Surgical Management of Obstructive Sleep Apnea in Acromegaly With Mandibular Prognathism and Macroglossia: A Treatment Dilemma

Abstract

Acromegaly is a rare disease resulting from chronic growth hormone excess largely owing to a growth hormone-secreting pituitary adenoma. Males and females appear to be equally affected, with an annual incidence of 3 to 4 per million. The diagnosis of the disease often occurs late, with an average age of 40 years, owing to its insidious onset and slow progression. 1 The prominent cosmetic features include enlarged extremities, thickened skin, widened nose, prominent cheekbones, course facial lines, and, occasionally, frontal bossing. The oral manifestations include mandibular overgrowth, resulting in prognathism, maxillary widening, dental malocclusion, macroglossia, and enlarged lips. 2 Systemic manifestations, including rheumatologic, cardiovascular, respiratory, and metabolic consequences, determine the prognosis. Obstructive sleep apnea (OSA) has been reported with a frequency of 60%. 3 The treatment of acromegaly is directed at reducing the growth hormone and insulin-like growth factor 1 levels to normal values and excising the adenoma. The present available therapies for acromegaly include transphenoidal surgery, radiotherapy, and medical therapy. 4 Although many of the systemic manifestations of acromegaly can be relieved with growth hormone homeostasis, relevant OSA remains. This can often be attributed to skeletal and soft tissue craniofacial changes that remain despite treatment of the primary condition. The treatment dilemma arises when attempts are made to correct the facial deformities by reducing hyperplastic bone, resulting in a decreased posterior airway space and worsening OSA. 3