Questions
- 1.
- 2.
What symptoms are typical of acromegaly?
- 3.
- 4.
What are the anesthetic considerations for patients with acromegaly?
- 5.
Describe the airway management concerns for patients with acromegaly.
- 6.
What structures lie within the transsphenoidal surgical field?
- 7.
- 8.
What are the postoperative concerns for patients with acromegaly?
A 44-year-old man with marked features of acromegaly presents for transsphenoidal hypophysectomy. The patient reports increasing shoe size, glove size, and worsening sleep apnea. Magnetic resonance imaging revealed a pituitary mass. Laboratory findings are within normal limits with the exception of serum glucose, which is 170 mg/dL. The patient does not have any allergies and does not take medications at home. Past surgical history includes carpal tunnel release bilaterally. He denies other medical problems.
1
What is acromegaly?
Acromegaly was previously considered a rare disease. However, more recent European studies and improved screening suggest that clinically significant pituitary adenomas occur in 1 per 1064 people. Growth hormone (GH)–secreting tumors of the pituitary constitute at least 10% of benign pituitary tumors. The pituitary gland is anatomically and functionally separated into the anterior pituitary (adenohypophysis) and posterior pituitary (neurohypophysis). In children, GH-secreting tumors cause gigantism; acromegaly occurs in adults whose epiphyses have fused. Acromegaly is most common in patients 20–60 years old, with equal distribution between the genders. The diagnosis is generally made 10–15 years after the onset of pathologic GH secretion. There is a twofold to fourfold increase in mortality versus the general population. If untreated, 50% of patients with acromegaly die before age 50 years. The most common cause of death is cardiac and may be the result of hypertension, coronary artery disease, compensatory hypertrophy as a result of generalized somatomegaly, or the direct effects of GH on the heart.
Acromegaly results from excess secretion of GH and subsequent elevation of circulating and locally produced insulin-like growth factor I (IGF-I). GH and IGF-I levels are controlled via several interactions rather than stimulating growth directly. GH induces the release of IGF-I, which promotes DNA, RNA, and protein synthesis as well as cell and tissue growth.
2
What symptoms are typical of acromegaly?
The structural changes of acromegaly cause chronic pain and discomfort. These symptoms reduce quality of life and life expectancy. Changes include skeletal overgrowth deformities (particularly of the hands, feet, and face), cardiovascular disease (hypertension, enlarged heart), arthropathy, neuropathy, and respiratory obstruction ( Boxes 19-1 and 19-2 ).
Anatomic
Hypertrophy
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Facial bones—large bulbous nose
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Nasal turbinates
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Soft palate
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Tonsils
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Epiglottis
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Glottic stenosis
Impaired mobility of cricoarytenoid joints
Compression of recurrent laryngeal nerves
Limitation in head and neck mobility
Physiologic
Development or exacerbation of sleep apnea
Hoarseness
Dyspnea
Anatomic
Skeletal overgrowth
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Gigantism
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Enlarged hands and feet
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Distortion of facial features
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Prognathism
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Soft tissue overgrowth
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Enlarged lips, tongue, epiglottis, and vocal cords
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Visceromegaly
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Connective tissue overgrowth
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Recurrent laryngeal nerve paralysis
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Peripheral neuropathy
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Carpal tunnel syndrome
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Physiologic
Glucose intolerance
Hypertension
Osteoarthritis
Osteoporosis
Skeletal muscle weakness
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