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Good Morning. 12 November 2002. Pituitary Tumor with Acromegaly. 麻醉科 林子富. Case Summary. A 43-year-old male Schizophrenia under medical control for 20 + years Insidious onset of enlargement of the jaw, hands, nose and feet which became prominent in recent 3 years

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slide1

Good Morning

12 November 2002

case summary
Case Summary
  • A 43-year-old male
  • Schizophrenia under medical control for 20+ years
  • Insidious onset of enlargement of the jaw, hands, nose and feet which became prominent in recent 3 years
  • Endocrinology work-up and brain MRI revealed pituitary tumor
  • Called on our OPD for surgical intervention
  • DM, HTN: --
  • Family history: --
slide4
NE: intact
  • VF: hemianopia (L>R)
  • CBC, coagulation profile, blood chemistry: WNL
  • Endocrinology:
    • T3, T4, TSH, cortisol: WNL
    • Elevated GH
  • MRI of sella: pituitary microadenoma
  • Surgical tumor excision
    • Endonasal, transsphenoid
pituitary disease and anesthesia

Pituitary Disease and Anesthesia

M. Smith and N. P. Hirsch. Br J Anaesth 2000; 85: 3–14

anatomy
Anatomy
  • The large anterior lobe or adenohypophysisand the smaller posterior lobe or neurohypophysis
  • The gland averages 6 × 13 × 9 mm3
  • Lie within the pituitaryfossa or sella turcica
  • Bounded by the roof of the sphenoid air sinus and cavernous sinuseswhich contain the carotid arteries and the third, fourth andsixth cranial nerves
physiology
Physiology
  • At least five celltypes within the anterior lobe:
    • Somatotrophs: growth hormone; 50%
    • Prolactin-producinglactotrophs; 10–25%
    • ACTH-producing corticotrophs; 15%.
    • Thyrotrophs: TSH; 5–10%
    • Gonadotrophs: FSH and LH; 10%
    • Null cells: non-functioning pituitary adenomas
growth hormone
Growth Hormone
  • Growth hormone acts on a wide variety oftissues, both directly and through release of insulin-like growthfactor I (IGF-I).
  • In addition tostimulating bone and cartilage growth, growth hormone and IGF-Iincrease protein synthesis and lipolysis whilst decreasing insulinsensitivity and causing Na+ retention.
pituitary pathology
Pituitary Pathology
  • Mostly arise from the anterior part of the gland
  • The majority are benign adenomas
    • 10–15%of intracranial neoplasms
    • 75% of them secrete inappropriateamounts of pituitary hormones
  • Malfunction of normal growth-regulating genes, abnormalitiesof tumour suppressor genes
  • Prevalence: 200 permillion of the population
  • Post-mortem studies: 10–27%. The majority are thereforeasymptomatic.
presentation
Presentation
  • Hormonal hypersecretion syndromes
    • hyperprolactinaemia,acromegaly and Cushing’s disease
  • Mass effect
    • visual disturbance or raised intracranial pressure
  • Non-specific
    • infertility, headache, epilepsyor pituitary hypofunction
  • Incidental
    • detectedduring imaging for other conditions
gh secreting tumours
GH-secreting tumours
  • Acromegaly in theadult and gigantism before epiphyseal closure
  • Annual incidenceof acromegaly is 6-8 cases per million
  • Insidious in onset, characterizedby enlargement of the jaw, hands and feet and increased softtissue growth
  • Associated complications of the disease
    • diabetesmellitus and hypertension
slide21

Clinical features of acromegaly

Affected area

Clinical features

Face

Increase in size of skull and supraorbital ridges; enlarged lower jaw; increase in spacing between teeth/malocclusion

Spade-shaped; carpal tunnel syndrome

Hands and feet

Mouth/tongue

Macroglossia; thickened pharyngeal and laryngeal soft tissues; obstructive sleep apnoea

Soft tissue

Thick skin; doughlike feel to palm

Skeleton

Vertebral enlargement; osteoporosis; kyphosis

Cardiovascular

Hypertension; cardiomegaly; impaired left ventricular function

Endocrine

Impaired glucose tolerance; diabetes

Other

Arthropathy; proximal myopathy

gh secreting tumours1
GH-secreting tumours
  • Preoperative diagnosis
    • A random serum GH concentration of >10 mU litre–1 (5 ng ml–1)
    • Failure of suppression of GHconcentrations to < 2 mU litre–1 (1 ng ml–1) followinga 75 g oral glucose load
    • Elevated IGF-I
  • Treatment
    • The primary treatment is surgery, with or without subsequentradiotherapy
    • Dopamine agonists
    • Long-acting analogues of somatostatin(such as octreotide)
preoperative assessment
Preoperative Assessment
  • Visual function
  • Signs and symptoms of raised intracranialpressure
  • Endocrine studies; and the effectsof hormonal hypersecretion
  • Co-morbidities, particularly in acromegaly or Cushing’ssyndrome
acromegaly
Acromegaly

1. Anatomical changes

  • prognathismand macroglossia
  • thickening of the pharyngeal and laryngealsoft tissues and vocal cords
  • reduction in the size of the laryngealaperture
  • hypertrophy of the periepiglottic folds
  • recurrentlaryngeal nerve palsy
  • enlarged thyroid: 25%
acromegaly1
Acromegaly

2. Sleep apnoea

  • a rare complicatingfactor, but is associated with a high risk of perioperativeairway compromise
  • upper airway obstruction is the majorcause, but central depressionmay also contribute
  • a history of loud snoring and daytime hypersomnolenceshould alert the anaesthetist to the possibility of sleep apnoea
acromegaly2
Acromegaly

3. Hypertension

    • occurs in 30% of patients, but usuallyresponds to therapy
    • myocardial hypertrophy and interstitialfibrosis are common and may be associatedwith reduced left ventricular function
  • Glucose intolerance
    • diabetes: 25%
surgical approach
Surgical Approach
  • The pituitaryfossa can be approached using the transsphenoidal, transethmoidalor transcranial route
  • The transsphenoidal route is preferredfor all but the largest of tumours
  • Transsphenoidalaccess to the pituitary fossa is obtained using a sublabialor endonasal approach
anesthetic management
Anesthetic Management

1. Hormone replacement

  • Preoperative hormone replacement therapy should be continuedinto the operative period
  • In general, hydrocortisone 100 mgshould be administered at induction of anaesthesia in all patientsundergoing pituitary surgery
anesthetic management1
Anesthetic Management

2. Airway management

  • Four grades of airway involvement:
    • grade 1-- no significant involvement
    • grade 2-- nasal and pharyngealmucosa hypertrophy but normal cords and glottis
    • grade 3-- glotticinvolvement including glottic stenosis or vocal cord paresis
    • grade 4-- combination of grades 2 and 3, i.e. glottic andsoft tissue abnormalities
slide30
2. Airway management
  • airwaymanagement and tracheal intubation proceed uneventfully in themajority of patients if large face masks and long-bladed laryngoscopesare used
  • fibreoptic intubation should be consideredin patients in whom difficult airway management is predicted
  • intubating laryngeal mask airway has also been used successfully
  • Equipment for tracheostomy shouldbe available if airway changes are advanced (recommendedfor grades 3 and 4)
slide31
2. Airway management
  • the mouth and posterior pharynx shouldbe packed before surgery begins
  • preventbleeding into the glottic region during surgery, but also entryof blood and secretions into the stomach which may precipitatepostoperative vomiting
anesthetic management2
Anesthetic Management

3. Maintenance of anaesthesia

  • short-actingagents are used to allow rapid recovery at the end of surgery
  • During transsphenoidal surgery, ventilation tonormocapnia should be employed. (Excessive hyperventilation willresult in loss of brain bulk and make any suprasellar extensionof the tumour less accessible from below)
  • longer-actingopioids are administered before the end of surgery so that patientsdo not awaken in pain (IV morphineor IM codeine 20–30 min before the end of surgery)
anesthetic management3
Anesthetic Management

4. Operative complications

  • surgeonloses the anatomical landmarks of the fossa during transsphenoidalsurgery. Deviation laterally may result in carotid damage.
  • risk of developmentof a false aneurysm in the postoperative period
  • If misses the fossa altogether,damage to the pons may occur
anesthetic management4
Anesthetic Management
  • 4. Emergence from anaesthesia
    • Smooth and rapid emergence from anaesthesia is essential to allow early neurological assessment and maintenanceof stable respiratory and cardiovascular variables.
    • use of short-acting agents for maintenanceof anaesthesia
postoperative care
Postoperative Care
  • Airway management
  • Postoperative analgesia
  • Hormone replacement
  • Postoperative hormone complications
slide36
學習心得…
  • 此類病人air way之 management, 雖然case 很少…
  • Keep in mind: endocrine abnormalities 所造成的 co-morbidities.
  • Awakening management after neurosurgery…