Background: Video-assisted thoracic (VAT) sympathectomy is used for patients with hyperhidrosis refractory to medical treatment1. Bronchial blockers (BB) are one of the main choices for achieving one lung ventilation (OLV).
Case report: A 43 years old female with severe axillary-palmar hyperhidrosis was scheduled for VAT sympathectomy. In the preanesthesia visit she asked not to be intubated because she worked as a radio-tv host and was afraid of suffering laryngeal injury.
One-lung ventilation was achieved using the I-gel mask and the EZ BB in order to avoid intubation. After confirming proper ventilation through the I-gel, the EZ BB was inserted through it with the aid of a 6.5 mm endotracheal tube (ETT), as both legs of the blocker must be kept together before passing the vocal cords so as not to damage them.The bevel of the ETT was left just above the vocal cords and the EZ BB was then passed through them under fiberoptic view. Finally, the ETT was removed and the blocker was properly placed over the carina. Peak pressures did not exceed 25 cmH2O during surgery and no air leakages were observed. The patient did not suffer any airway injury.
Discussion: Although the use of supraglottic devices can cause airway injuries, laryngeal morbidity has been more frequently related to endotracheal intubation2. Direct laryngoscopy, which is not needed for supraglottic device insertion, can also damage the airway. In addition, postoperative hoarseness, sore throat and vocal cords lesions occur more frequently with double lumen tubes than with BB3. 
References: 
1.Milanez de Campos JR, et al. Video-Assisted Thoracic Sympathectomy for Hyperhidrosis. Thorac Surg Clin.2016 Aug;26(3):347-58. 
2.Saeki H, et al. [Postoperative sore throat and intracuff pressure: comparison among endotracheal intubation, laryngeal mask airway and cuffed oropharyngeal airway]. Masui. 1999 Dec;48(12):1328-31.
3.Knoll H, et al.Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology. 2006 Sep;105(3):471-7.
Learning points: Video-thoracic sympathectomy may be performed with the I-gel and the EZ BB, which is a technique that has not been reported so far. Patients who are afraid of suffering laryngeal damage secondary to endotracheal intubation may benefit from the use of supraglottic devices and BB instead of double lumen tubes, depending on the surgery and the clinical situation.

Use of the Ez-blocker through the I-gel airway device for video thoracic sympathectomy