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Paediatric Patient With Acromegalic Features and Mallampati Class Zero Airway: A Rare Association.

To JNA Readers: Acromegaly is a medical condition characterized by oversecretion of growth hormone (GH) which can occur secondary to either excessive secretion of GH releasing hormone from the hypothalamus or GH from the pituitary gland itself. GH excess in pediatric patients (gigantism) can also occur before epiphyseal fusion and manifest with the characteristic physical features of acromegaly consisting of acral enlargement, thick eyelids, and coarse features. Apart from the constellation of physical manifestations, macroglossia, prognathism, malocclusion, hypertrophy of laryngeal soft tissues, epiglottis, and aryepiglottic folds can complicate conventional airway management in acromegalics. Acromegalic individuals are therefore, well recognized as patients having difficult airway with a 4-fold to 5-fold higher incidence of difficult intubation as compared with normal subjects.1 The traditional Mallampati scoring (MPS) which consisted of 4 classes (I, II, III, and IV) was modified by Ezri et al by addition of a class 0 (zero) which suggested that a visible epiglottis on mouth opening was a predictor of excellent grade I laryngoscopy.2 Prabhakar et al3 had previously reported the unusual finding of MPS class zero in an adult acromegalic patient which was revealed during preanesthetic airway assesment. We recently encountered a pediatric patient with acromegalic features who presented with MPS class zero. To the best of our knowledge, this finding has not been reported till date. After obtaining written consent from the patient’s guardians we wish to report this association. An 11-year-old male patient diagnosed with functioning pituitary microadenoma was posted for transsphenoidal excision of tumor. He had characteristic acromegalic features in the form of thickened lips, large nose, macroglossia, thickened skin, and enlarged mandible. During the airway assessment of the patient in the preoperative period, we discovered that the patient had a visible epiglottis on mouth opening in both the sitting and supine positions (Fig. 1). Rest of the relevant preanesthetic findings were unremarkable. For induction of anesthesia, the patient was administered intravenous general anesthetics. He could be satisfactorily ventilated through face mask and the trachea could be intubated easily using conventional laryngoscopy (Cormack and Lehane Grade I visualization). He had an uneventful surgical course and could be extubated safely at the completion of surgery. A higher incidence of class zero airways has been observed in pediatric patients. Anatomic reasons implicated for the same includes the lack of caudal descent of larynx with increasing age. Inspite of the general belief that MPS class zero is an indicator of a technically easier airway to secure, in sporadic situations, airway management has actually been complicated due to presence of a visible epiglottis. Previous reports have described difficult mask ventilation and intubation in patients with MPS class zero airways. The overhanging epiglottis acting as a flap blocking the glottic opening during positive pressure ventilation and impeding the laryngeal view is the explanation for these situations.4,5 We, however, did not experience these problems and the airway FIGURE 1. Epiglottis (arrow) is seen on mouth opening in the pediatric patient with acromegalic features.