Anesth Analg 2005;101:1812-1815
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000184195.28728.CD
NEUROSURGICAL ANESTHESIA
Section Editor:
David S. Warner
Airway Problems Caused by Hypogonadism in Male Patients Undergoing Neurosurgery
Sethuraman Manikandan,
Praveen Kumar Neema, and
Ramesh Chandra Rathod
Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
Address correspondence and reprint requests to Dr. S. Manikandan, B-14, New Faculty Quarters, SCTIMST, Poonthi Rd., Kumarapuram, Trivandrum-695011, Kerala, India. Address e-mail to kanmanisethu{at}yahoo.com.
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Abstract
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Unanticipated difficult endotracheal intubations can pose challenges for the anesthesiologist. Risks include airway injury, hypoxemia, and death. There is intubation difficulty in various conditions including Downs syndrome, achondroplasia, acromegaly, and dwarfism. We describe difficulty in intubating the trachea with an appropriate sized endotracheal tube in two young male patients with hypogonadism presenting for neurosurgical procedures under general anesthesia. We discuss the role of hypogonadism and the effects of gonadotropin hormones on pubertal laryngeal growth in male patients.
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Introduction
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Unanticipated difficult tracheal intubation can pose problems for the anesthesiologist and can result in trauma to the airways caused by multiple attempts at laryngoscopy and intubation (1). Airway abnormalities are described in patients with endocrine disorders, especially in those with pituitary dysfunction. Difficult intubation has been described in patients with dwarfism (2,3) and acromegaly (4). However, airway problems have not been identified in patients with hypogonadism. We describe unanticipated intubation difficulty in two male patients with hypogonadism undergoing neurosurgery and discuss the effects of gonadotrophic hormones on pubertal laryngeal growth.
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Case Reports
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Case 1
A 19-yr-old man (weight, 37 kg; height, 154 cm) presented with history of headache, fatigue, rapidly deteriorating visual acuity, blurring of vision, polyuria, and polydipsia. He had lost 10 kg in body weight in the preceding 4 mo. His physical examination was characterized by bitemporal hemianopia, absent secondary sexual characters in the form of absent pubic, facial, and chest hairs, and a high-pitched feminine voice. Computed tomographic (CT) and magnetic resonance imaging (MRI) of the brain showed a suprasellar mass suggestive of craniopharyngioma. A hormonal profile, taken in early morning, showed decreased values of all hormones except prolactin and thyroid hormones (Table 1). The patient was treated with thyroxine orally, dexamethasone IM, and phenytoin orally. Because of rapidly deteriorating vision, he was scheduled for emergency intracranial decompression of tumor. His premedication consisted of oral thyroxine, dexamethasone, phenytoin, and glycopyrrolate IV. In the operating room, after the induction of general anesthesia, endotracheal intubation was attempted with an 8.0-mm ID endotracheal tube (SIMS Portex Limited, Hythe, Kent, UK). The tube could not be passed beyond the level of the vocal cords. Attempts to pass 7.5- and 6.5-mm ID endotracheal tubes also failed. Finally, a 6.0-mm ID (SIMS Portex Limited) tube was passed. It was fit snuggly, and the cuff of the endotracheal tube was inflated to a pressure of 15 cm H2O. At the end of the surgery, neuromuscular paralysis was reversed with neostigmine and glycopyrrolate, and the patient was tracheally extubated. Immediately after extubation, the patient showed signs of inspiratory stridor, which was treated with humidified oxygen and systemic steroids. The stridor subsided within 10 min. His postoperative course was otherwise uneventful. The patient’s airway was evaluated to identify the cause of the intubation difficulty. The diameter of the trachea in a anterior-posterior (AP) chest radiograph and chest CT was 12 mm and 11 mm, respectively. Review of the brain MRI showed the laryngeal structures. The measured internal diameter was 7 mm at the level of the thyroid cartilage, which was less than the diameter measured at the tracheal level.
Case 2
A 18-yr-old man (weight, 45 kg; height, 160 cm) presented with headache, vomiting, and drowsiness. General examination showed gynecomastia and absence of pubic and facial hairs. He retained a childlike voice. Brain CT showed a large fourth ventricular mass with gross hydrocephalus of all ventricles. Because his neurological state was rapidly deteriorating, the patient was taken for emergency endoscopic third ventriculostomy. After anesthetic induction, attempts to intubate the trachea with 8.5-mm, 7.5-mm, and 6.5-mm ID endotracheal tubes failed. Finally, the patient was tracheally intubated with a 6.0-mm ID Portex endotracheal tube. His preoperative chest radiograph showed narrowing at the laryngeal level (Case 2; Fig. 1). At the end of the surgery, neuromuscular blockade was reversed; however, because of delayed recovery, tracheal extubation was delayed for an hour. Because of unexpected delayed awakening, an endocrine profile was measured with the sample taken at 7 am. It showed hypopituitarism (Table 1). His larynx was analyzed by CT scan, which showed narrowing at the levels of cricoid and thyroid cartilage (Case 2; Fig. 2; and Case 2; Figure 3) with AP and transverse (Tr) diameters of 11 mm x 7 mm for the cricoid cartilage and 8mm x 10mm for the thyroid cartilage. He was given supplemental thyroid hormone and steroids. He later underwent surgical decompression of the tumor uneventfully.
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Figure 2. Compute tomographic (CT) scan showing the cross section at the level of thyroid cartilage (Case 2).
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Figure 3. Compute tomographic (CT) scan showing the cross section at the level of cricoid cartilage (Case 2).
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Discussion
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Intubation difficulty was encountered when using age-appropriate sized endotracheal tubes in two postadolescent male patients undergoing neurosurgery with different pathologies. Both patients showed clinical features of hypogonadism and low serum levels of pituitary hormones. In the first patient, a high-pitched feminine voice and presence of a tumor in pituitary region suggested inhibited pubertal maturation of the larynx. However, in our second patient, the voice was still childlike in development. Although the second patient presented with a similar phenotype, his tumor was located in the fourth ventricle. We believe the endocrine abnormalities and delayed sexual characteristics were caused by gross hydrocephalus causing dysfunction of the hypothalamus or pituitary gland, despite there being no structural lesion in the pituitary region.
In our first patient, multiple attempts of tracheal intubation were initially thought to be the cause of stridor. However, MRI showed an airway diameter of 7 mm at the subglottic level. We had inserted a 6.0-mm ID endotracheal tube with an outer diameter of 8.2 mm, which was inappropriately large for the patient and a more likely cause of the stridor (5). If we had inserted a tube smaller than 6.0 ID, perhaps this complication could have been averted. In the second patient, the dimensions of the cricoid cartilage were also less than the mean for his age (11,6).
Pulsatile release of gonadotrophic hormone causes growth of testes and testosterone secretion, which, in turn, is responsible for the pubertal growth spurt and development of secondary sexual characteristics (7). The increase in testicular volume associated with puberty has been correlated with the growth of the larynx in the male and changes in fundamental voice frequency (8). Studies focusing on the growth of the prepubertal to pubertal larynx were based on animal experiments (9) and cadaveric measurements (10). The average cadaveric measurements of the AP and Tr diameter of the cricoid cartilage at prepubertal and pubertal age in boys and girls are shown in Table 2. Kahane (11) has shown that prepubertal laryngeal dimensions in girls are closer to adult dimensions compared to boys. However, prepubertal to pubertal growth of the thyroid and cricoid cartilage were 2–3 times greater in boys compared with girls based on a cadaveric analysis (10). Hence, the airways of boys will be more affected than girls by hypogonadism. Kahane (11), using a linear regression analysis, further verified that a biological measure of age (Crown-Heel length) was a better predictor of circum-pubertal laryngeal growth than chronological age (10).
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Table 2. A Comparison of the Mean Internal Diameter of Cricoid Cartilage in Males and Females Between Prepubertal and Pubertal Age Groups
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Beckford et al. (9) studied the effects of androgen administration in castrated lambs on laryngeal growth and found that androgen plays a major role in the male larynx development. High-affinity androgen receptors have been demonstrated in human larynx (12). However, information on the role of androgens in pubertal growth and dimensions of larynx based on CT and MRI in humans in normal, as well as hypogonad, males is lacking. Meston et al. (13) has found a positive correlation between obstructive sleep apnea severity and secondary hypogonadism in male patients. However, there is no report on the airway problems in patients with hypogonadism.
Our case reports suggest that the possibility of difficult tracheal intubation caused by under-developed laryngeal cartilages should be considered when anesthetizing male patients with features of hypogonadism. The height of the patient should be considered in the selection of the appropriate sized endotracheal tube rather than age alone. Though conventional radiograph imaging continues to play a major role, helical CT and MRI are the method of choice to image the larynx because they provide a more accurate delineation of cartilages and soft tissues (14). Because CT and MRI are routinely used to diagnose the lesions around the sellar region, additional imaging of the larynx could give more accurate and detailed information about the dimensions of larynx, especially in the pubertal age group of patients with hypogonadism. This would provide valuable information to the anesthesiologist.
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Footnotes
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Accepted for publication June 10, 2005.
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References
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- Stauffer JL, Olson DE, Petty TL. Complication and consequences of endotracheal intubation and tracheostomy. Am J Med 1989;70:65–76.
- Berkowitz ID, Raja NS, Bender KS, et al. Dwarfs: pathophysiology and anesthetic implications. Anesthesiology 1990;73:739–59.[Web of Science][Medline]
- Herlich A. Complications from securing the difficult airway. Int Anesthesiol Clin 1997;35:13–30.[Medline]
- Kitahata LM. Airway difficulties associated with anaesthesia in acromegaly: three case reports. Br J Anaesth 1971;41:1187.
- Kastanos N, Estopa Miro R, Marin PA, et al. Laryngotracheal injury due to endotracheal intubation: incidence, evolution and predisposing factors—a prospective long-term study. Crit Care Med 1983;11:362–7.[Web of Science][Medline]
- Harjjet, Jit I, Sahni D. Dimensions and weight of the cricoid cartilage in northwest Indians. Indian J Med Res 2002;116:207–16.[Medline]
- Terasawa E, Fernandez DL. Neurobiological mechanisms of the onset of puberty in primates. Endocr Rev 2001;22:111–51.[Abstract/Free Full Text]
- Harries MLL, Walker JM, Williams DM, et al. Changes in the male voice at puberty. Arch Dis Child 1997;77:445–7.[Abstract/Free Full Text]
- Beckford NS, Rood SR, Schaid D, et al. Androgen stimulation and laryngeal development. Ann Otol Rhinol Laryngol 1985;94:634–40.[Medline]
- Kahane JC. Growth of the human prepubertal and pubertal larynx. J Speech Hear Res 1982;25:446–55.
- Kahane JC. A morphological study of the human prepubertal and pubertal larynx. Am J Anat 1978;151:11–20.[Medline]
- Saez S, Martin PM. Androgen receptors in human pharyngo-laryngeal mucosa and pharyngo-laryngeal epithelium. J Steroid Biochem 1976;7:919–21.[Medline]
- Meston N, Davies RJ, Mullins R, et al. Endocrine effects of nasal continuous positive airway pressure in male patients with obstructive sleep apnoea. J Intern Med 2003;254:447–54.[Web of Science][Medline]
- Becker M. Larynx and hypopharynx. Radiol Clin North Am 1998;36:891–920.[Medline]
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Abstract
Introduction
