79th PostGraduate Assembly in Anesthesiology 2025

Learning Objective

Although rare, bilateral vocal cord paralysis represents a clinically significant complication of acromegaly and should be considered in patients presenting with the acromegaly phenotype and clinical signs of respiratory distress.

Case Description

45-year-old man with a past medical history of hypertension and non-insulin dependent type 2 diabetes mellitus presents to the emergency department for stridor

Recent visit for ENT office for months of progressively worsening nasal congestion, noted to have audible stridor
Recent outpatient flexible laryngoscopy showed bilateral vocal cord weakness, but was not noted to be in respiratory distress
In the ED, noted to be saturating 100% on room air, and denied dyspnea
Labs showed acute hypercapnia, for which ENT was consulted
Flexible laryngoscopy in the ED showed, limited true vocal fold abduction with very narrow glottic opening
Decision was made to bring patient emergently to the OR for intubation and tracheostomy creation

Perioperative Course

Patient was brought into the operating and connected to monitors
Preoxygenated with 100% FiO2 at 15LPM for 2 minutes
Rapid sequence induction performed with fentanyl, propofol, and succinylcholine
Intubation performed with Glidescope Size 4 Blade and 7.5 endotracheal tube – grade 2b view was obtained and the tube was pass atraumatically through the cords
Other than mild hypotension, treated with phenylephrine, operative course proceeded well without complication
Tracheostomy was performed, orotracheal tube was removed and the patient was emerged from anesthesia and transported to PACU in stable condition

Postoperative Course and Follow Up

Post-operatively the patient was recovered in the PACU before transfer to the surgical step-down unit
Endocrinology consulted for acromegnaly phenotype
IGF-1 elevated
MRI Brain: "8 x 9 mm heterogeneously enhancing mass in the right aspect of the sella displacing the pituitary stalk to the left"
Acromegaly diagnosis was confirmed, and patient was scheduled for transphenoidal resection

Laryngeal Anatomy

Third to sixth cervical vertebrae
Contains epiglottis and vocal cords and extends from the superior border of the epiglottis to the cricoid cartilage
The muscles of the larynx
Cricothyroid – innervated by external branch of superior laryngeal nerve
All others – innervated by recurrent laryngeal nerve (lateral cricoarytenoid, posterior cricoarytenoid)

Anesthetic Relevance

Anesthesiologists must be prepared to manage challenging airways
Having access to as many tools as possible increases likelihood of airway success
The anatomic changes in acromegaly can make intubation and mask ventilation particularly difficult
Laryngeal involvement of acromegaly can make this more challenging due to urgent/emergent nature of these cases
This case shows the feasibility of utilizing video laryngoscopy using Glidescope to obtain airway access
Highlights the importance of the anesthesiologist's mastery of all airway techniques

Acknowledgements

We would like to thank the operating room team during this difficult case, their dedication to patient safety was critical. Additionally, we would like to thank the Montefiore Medical Center Department of Anesthesiology for their commitment to clinical research and improving patient outcomes.

References

Cooper T, Dziegielewski PT, Singh P, Seemann R. Acromegaly Presenting With Bilateral Vocal Fold Immobility: Case Report and Review of the Literature. J Voice Off J Voice Found. 2016;30(6):758.e13-758.e16. doi:10.1016/j.jvoice.2015.09.008

Smaily H, and Matar N. Laryngeal manifestations in acromegaly: A systematic review of the literature. Acta Oto-Laryngol Case Rep. 2020;5(1):57-63. doi:10.1080/23772484.2020.1809421

Culp JM, Patel G. Recurrent Laryngeal Nerve Injury. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560832/

79th PostGraduate Assembly in Anesthesiology 2025

Airway Management in a Patient with Suspected Acromegaly and Bilateral Vocal Cord Paralysis

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