Tomurcuk DEMİRCİ, Şennur UZUN, Başak AKÇA, Ülkü AYPAR

Hipofiz Cerrahisi Yapılan Akromegalik Hastalarda Hava Yolu Yönetiminin Retrospektif Değerlendirilmesi

Amaç: Akromegali, büyüme hormonu ve insülin benzeri büyüme faktörü seviyelerinin yüksekliğine bağlı belirgin mortalite ve morbiditesi olan endokrinolojik bir hastalıktır. Akromegalide akral değişikliklere bağlı büyük burun, makroglossi, mandibulada genişleme, kalın ve büyük dudaklar görülür. Farinks, larinks, tonsil, vokal kordlar, mukoza ve yumuşak dokularda hipertrofi olabilir. Akromegalinin bu özelliklerinden dolayı zor maske ventilasyonu ve zor entübasyon söz konusu olabilir. Bu çalışmada amacımız, transsfenoidal hipofiz cerrahisi geçiren akromegali hastalarının hava yolu yönetimi sırasında yaşanan zorlukların ve kullanılan yöntemlerin dökümentasyonunu sağlamak ve bu yöntemlerin başarı oranlarını karşılaştırmaktır. Yöntem: Etik Kurul onayı alındıktan sonra, 2003-2013 tarihleri arasında üniversitemizde transsfenoidal hipofiz adenomu rezeksiyonu uygulanmış 120 akromegali hastasının perioperatif kayıtları değerlendirildi. Bulgular: Zor entübasyon sıklığı %10 olarak bulundu ve bulunan sonuçlar literatüre benzerdi. Zor laringoskopisi olan hastalar blade değişimi, eksternal krikoid bası ve guide kullanılarak entübe edildi. Tek bir hastanın entübasyonu için fast-trach LMA kullanıldı. Akromegali hastalarında obstrüktif uyku apne sendromu (OSAS) sıklıkla rastlanan bir komorbiditedir ve bu iki durumun birlikte olmasının da zor entübasyon olasılığını arttırdığı gözlemlendi. Sonuç: Mallampati skorları ve zor entübasyon sıklığı açısından belirgin korelasyon bulunmaktadır. Akromegalik hastalarda obstrüktif uyku apne sendromunun (OSAS) görülme sıklığı da artmıştır. Sonuç olarak, mallampati skoru yüksek olan, OSAS ın sıklıkla eşlik ettiği akromegali hastalarında hava yolu yönetiminin zor olabileceği ve bu hastalarda anestezi indüksiyonuna zor hava yolu önlemleri alınarak başlanması gerektiği düşüncesindeyiz.

A Retrospective Analysis of Airway Management of Acromegalyic Patients Undergoing Pituitary Surgery

Objective: Acromegaly is an endocrinological disease that has morbidity and mortality characterised by high levels of growth hormone (GH) and insülin like growth factor-I (IGF-I). Typical big nose and lips, macroglossia, enlargement of mandible may be observed due to acral changes. Hypertrophy of pharynx, larynx, tonsils, vocal cords, mucosa and soft tissue may occur in acromegaly. Due to the characteristics of acromegaly, difficult mask ventilation and airway management might be anticipated in these patients. The purpose of this study was to document the challenges and methods used in airway management in acromegaly patients undergoing transsphenoidal pituitary surgery and to compare the success rates of these methods. Methods: The perioperative records of 120 patients that underwent transsphenoidal resection of pituitary adenoma at our university hospital between 2003-2013 were reviewed. Results: Among the patients studied, difficulty with intubation was encountered in %10 of patients which is consistent with literature. Patients whose laryngoscopy was challenging were intubated by changing blade, application of external laryngeal pressure or using a guide. One patient was intubated using LMA FastrachTM. Obstructive sleep apnea syndrome (OSAS) is a frequent comorbidity in acromegalic patients and this co-occurrence is also associated with difficult intubation. Conclusion: Significant correlation was observed between Mallampati gradings and incidence of difficult endotracheal intubation. Also obstructive sleep apnea syndrome (OSAS) which is very frequent in acromegalic patients is also associated with difficulty in airway management. We think that induction of anesthesia should be attempted after taking precautions to overcome difficult airway management in these patients.

PDF

___

Carpenter, Griggs, Loscalzo. Endokrin Hastalıklar, Akromegali ve Gigantizm. Cecil Essentials of Medicine, Nobel Tıp Kitabevi 2002; 550-551.
Holdaway IM, Rajasoorya C. Epidemiology of acromegaly. Pituitary 2. 1999; 29-41. https://doi.org/10.1023/A:1009965803750
Klibanski A, Zernas NT. Diagnosis and management of hormonesecreting pituitary adenomas. N Engl J Med. 1991;324:822-31. https://doi.org/10.1056/NEJM199103213241207
Colao A, Auriemma RS, Lombardi G, et al. Resistance to somatostatin analogs in acromegaly. Endocrine Reviews. 2011;32:247-71. https://doi.org/10.1210/er.2010-0002
Sandret L, Maison P, Chanson P. Place of cabergoline in acromegaly, a meta-analysis. J Clin Endocrinol Metab. 2011;96:1327-35. https://doi.org/10.1210/jc.2010-2443
Tüzüner F. Zor Havayolu Tanımlaması ve Yaklaşım. Tüzüner Anestezi, Yoğun Bakım, Ağrı, Nobel Tıp Kitabevi 2009; 141-146.
Asbjornsen H, Kuwelker M, Softeland E. A case of unexpected difficult airway due to lingual tonsil hypertrophy. Acta Anesthesiologica Scandinavica. 2008;52:310-2. https://doi.org/10.1111/j.1399-6576.2007.01485.x
Law-Koune JD, Liu N, Szekely B, et al. Using the intubating laryngeal mask airway for ventilation and endotracheal intubation in anesthetized and unparalized acromegalic patients. Journal of Neurosurgical Anesthesiology. 2004;16:11-3. https://doi.org/10.1097/00008506-200401000-00003
Nemergut, Edward C, Zuo Zhiyi. Airway management in patients with pituitary disease: A reiew of 746 Patients. Journal of Neurosurgical Anesthesiology. January 2006;18:73-7. https://doi.org/10.1097/01.ana.0000183044.54608.50
Maeda T, Saito T, Harimaya K, et al. Atlantoaxial instability in neck retraction and protrusion in patients with romatoid artritis. Spine 1. 2004;29:757-62. https://doi.org/10.1097/01.BRS.0000113891.27658.5F
Schmitt H, Buchfelder M, Radespiel-Tröger M, et al. Difficult intubation in acromegalic patients. Anesthesiology. 2000;93:110-4. https://doi.org/10.1097/00000542-200007000-00020
Deepak S, Hemanshu P, Bithal Parmod K, et al. Predicting difficult laryngoscopy in acromegaly. J Neurosurg Anesthesiol. 2010;22:138-43. https://doi.org/10.1097/ANA.0b013e3181ce6a60
Arun K. Gupta, Adrian W. Gelb. Nöroanestezi ve Nöroyoğunbakımın Esasları, Güneş Tıp Kitabevi 2013; 141-147.
Alberto AU, David AZ, Erika GP, et al. BMI as a predictor for potential difficult tracheal intubation in males. Front Med (Lausanne). 2015;2:38. https://doi.org/10.3389/fmed.2015.00038
Stone Dj, Galt J. Airway Management, Miller RD Anesthesia. Churchill Livingstone, NewYork. 2000;39:1444-5.
Friedel ME, Johnston DR, Singhal S, et al. Airway management and perioperative concerns in acromegalic patients undergoing endoscopic transsphenoidal surgery for pituitary tumors. American Academy of Otolaryngology-Head and Neck Surgery. 2013;149:840-4.
Hakala P, Randell T. Laryngoscopy and fiberoptic intubation in patients with acromegaly. Br J Anesth. 1998;80:345-7. https://doi.org/10.1093/bja/80.3.345
Ali Z, Bithal PK, Prabhakar H, et al. An assesment of the predictors of difficult intubation in patients with acromegaly. J Clin Neurosoi. 2009;16:1043-5. https://doi.org/10.1016/j.jocn.2008.11.002
Khan, Zahid hussain, Rasoluli, et al. Intubation in Patients with Acromegaly: experience in more than 800 patients. Europian Journal of Anesthesiology. 2009;26:354-5. https://doi.org/10.1097/EJA.0b013e32831bc6fb
Kheterpal S, Han R, Tremper KK. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105:885-91. https://doi.org/10.1097/00000542-200611000-00007
Frerk CM. Predicting difficult entubation. Anesthesia. 1991;46:1005-8. https://doi.org/10.1111/j.1365-2044.1991.tb09909.x
Wilson ME, Spiegelhalter D, Robertson HA. Predicting difficult intubation. Br J Anaesth. 1993;71:333-4. https://doi.org/10.1093/bja/71.3.333
Hiremath AS, Hillman DR, James AL, et al. Relationship between difficult tracheal intubation and obstructive sleep apnea. British Journal of Anesthesia. 1998;80:606-11. https://doi.org/10.1093/bja/80.5.606
Lee SJ, Lee JN, Kim TS, et al. The relationship between the predictors of obstructive sleep apnea and difficult intubation. Korean J Anesthesiol. 2011;60:173-8. https://doi.org/10.4097/kjae.2011.60.3.173
Zhang Y, Guo X, Pei L, et al. High levels of IGF-1 predict difficult intubation of patients with acromegaly. Endocrine. 2017;57:326-34. https://doi.org/10.1007/s12020-017-1338-x