Impossible insertion of Laryngeal Mask Airway in acromegaly patient

Acromegaly is a chronic, insidious and debilitating disease that often occurs due to excessive secretion of growth hormone by the anterior pituitary adenoma. Patients with this disorder often have multisystem involvement, including respiratory, cardiovascular, neuromuscular, neurological, and skeletal.Airway management in these patients faces anesthesiologist to a great challenge due to overgrowth of airway soft tissue (enlargement of tongue and epiglottis), skeletal changes, recurrent laryngeal nerve palsy, cricoarytenoid joint involvement and thickening of vocal cords and predispose the patient to airway obstruction. We present a case in which the patient airway administration was unexpected.

A 25-year-old man with a history of acromegaly was referred to our anesthesiology clinic for severe decrease visual acuity in right eye for vitrectomy. After taking the history and performing the necessary examinations, tests and consultations for the operation, it was decided to undergo general anesthesia and insert a laryngeal Mask Airway. Despite using different mask sizes, changing head position and standard techniques, thumb, 90-degree rotation, 180-degree, partial inflation, and laryngoscopic guide, we were unable to insert the LMA and the patient completed surgery and recovery without complications.

Complete preoperative evaluation of acromegaly patients is very important in the anesthesia and airway management. This preoperative evaluation helps the anesthesiologist to make the necessary arrangements in the patient's airway management to prevent the risks. Supraglottic devices such as laryngeal masks are useful in cases where mask ventilation and tracheal intubation are difficult. But the opposite can also happen. Therefore, our scientific evaluation and decision-making may not take place before the procedure during the procedure and we may have to use other methods. Therefore, the anesthesiologist must be prepared to implement the difficult airway management algorithm.