ACROMEGALY

By

Dr. Sahar Marzouk

Prof. Anesthesia Cairo

University

OBJECTIVESDefinitionHistory Clinical pictures of acromegaly Airway changes in acromegaly Relation between GH level &symptomsManagement of acromegaly with difficult AWAnesthetic consideration in acromegaly

Definition

Increase growth hormone production before Epiphyseal plate closure is called Gigantism.

Increase growth hormone production after Epiphyseal plate closure at puberty is called

Acromegaly

The name Acromegaly comes from the Greek words for “extremities”(acro) and”great”(megaly) because one of the most commen symptom of this condition is abnormal growth of the hands and feet.

History

Acromegaly was first described by Marie (1886).

Chapell(1896)first case reportNeufeld(1907)Jackson(1918),Grotting (1950), Siegeler(1952), Bhatia, Misra and Prakash(1966) made association of the disease with changes in voice &with alternations in laryngeal structure and function

Clinical pictures

Face& head:(nose,lip,ears&forhead) becomes broader,larger&swollen. The tongue enlarges, the space between teeth grows,increase facial hairgrowth , headache may occur

Throat:excessive soft tissue growth of the throat&voice box can lead to hoarse of voice or sleep apnea.

Hands&Feets:enlargement occur, often requiring patients to wear larger sized rings, gloves&shoes.overegrowth of soft tissues in wrist can compress nerves of hands leading to tingiling or pain in fingers(carpal tunnel syndrom)

Skins: may thicken, skin tags& sweeting.

Bones: overgrowth of ends of bones damage joints leads to arthritis

Heart: cardiomyopathy with cardiac enlargement leading to congestive HFHypertension occur in 1/3, half of which have increased Lt Vent. Mass or Lt Vent. Wall thickness

Lung:Increase lung volume with V/Q mismatch , impaired respiration also occure

Others :liver &kidney engorged

impaired glucose tolerance as GH is antiinsuline

Airway changes in Acromegaly

• Prognathism• Thickened lips ,macroglossia& large nose• Enlarged larynx (palpitation),congested

mucous membrane• Thickening of epiglottis &aryepiglottic

folds,vocal cords,arytenoid cartilages, ventricular folds and a very small opening between the vocal cords

Special airway concerns• Difficult mask fit ( facial anatomy distortion)• mask ventilation• May be difficult intubation(size of airway)• May require awake FOB• Prone to subglottic stenosis• Increased effort is required to displace the

tonge into the restricted submental space make it harder to align the laryngeal& pharyngeal axis and therfore laryngoscopicvisualisation becomes more difficult

The incidence of Acromegaly is 3-4 patients per million

The incidence of ditticult intubation in

patients with acromegaly is about four to

five times higher than those without acromegaly.

Relation between GH level&symptoms

Growth hormone(GH) levels are not related to the degree of acromegalicsymptoms, but the duration of the disease affects the incidence and severity of symptoms(cardiac, respiratory and airway)

Predictors of difficult intubation• Mallampati III&IV is found to be a

predictor of laryngoscopy grade III & IV.(ansari nagar)2009

• Limitations in head &neck mobility also contribute to DA.

• Increase body weight contribute to DA• Increased thyromental distance was

found in patients with a long duration of disease,however increased thyromentaldistances was not associated with difficult laryngoscopy

Airway Management of Acromegaly

• The safest &ideal Is Awake fiberoptic or preoperative tracheostomy(if difficulties is anticipated)

• The use of supraglottic devices (ILMA)have also tried ( J. neurosurgery anesth. 2004)

• Our first experience in using air-q was successful with blind intubation(3 cases)

Anesthetic consideration in AcromegalyAirway: airway assesment

monitor glucose (insulin resistance because diabetogenic effect of GH) Perioperative insuline therapy in 30% of cases

Titrate muscle relax if history or skeletal muscle weakness(keep on lower range)

Controle of hypertension &manage IHD

TH

A

NK

s

Conclusion:Acromegaly is an endocrine disorder result from

increase growth hormone production after

epiphyseal plate closure

Aiway assessment is life saving in such patients

If difficulties is anticipated ,go for awake FO or

preoperative tracheostomy

Preoperative:Controle Diabetes,hypertension

&IHD•

Intaoperative:Titrate the dose of muscle relaxant

Questions