judged that sufficient decompression had been achieved. At 1 year postoperatively, the patient’s facial nerve paralysis score has improved to 36 points. In traumatic facial nerve palsy, when paralysis does not improve, repeated ENoG should be performed and the need for decompression should be considered on an ongoing basis.

Methotrexate (MTX) is the main pharmacologic treatment for rheumatoid arthritis (RA). Some side-effects of MTX have been reported, such as myelopathy, interstitial pneumonia and compromised immunity. MTX-associated lymphoproliferative disorders (MTX-LPD) have been gradually reported over the past several decades. Herein, we report a case of a 70-year-old woman with RA who was treated with MTX and complained of left ear fullness. At her first visit to our hospital, otitis media with effusion (OME) was observed in her left ear, but no tumorous lesion was evident in the nasopharynx. After conservative treatment for one month, the OME was cured. However, five months later, the patient again returned with left OME and a nasopharyngeal tumor was detected. A biopsy was performed and the histopathological findings and the medical history of MTX led to the diagnosis of MTX-LPD. Six weeks after the discontinuation of treatment of the MTX, the MTX-LPD began to reduce and was diminished at nine weeks. MTX-LPD can be recurrent, and sites of extranodal involvement can occur. It is necessary to observe the nasopharynx of patients with OME during their first visit. Even if no tumorous lesion is observed in the nasopharynx, it is also important to repeatedly observe the nasopharynx of patients with recurrent OME.