A 37-year-old man underwent extraction of bilateral impacted lower third molars under general anesthesia. Two hours after the operation, his right cheek suddenly became swollen after nose-blowing. We recognized rapid swelling from the right cheek to the angle of the mandible and submandibular area and crepitus on palpation over the submandibular area. We diagnosed it as subcutaneous emphysema and administered an intravenous antibiotic. CT analysis on the next day revealed subcutaneous emphysema bilaterally, and the right side one in particular extended to the mediastinum. The air compressed by nose-blowing might have entered the subcutaneous tissue via a bone defect in the extraction socket. After one week, the emphysema had nearly disappeared. We confirmed the complete disappearance after 3 weeks on CT. The main cause of emphysema after extraction of the mandibular third molars is the use of an air-turbine handpiece. However, even when not using an air-turbine handpiece, we should perform treatment with care to avoid emphysema.

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(こうび, 鼻かみ) 後に生じた稀な外リンパ瘻の2症例を経験した. 外リンパ瘻とは, 急激な中耳圧の上昇によってアブミ骨が外れ, 外リンパが中耳に漏出する病態である. 変動する難聴が主訴の1症例はCoclin-tomoprotein (CTP) 検査が陽性で, 手術前に診断が確定し, 早期の鼓室形成術によって聴力は回復した. 激しいめまいと難聴の症例は, 内耳に空気塞栓を認め, 大量の外リンパ漏出による内耳障害は高度で, 鼓室形成術を施行するも診断の遅れのために聴力は回復しなかった. 術中のCTP検査は陰性で, すでに外リンパは枯渇するほど漏出したと推察した. CTP検査は外リンパ瘻の診断に有用だが, 検査のタイミングによって, 結果を解釈する必要があった. 外リンパ瘻は早期に診断して手術すれば回復する疾患なので, 迅速診断法の確立と, 疾患概念の医療関係者への周知が望まれる.

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両側口蓋扁桃摘出術後に、頻回の

により頸部皮下気腫、縦郭気腫を来した症例を経験した。43 歳、女性、胸肋鎖骨過形成症、掌蹠膿疱症の既往があり、口蓋扁桃摘出術を希望して当科へ紹介となった。両側口蓋扁桃摘出術を施行し、手術は問題なく終了したが、術後から鼻閉・鼻汁の訴えがあり、頻回なを行った後から呼吸苦を訴えた。触診で頸部、腋窩、前胸部の握雪感を認め、CT では頸部間隙や前胸部、縦隔全体に広がる気腫像を認めた。縦隔気腫、皮下気腫の原因と思われたを禁止し、安静によって気腫が増悪することなく良好な経過を得た。

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皮下および縦隔気腫は口腔および顎顔面領域の手術において関連する重要な合併症である．今回，われわれは皮下・縦隔気腫の1例を経験したので，文献的考察を加えて報告する．

患者は52歳の男性で，口腔癌の根治的治療のため全身麻酔下で外科手術（外科的気管切開術，オトガイ下および両側顎下部郭清術，および口底悪性腫瘍切除術）を施行した．手術から4日後，患者の気管チューブを抜去し，手術から6日目に患者が激しい咳をしたために頬部および頸部から胸壁に及ぶ巨大な皮下気腫を発症した．その後，CT検査を行い頸部および胸部におよぶ，縦隔気腫を確認した．

抗菌薬の継続投与を行い，保存的に治療を行った．手術から12日後，気腫の増大等の異常所見は観察されず，全身の健康状態および創部の治癒経過は良好であったため，術後3週間後に退院した．

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Although orbital emphysema is a relatively rare condition, intra-orbital emphysema most often develops after maxillofacial injuries, such as an orbital blowout fracture; orbital emphysema is rarely caused by conditions other than trauma. We report a case in which sneezing was thought to have caused orbital emphysema and fracture of the medial wall of the orbit, in the absence of any history of trauma or sinus surgery.

A 25-year-old female patient visited a neighborhood ophthalmologist with a swollen eye after a bout of sneezing, and examination revealed swelling and emphysema of the eyelids, and the patient was referred by the ophthalmologist to our hospital for further management.

Examination at our hospital revealed swelling of the right upper and lower eyelids and a snow-grasping sense and mild tenderness on palpation. No abnormalities were found in the nasal cavity, except for pallor of the inferior turbinate. There was no diplopia, restriction of eye movements, or decrease of the visual acuity. Computed tomography of the orbit and sinuses revealed extensive emphysema under the right upper and lower eyelids, and the posterior end of the emphysema reached the posterior part of the eyeball. In addition, a blowout fracture of the medial wall of the orbit toward the ethmoid sinus was observed. The patient was instructed not to block the nose while sneezing, and prescribed an antibacterial drug for follow-up. After 1 week, the eyelids and orbital emphysema disappeared. No recurrence was observed until the last follow-up at 2 years after the event.

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アレサガ_®テープは第2世代抗ヒスタミン薬であるエメダスチンフマル酸塩を有効成分とする世界初の経皮吸収型アレルギー性鼻炎治療剤である．エメダスチンフマル酸塩は強力な抗ヒスタミン作用に加えて，ケミカルメディエーター遊離抑制作用，好酸球遊走抑制作用によりアレルギー性鼻炎の症状を改善すると考えられている．ラットヒスタミン誘発血管透過性亢進モデルを用いた薬効評価において，本剤は用量依存的な抗ヒスタミン作用を示し，その作用は投与後24時間まで持続していた．季節性アレルギー性鼻炎を有する患者を対象とした薬物動態試験において，本剤は1日1回の投与で，投与7回目までに定常状態に達した．季節性アレルギー性鼻炎患者を対象とした第Ⅲ相比較試験において，本剤は鼻症状（くしゃみ発作，鼻汁及び鼻閉）に対して有効性を示し，1日を通して効果が持続した．通年性アレルギー性鼻炎患者を対象とした長期投与試験において，安全性に問題は認められず，投与期間を通して長期にわたり血中薬物濃度が維持され，効果の減弱は認められなかった．以上のことから，アレサガ_®テープはアレルギー性鼻炎治療の新たな選択肢を提供できると考えられる．

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We report a case of subcutaneous and mediastinal emphysema due to laceration of the pharyngeal mucosa with an endotracheal tube.

　The patient was an 82-year-old man who underwent a sequestrectomy for left mandibular osteomyelitis. There were no problems in the course up to the second postoperative day, however on the third postoperative day, subcutaneous/mediastinal emphysema appeared in the neck. An X-ray and CT scan showed extensive subcutaneous/mediastinal emphysema. Laceration on the right posterior nasopharyngeal wall was confirmed by optical fiber scope. An antibiotic was administered prophylactically and the patient was followed up. There was no sign of infection, and the subcutaneous emphysema improved. Oral ingestion was started on the fifth day after surgery, and the patient was discharged on the thirteenth day after surgery. The patient had a strong nasal obstruction sensation after surgery, and he frequently blew his nose. It was presumed that during nose blowing air entered from the laceration of the posterior nasapharyngeal wall and caused subcutaneous emphysema and mediastinal emphysema. Emphysema can cause severe dyspnea and mediastinitis, therefore it is important to be prepared for an emergency response.

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鼻腔に壊死をきたす原因は鼻性NK/T細胞リンパ腫，多発性血管炎性肉芽腫症，白血病，感染症，薬物など多岐にわたる。今回我々はAspergillusの感染により鼻中隔壊死をきたした1例を経験したので報告する。症例は78歳，女性。骨髄異形成症候群にて当院血液内科に通院中であった。発熱をきたしたため血液内科に入院。骨髄検査で骨髄異形成症候群から低形成骨髄性白血病への移行が認められ，化学療法が開始となった。発熱が持続するため熱源の精査目的に当科紹介となった。初診時，鼻中隔左側に痂皮の付着が認められた。CTでは両側上顎洞に石灰化や骨破壊を伴わない軟部陰影を認め，MRI-T2強調画像で左上顎洞の陰影が低信号であったことから真菌の存在が疑われた。血小板低下が認められており，痂疲の除去に伴う出血のリスクを考慮し保存的な治療を行っていたが，両側鼻中隔に痂皮が認められるようになり組織生検を行ったところ，壊死組織にAspergillusが認められ，壊死周囲の粘膜には腫瘍細胞，真菌の侵入は認められなかった。Aspergillusの感染による鼻中隔の壊死を疑ったが，白血病細胞の浸潤などの可能性を否定できなかったため，十分な量の組織生検，壊死組織除去，左上顎洞病変の診断治療目的に全身麻酔下に手術を行った。鼻中隔の組織には腫瘍細胞を認めず，Aspergillusの浸潤を認め，Aspergillus感染による壊死と考えられた。上顎洞内には乾酪様の貯留物を認めたが，病理検査では真菌は認めなかった。

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High-energy trauma often results in multiple maxillofacial fractures and intracranial injuries, and may be accompanied by cerebrospinal fluid （CSF） leaks and pneumocephalus. We report a case of tension pneumocephalus that developed two months after surgery for multiple maxillofacial fractures. The patient was a 67-year-old man who was injured when he collided with a car while riding a bicycle. The patient had an anterior skull base fracture including a frontal bone fracture, and maxillofacial fractures. He showed cerebral contusion, subdural hematoma, and pneumocephalus without CSF leakage. Open reduction and internal fixation were performed after 10 days of bed rest. The postoperative course was uneventful and he was transferred to another hospital for rehabilitation. However, 2 months after the injury, he developed tension pneumocephalus. Emergency operation was performed to repair the CSF leakage and the prognosis was good. In the case of anterior skull base fractures associated with cerebral contusions, close consultation with relevant departments, appropriate treatment, and careful postoperative management and follow-up are important.

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鼻中隔膿瘍は日常臨床で遭遇することは少ないが，鞍鼻や頭蓋内合併症などを来さないよう適切な対応が求められる。今回我々は，稀な真菌性鼻中隔膿瘍の1例を経験したので報告する。

症例は89歳男性。発熱，鼻根部痛にて前医を受診し急性副鼻腔炎の診断で入院，抗菌薬治療を受けたが改善せず，当科を紹介受診した。鼻背は腫脹し圧痛を認め，鼻中隔は高度に発赤腫脹していた。副鼻腔CTでは鼻中隔前方の腫脹と左上顎洞に石灰化を伴う軟部陰影を認め，右副鼻腔は全て陰影を認めた。鼻中隔穿刺にて膿が吸引され鼻中隔膿瘍と診断し，切開排膿・ドレーン留置と抗菌薬投与を行ったが改善に乏しく，膿からの糸状菌検出と血清β-Dグルカン上昇から真菌性鼻中隔膿瘍と診断しVRCZの投与を開始した。副鼻腔病変の関与を疑い両ESSと鼻中隔の生検を施行した。両上顎洞内に認めた乾酪様物質は病理学的にAspergillusの菌塊と診断され，鼻中隔軟骨に真菌浸潤を認めた。後日，鼻中隔の膿培養からAspergillus fumigatusが同定された。症状軽快にて第26病日退院となったが鞍鼻は残存した。6ヶ月間VRCZ投与を行い，治療終了後も再燃は認めていない。

真菌性鼻中隔膿瘍は易感染性宿主や糖尿病合併例，副鼻腔真菌症合併例がリスクといえる。これらの背景を持つ鼻中隔膿瘍患者では，真菌も原因微生物として当初から鑑別に挙げて対応することが必要である。

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We encountered a case of sudden hearing loss in a 4-year old boy. The patient was brought to the hospital with a history of having developed tinnitus and vertigo simultaneously. He could not walk due to the severe vertigo. We detected acute sensorineural hearing loss of his right ear, and horizontal and rotatory nystagmus. Hematological examination, CT of the temporal bone and MRI of the brain revealed no abnormalities. Consequently, we diagnosed the case as a case of idiopathic sudden hearing loss. We administered prednisolone for seven days, which led to improvement of the vertigo, but not of the hearing loss.

Sudden hearing loss in childhood is often accompanied by vertigo, as compared to sudden hearing loss in adulthood. However, the prognosis of sudden hearing loss is similar in adults and in children.

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In recent years, reports of subcutaneous and mediastinal emphysema resulting from the use of dental lasers have increased. This paper reports a case of mediastinal emphysema caused by CO₂ laser irradiation. The patient was a 76-year-old man who underwent CO₂ laser irradiation to treat a gingival abscess between the upper right canine and the first premolar at a dental clinic. During the treatment, his right cheek and right eyelid suddenly became swollen. Subsequently, the swelling spread from the right submandibular region to the neck and he was referred to our hospital. A CT examination revealed subcutaneous emphysema from the right temporal region to the bilateral cervical region, as well as mediastinal emphysema extending to the aortic arch. The patient was hospitalized and received anti-inflammatory therapy. The emphysema had nearly disappeared by the 7th day, and he was discharged on the 8th day. We need to recognize the possibility of mediastinal emphysema caused by CO₂ laser irradiation and to know how to treat it appropriately.

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Recently there have been cases of vertigo patients with Superior Semicircular Canal Dehiscence Syndrome. In this present report, we describe a 40 y.o. female patient with vertigo after nose-blowing. Although a vertigo patient with nose-blowing is often diagnosed as having a perilymph fistula, our patient was diagnosed as having left Superior Semicircular Canal Dehiscence Syndrome by interview, clinical course findings and CT findings. She did not suffer hearing loss, tinnitus nor any abnormality in the electric nystamography test. The eustachian tube function test revealed the stenosed type. Advice to be careful when blowing her nose helped her vertigo disappear especially as she did not wish to have any operative procedures.

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This article reports on subcutaneous emphysema with extensive bleeding caused by root canal therapy of a left maxillary first molar. A woman in her 60s visited the otolaryngology department of our hospital for treatment of maxillary sinusitis but was transferred to our department and underwent root canal treatment of the left maxillary first molar because of dental focal infection.
After washing by H₂O₂ and NaClO, she claimed a sense of incongruity of the left gena. She suffered sudden swelling of the left buccal region afterwards. Left gena subcutaneous emphysema and extensive bleeding were found by CT. She was hospitalized for follow-up because of intense pain and trismus. She suffered dyspnea after hospitalization and was given a steroid dosage, which immediately improved the dyspnea.
It is important to recognize that serious symptoms can be accidentally caused by root canal treatment, to consider ways to prevent occurrence, and to devise a counterplan in case of occurrence.

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症例は77歳，男性．肺気腫合併あり．左上葉肺癌に対して胸腔鏡下左上葉切除を施行した．術後3病日，胸腔ドレーンのクランプテスト中に急激な皮下気腫の拡大を認めた．CT検査では残下葉S6に5.5 cm大の肺気瘤の形成を認め，エアリークが持続したため術後7病日に再手術を施行した．残下葉S8に著明なエアリークを伴う肺裂傷を認め修復を行ったが，肺気瘤からのエアリークはなく処置は行わなかった．再手術後の経過は良好で，肺気瘤は縮小傾向を認めた．術後補助化学療法を開始後，X線検査で左横隔膜上に9.5 cm大の肺気瘤の新出を認めた．一時的に血痰を伴ったが軽快し，以降化学療法は中止として経過観察の方針とした．術後1年時点で肺癌の再発はなく，いずれの肺気瘤も自然経過で消退を認めた．術後肺気瘤は非常に稀であり治療方針は定まっていないが，保存加療で治癒が得られる可能性が示唆された．

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We report a case of mediastinal emphysema and pneumothorax following intraoral vertical ramus and Le Fort I osteotomies. A 19-year-old man was presented at our hospital with anterior cross-bite. We diagnosed open bite, retromaxillism and skeletal class III malocclusion and, following preoperative orthodontics, he was admitted for surgery in March 2011. Intraoral vertical ramus and Le Fort I osteotomies were performed under general anesthesia. However, bilateral nasal obstruction and labored breathing appeared after the operation. Moreover, he felt something wrong in the precordium and neck on the day following the operation. He had difficulty in breathing and fine crackle was heard in the supraclavicular space and sternum region on postoperative day five. Lucencies were acknowledged by computed tomographic scanning in the right pterygomandibular space, both sides of the prestyloid and retrostyloid parapharyngeal space, retropharyngeal space, anterior tracheal wall, upper mediastinal space, and left thoracic cavity. The lower lobe of the left lung had shrunk. He was diagnosed with subcutaneous emphysema from the neck to the mediastinum, and left pneumothorax. His breathing normalized after removal of the surgical splint. Twelve days after onset a chest X-ray showed his mediastinal emphysema and pneumothorax had improved, and he was discharged on postoperative day 14.

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A case of subcutaneous emphysema of the face and neck region caused by nose blowing after Le Fort I osteotomy is reported.
A 28-year-old woman presented at our hospital because of masticatory and esthetic impairment. She was given a diagnosis of open bite retrognathia. After preoperative orthodontic treatment, Le Fort I osteotomy and bilateral sagittal split ramus osteotomy were performed. After she strongly blew her nose on the second postoperative day,swelling of the left lower eyelid with difficulty in eye opening occurred.
A computed tomographic （CT） scan revealed low-density areas in the subcutaneous tissue of the face to the anterior neck region, and a diagnosis of subcutaneous emphysema was made.
She was given antibiotics for 8 days to prevent infection. Her clinical course improved, and a CT scan obtained on the 8th day showed no free air remaining in the head and neck region.
We believe that the medical personnel should be fully aware of the risk of subcutaneous emphysema following Le Fort I osteotomy. Patients should be explained the reason why certain actions should be avoided to minimize complications.

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Emphysema is the abnormal introduction of gas in body tissues, and emphysema in the stomatognathic region is caused by various factors such as dental treatment, head and neck surgery, and trauma. In the dental field, instruments such as handpieces and air syringes have been reported as the main causes of emphysema. The characteristic symptoms are marked swelling and crepitus on palpation. A computed tomographic scan demonstrates low-density areas in the subcutaneous tissues. To prevent infection, it is necessary to give antibiotics.
We report four cases of emphysema related to CO2 laser, trauma, sneezing, and straining, presenting in the stomatognathic region. In conclusion, all patients were given antibiotics to prevent infection, which improved the emphysema without any complications. It is important to recognize the various causes of emphysema and to treat it appropriately.

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