Abstract
Objectives
Acromegalics present with a wide range of otolaryngic symptoms, including rhinosinusitis, changes in facial appearance, obstructive sleep apnea (OSA), and voice disturbances. Treatment typically involves transnasal-transsphenoidal (TNTS) resection of the offending pituitary adenoma. In this study, we identify the prevalence of otolaryngic symptoms of acromegalic patients, and evaluate Sinonasal Outcome Test (SNOT-22) scores preceding and following pituitary resection.
Design
Retrospective chart review.
Setting
Tertiary academic medical center.
Participants
Patients diagnosed with acromegaly who underwent surgical resection of a growth-hormone secreting pituitary adenoma between August 2010 and September 2013.
Main outcome measures
Subjects were asked to complete questionnaires detailing otolaryngic symptoms as well as SNOT-22 surveys before and after TNTS surgery. A Student’s t -test was used to compare preoperative and postoperative SNOT-22 scores.
Results
Twenty-five patients underwent pituitary surgery for acromegaly. Acromegalic patients were found to have macroglossia (60%), OSA or sleep-disordered breathing (52%), thyroid neoplasia (20%), hearing loss/tinnitus (20%), sinonasal symptoms (16%), and parathyroid pathology (8%). Differences in preoperative and postoperative SNOT-22 scores were not statistically significant.
Conclusion
Acromegalics present with assorted otolaryngic complaints. Routine screening of all acromegalics with sleep evaluations (for both surgical and perioperative planning), thyroid ultrasound, and audiologic testing should be strongly considered.
1
Introduction
Acromegaly, the syndrome resulting from excessive growth hormone secretion by a hyperfunctioning pituitary gland tumor, has been described for centuries, but it was not until the early 1900s that Cushing postulated excessive growth hormone as an etiology . Cushing noted that some patients who had undergone hypophysectomies experienced clinical remission . Treatment has evolved significantly over the intervening century, and today, transnasal, transsphenoidal (TNTS) resection of pituitary tumors remains the therapy of choice for the initial management of acromegaly . Concurrently, medical treatment options have also matured, with somatostatin receptor ligands, dopamine agonists, and a growth hormone receptor antagonist emerging as three classes of drugs effective against the biochemical derangements of acromegaly . In addition, radiation therapy still remains an option for unresectable tumors or for patients failing medical and surgical therapy.
There is significant evidence that acromegaly is associated with an increased risk of cardiovascular and respiratory comorbidities . Whether acromegaly intrinsically confers an increased risk of neoplastic disorders and subsequent mortality remains a subject of debate . Regardless of cause, mortality in acromegalics appears to be increased compared to age-matched controls . Acromegalics also experience symptoms specific to the head and neck, though the characteristics of disease manifestations have not been previously explored. In this study, we sought to characterize the otolaryngic manifestations of acromegaly, and to estimate the impact that TNTS pituitary resection had on patients’ otolaryngic (i.e., sinonasal) symptoms as validated by the 22-item Sinonasal Outcome Test (SNOT-22).
2
Methods
Institutional review board approval was obtained for this study. Inclusion criteria included a diagnosis of a growth-hormone secreting pituitary adenoma treated with TNTS surgery by a skull base surgery team (one otolaryngologist and one neurosurgeon) between August 2010 and September 2013, and patient charts were retrospectively reviewed for otolaryngic symptoms at presentation ( Fig. 1 ). An additional subset of patients who completed preoperative and/or postoperative SNOT-22 questionnaires was identified. The SNOT-22 questionnaire is a commonly used outcomes instrument meant for assessing quality-of-life related to rhinologic disease , though it may also be applied more broadly to other otolaryngic issues . Differences between the preoperative and postoperative SNOT-22 questionnaire scores were compared using a Student’s t -test with a significance level of 0.05.
2
Methods
Institutional review board approval was obtained for this study. Inclusion criteria included a diagnosis of a growth-hormone secreting pituitary adenoma treated with TNTS surgery by a skull base surgery team (one otolaryngologist and one neurosurgeon) between August 2010 and September 2013, and patient charts were retrospectively reviewed for otolaryngic symptoms at presentation ( Fig. 1 ). An additional subset of patients who completed preoperative and/or postoperative SNOT-22 questionnaires was identified. The SNOT-22 questionnaire is a commonly used outcomes instrument meant for assessing quality-of-life related to rhinologic disease , though it may also be applied more broadly to other otolaryngic issues . Differences between the preoperative and postoperative SNOT-22 questionnaire scores were compared using a Student’s t -test with a significance level of 0.05.
3
Results
Twenty-five patients were diagnosed with acromegaly and treated with TNTS surgery; the mean age was 46 (range, 16–66). Of these, 14 (56%) were male and 11 (44%) were female. Mean body mass index (BMI) was 29.3 (range, 20.8–39.8). No additional endoscopic sinus, septal, or turbinate surgery was indicated at the time of the procedure, with good access to the sella achieved through a TNTS approach. Four patients (16%) indicated that they were bothered by sinonasal symptoms, including nasal obstruction, nasal discharge, facial pressure or pain, or hyposmia/anosmia ( Fig. 2 ). Eight (32%) suffered from polysomnogram-proven obstructive sleep apnea (OSA), with an additional 5 (20%) reporting symptoms consistent with sleep-disordered breathing. Of the 8 patients with OSA, 3 used a continuous positive airway pressure (CPAP) machine at night. Fifteen patients (60%) had macroglossia. Two patients (8%) harbored an additional diagnosis of papillary thyroid carcinoma, while 3 others (12%) were diagnosed with benign thyroid nodules. One patient (4%) presented with a concurrent parathyroid adenoma, while another, diagnosed with multiple endocrine neoplasia (MEN) type I, underwent parathyroidectomy for parathyroid hyperplasia. One patient presented with a chief complaint of a sonorous voice. Other otolaryngic symptoms included hearing loss and tinnitus (5 patients, 20%). These results are summarized in Table 1 .
