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Acromegaly: Airway

Acromegaly is a chronic progressive multisystem disease mainly caused by an anterior pituitary tumor secreting excessive growth hormone (GH). From an airway perspective, these patients often have overgrowth of the mandible, soft tissues, connective tissues, and vocal cords, likely leading to both difficult mask ventilation and laryngoscopy/intubation:

• Mandible: Macrognathia

• Soft tissue: Thickened lips, macroglossia, enlarged tonsils, and enlarged/thickened epiglottis impedes visualization of vocal cords. Polypoid masses may develop in pharyngeal tissue, making airway susceptible to obstruction. 60-70% OSA prevalence.

• Connective tissue: Recurrent laryngeal nerve paralysis caused by stretching of tissues as cartilaginous structures in the neck expand, leading to abnormal VC movement.

• Vocal cords: Chondrocalcinosis of larynx leads to VC thickening and stricture formation. Cricoarytenoid joint involvement may cause impaired movement of the VC.

Airway Management: In general, consider using a larger blade for DL, as the distance between the lips and VC will be increased by macrognathia. Videolaryngoscopy may be useful if large tongue and epiglottis impede the line of vision. Consider using a smaller ETT due to possible narrowing of the cricothyroid ring and glottic opening. If patient has evidence of OSA, consider fully awake extubation.


  1. Nemergut EC, Zuo Z. Airway management in patients with pituitary disease: a review of 746 patients. J Neurosurg Anesthesiol. 2006 Jan;18(1):73-7. PubMed Link
  2. Sharma D, et al. Predicting difficult laryngoscopy in acromegaly: a comparison of upper lip bite test with modified Mallampati classification. J Neurosurg Anesthesiol. 2010 Apr;22(2):138-43. PubMed Link
  3. Khan RH, Rasouli MR. Intubation in patients with acromegaly: experience in more than 800 patients. Eur J Anaesthesiol. 2009 Apr;26(4):354-5. PubMed Link