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Branchial cysts are relatively rare lesions with lymphoid tissue in the underlying epithelium of the cyst wall. The present study describes the case of a branchial cyst with keratinization and calcification that occurred in the right submandibular region, along with a review of the literature. A 49-year-old female patient presented with a complaint of swelling in the right submandibular region. Computed tomography revealed a well-defined, cystic lesion located anterior to the sternocleidomastoid muscle, outside the hyoid bone, and in front of the submandibular gland. The cystic cavity presented an opaque image suggestive of calcification. Magnetic resonance imaging showed high-intensity lesions on both T2-weighted and short-τ inversion recovery images on the anterior margin of the right sternocleidomastoid muscle, just below the platysma muscle, with a clear demarcation from the surrounding tissue, and posterior compression and flattening of the submandibular gland. Cystectomy was performed under general anesthesia, and histopathological examination confirmed the diagnosis of branchial cyst with keratinized and calcified substances. The patient recovered well and had no complications or recurrence at ~2-year follow-up. This case highlights the rare occurrence of a branchial cyst containing calcification in the cystic cavity and provides a literature review of the factors contributing to the calcification.

Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that causes a deficiency in or dysfunction of C1 esterase inhibitor (C1-INH). HAE attacks are caused by trauma, drugs, infection, or mental stress. Dental procedures in patients with HAE can trigger fatal laryngeal edema. We herein report a female patient with HAE who required tooth extraction. A 58-year-old Japanese woman was referred to our hospital for dental caries. Maxillary teeth contained residual roots that could not be preserved, and mandibular teeth had poor plaque control and progressive periodontal disease. Therefore, consent was obtained from the patient to create dentures after extraction of all remaining teeth. The patient had recurrent edema since she was approximately 20 years old. She was diagnosed with HAE due to C1-INH deficiency at our hospital. She had an HAE attack of the tongue and laryngeal edema and underwent emergency tracheotomy. Subsequently, she had repeated edema of the tongue and lips several times a month. She had edema following tooth extraction. She was referred to our hospital and her condition improved by intravenous administration of C1-INH. C1-INH and tranexamic acid were prophylactically administered 1 h preoperatively. Anesthesia was induced with intermittent infusion of midazolam and continuous infusion of dexmedetomidine. Local anesthesia was provided using 3% propitocaine with felypressin. The patient was transferred to the intensive care unit for further observation. There was no postoperative complication. She was discharged after 3 days. No other HAE complications occurred during the perioperative period, and perioperative management went well.

Phrenic nerve paralysis is a rare complication after radical neck dissection. Here, we describe our experience of a case of transient phrenic paralysis due to invasion by a nerve stimulation device. A 41-year-old woman underwent bilateral radical neck dissection for cervical lymph node metastasis of tongue squamous cell carcinoma. Right radical neck dissection and left supraomohyoid neck dissection were performed under general anesthesia. Postoperative chest X-ray showed prominent elevation of the right diaphragm and positive silhouette sign. Based on these findings, we diagnosed the patient with phrenic nerve paralysis and atelectasis. Because she was hemodynamically stable and phrenic nerve paralysis was unilateral, the decline in respiratory function seemed to be mild. However, the possibility of exacerbation of atelectasis was not excluded because her oxygen saturation decreased frequently even with oxygenation and she was obese （body mass index: 35, height: 154cm, weight: 83kg）. Therefore, we decided to implement continuous positive airway pressure in the intensive care unit. On the 8th postoperative day, elevation of the diaphragm was not observed on chest X-ray. The patient was discharged without recurrence of phrenic nerve paralysis after receiving radiation therapy and chemotherapy. Clinicians should carefully consider use of a nerve stimulation device due to the potential risk of paralysis caused by the device, even when used to protect the phrenic nerve during surgery.