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+A 30-year-old female (65 kg) underwent rhinoplasty under general anaesthesia, which was induced using a combination of a bolus of Remifentanyl (0.5 μg/kg) and Propofol 2 mg/kg.
+Muscle paralysis was obtained with Cisatracurium (0.15 μg/kg).
+Transoral intubation was performed with a Macintosh blade (No.3) and a size 7 mm diameter reinforced tracheal tube was easily and gently placed in the trachea, on the first attempt and was then fixed to the right corner of the mouth.
+No problems were encountered during laryngoscopy and intubation.
+The cuff of the tube was inflated with a pressure ≤ 20 cm H2O.
+No adjustment of cuff volume was made intra-operatively.
+N2O was not used for inhalation anaesthesia.
+The throat pack was placed in the pharynx to avoid the passage of blood in the aero-digestive tract.
+General anaesthesia was maintained with Sevofluorane in oxygen/air and Remifentanyl in continuous infusion 0.25 μg/kg/min.
+Moderate arterial hypotension was maintained with a cuff systolic artery pressure of approximately 90 mmHg.
+The operation was carried out in a semi-supine position with the head slightly inclined forward and laterally and trunk slightly elevated.
+Duration of the operation was 100 minutes.
+The patient was extubated, after removal of the throat pack without problems.
+The following day the patient complained of difficulty in swallowing, dysphonia and hoarseness.
+Examination revealed deviation of the tongue to the right side and vocal cord paralysis, expression of hypoglossal and recurrent laryngeal nerve injury without local oedema or haematoma.
+The movements of the pharynx and soft palate were normal.
+Meticulous neurological examination, including also magnetic resonance imaging (MRN) revealed no other evidence of central or cranial nerve involvement.
+Conservative management included steroids, vitamins together with speech and swallowing therapy.
+Full recovery of lingual and laryngeal functions was obtained within four months after surgery.