Background: Tympanomastoidectomy with facial nerve monitoring usually impairs muscle relaxants’ use. Airway hyperresponsiveness is common while manipulating a smoker’s airway, particularly during endotracheal intubation.(1) Increasing the depth of anesthesia as well as blunting airway reflexes may be useful in these cases.(1) 
Case report: 59 year-old woman with heavy smoking habits was admitted for tympanomastoidectomy. She was submitted to surgery under total intravenous anesthesia, using ASA standard monitoring, capnography, BIS and facial nerve monitoring. Remifentanil and propofol perfusions were used for induction. We did not use muscle relaxant and after intubation the patient presented upper airway hyperresponsiveness although pulmonary auscultation remained normal. We used high rates of propofol and remifentanil perfusions and added sevoflurane. Though the deepen anesthesia, the hyperactivity remained, even without exogenous stimuli. After discussion with the ENT surgeons, we decided to perform a bilateral block of the internal branch of the superior laryngeal nerve, associated with transcricoid infiltration, with lidocaine. The upper airway blocks were effective, without complications. The procedure lasted 6 hours and the patient was extubated without incidents. At 15th post-operative day the patient is still hospitalized due to a resolved liquor fistula and an ongoing bullous dermatitis and mucositis caused by antibiotic therapy.
Discussion: The potent reflex to airway’s stimulation can be attenuated by upper airway nerve blocks.(2) The described blocks are usually performed in awake/anesthetized laryngoscopy, awake fiberoptic bronchoscopy and as an adjuvant to general anesthesia to facilitate intubation without muscle relaxant.(2) They attenuate catecholamine release and hemodynamic response to airway’s manipulation, with lower incidence of cough and bulking, providing significant analgesia(2). Aspiration is not a concern because swallowing reflex is preserved. (2) 
Learning points: Upper airway blocks are useful in laryngoscopy, awake fiberoptic bronchoscopy and intubation without muscle relaxation and should be performed by skilled professionals.
References: 
1- Duggappa et al. Anaesthesia for patient with chronic obstructive pulmonary disease. Indian Journal of Anaesthesia. 2015; 59. 
2- Ahmed et al. Superior laryngeal nerve block as an adjuvant to General Anesthesia during endoscopic laryngeal surgeries. Egyptian Journal of Anaesthesia. 2015; 31.

Refractory airway hyperresponsiveness controlled with upper airway blocks during general anesthesia – a case report