ACROMEGALY By Dr. Sahar Marzouk Prof. Anesthesia Cairo University
OBJECTIVES Definition History Clinical pictures of acromegaly Airway changes in acromegaly Relation between GH level &symptoms Management of acromegaly with difficult AW Anesthetic 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 report Neufeld(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 HF Hypertension 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 laryngoscopic visualisation 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 acromegalic symptoms, 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 thyromental distances 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 Acromegaly Airway: 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