Anaesthetic management in a patient with acromegaly and

multinodular goiter undergoing endoscopic transphenoidal

pituitary surgery
Boon Tat Yeap1,4 , Wan Mohd Nazarudin Wan Hassan2,4, Jabraan Jamil3, Laila Ab
Mukmin2.4, Mohamad Hasyizan Hassan2,4
1Department of Anaesthesia & Intensive Care, Faulty of Medicine and Health Sciences, Universiti Malaysia
Sabah, 88400 Kota Kinabalu, Sabah, Malaysia
2Department of Anaesthesia & Intensive Care Unit, School of Medical Sciences, Health Campus, Universiti

Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia

3Department of Anaesthesia & Intensive Care Unit, Queen Elizabeth Hospital, 88200 Kota Kinabalu, Sabah,

Malaysia
4Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia

Introduction Results
• Acromegaly is a rare systemic disorder which is caused by a • He was planned for endoscopic transsphenoidal resection of
functioning growth hormone (GH)-secreting pituitary pituitary macroadenoma.
adenoma. Rarely, these patients may develop thyroid lesions • In view of anticipated difficult intubation, we planned for AFOI
that may compromise the airway. using the spray as you go (SAY-GO) method with TCI
• A young man with newly diagnosed acromegaly caused by a remifentanil. A size 7.5 mm flexometallic ETT was rail-roaded to
pituitary macroadenoma complicated by a large multinodular the fibrescope and anchored at 21cm. No muscle relaxants
goitre was posted for an elective transsphenoidal were used throughout the surgery.
hypophysectomy. • GA was maintained using TCI remifentanil and propofol at a
• The aim of this report is to discuss the perianaesthetic range of 2-9 ng/ml and 3-6 mcg/ml, respectively, which were
approach in an acromegalic patient with a high risk of airway guided by BIS at the range of 40-60.He was extubated in the
compromise undergoing pituitary surgery. OT after 4 hours of surgery.
• The HPE of the tumor showed a suprasellar lesion with
synchronous prolactin and GH-secreting pituitary adenoma.
Methods • A month later, he claimed that the neck mass had mildly
shrunken.
• A 48-year-old man (weight=80kg, height=1.72m)presented
with progressive acral changes for 16 years which was
associated with sexual dysfunction and peripheral vision loss. In
addition, he complained of having a small painless swelling on
the right side of his neck. He denied symptoms of
hypothyroidism or hyperthyroidism.
• Clinically, his GCS was full. He has pectus excavatum and a
palpable painless right thyroid mass measuring 3 cm x 2 cm in
size (Figure 1). Face and limbs examination showed features
of acromegaly. Airway assessment revealed Mallampati 3 and Figure 1
TMD of more than 6 cm.
• The hormonal investigations revealed elevated GH, IGF-1 and
prolactin. The TFT were normal.
• MRI brain showed a large lobulated sellar mass with the size
was 3 cm x 4.5 cm (Figure 2).
• HRCT of the thorax showed pectus excavatum and a
retrosternal mass C3-C4 (Figure 3). There was a lesion arising
from the inferior pole of the right thyroid lobe measuring 4.1
cm x 3.7 cm which exerted mass effect to the trachea.

Conclusion Figure 2 Figure 3

• Acromegaly is a rare, progressive, multisystem disorder characterized by disproportionate tissue and organ growth due to excess
GH exposure from a secretory pituitary adenoma after puberty.
• The clinical presentation of acromegaly is related to local mass effect by the adenoma and the sequelae of GH excess [1-3]. Our
patient presented with painless systemic changes consistent with acromegaly.
• As his disease progressed, he started to lose his peripheral vision. Furthermore, he had clinical signs of hypogonadism and
hyperprolactinemia, suggesting stalk compression syndrome from a GH-secreting pituitary macroadenoma [4, 5]. In addition, he
developed a huge MNG with retrosternal extension in addition to pectus excavatum, possibly due to hypertrophic effects of GH on
the thyroid gland, sternum and ribs.
• Anaesthesia in acromegalics for pituitary surgeries is extremely challenging; especially in patients with a huge MNG.
• Hollistic perioperative planning, with extra care in airway management, is important to avoid total airway obstruction. AFOI is the
gold standard in maneuvering this anticipated difficult airway.
• TCI remifentanil and propofol guided by BIS is highly recommended during induction and maintenance of anaesthesia for
transsphenoidal surgeries in acromegalics.
References
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