SAT-028 - Acute Airway Compromise in Acromegaly from Bilateral Vocal Fold Immobility

Introduction: Acromegaly is a rare endocrine disorder commonly caused by chronic excess growth hormone secretion from a pituitary adenoma. Diagnosis is frequently delayed due to an insidious onset of symptoms, including coarse facial features and metabolic or cardiovascular co-morbidities. While voice changes are frequently reported, clinically significant reductions in vocal fold (VF) motion are exceedingly rare, with only a few cases reported to date. We describe a case of acromegaly presenting with stridor due to bilateral VF immobility.

Case Description: A 45-year-old male with T2D, class III obesity, HTN, HLD, multiple colon polyps, and nasal turbinate hypertrophy presented to the emergency department with progressive difficulty breathing and stridor. An urgent flexible laryngoscopy was performed revealing minimal abduction of both true VF and a narrowed glottic opening. Due to respiratory distress and hypercarbia, tracheostomy and direct laryngoscopy were performed. Intraoperative findings included passively mobile bilateral cricoarytenoid joints. On further evaluation, he reported chronic increases in shoe, ring, glove, and hat sizes; decreased libido; weight gain; and difficulty breathing while asleep. Physical exam revealed frontal bossing, prognathism, dental spacing, macroglossia, acrochordons, and large doughy hands. 8 AM Labs showed IGF-1 725 ng/mL, 607 ng/mL, and 1185 ng/mL (ref 52-328 ng/mL), prolactin 20.7 ng/mL (ref < 15 ng/mL), cortisol 8.3 ug/dL (ref 4-20 ug/dL), ACTH 108 (ref 7.2-63.3 pg/mL), TSH 2.27 uU/mL (ref 0.3-4.2 uU/mL), free T4 1.0 ng/dL (ref 0.6-1.5 ng/dL), total testosterone 254 ng/dL (ref 250-1100 ng/dL), FSH 5.9 mIU/mL, and LH 4.7 mIU/mL. LNSC were 0.03 mcg/dL and < 0.03 mcg/dL (ref < 0.09 mcg/dL). Pituitary MRI identified an 8 x 9 mm heterogeneous sellar mass with leftward stalk deviation. He underwent transsphenoidal pituitary resection. Pathology confirmed a densely granulated pituitary neuroendocrine tumor with IHC positivity for PIT1, GH, and PRL. At 4 months post-operatively, IGF-1 normalized to 255 ng/mL demonstrating cure and flexible laryngoscopy showed persistent limited bilateral true VF abduction with minimal motion at the arytenoids. The patient remains with tracheostomy.

Conclusion: Bilateral VF immobility is a rare but potentially life-threatening manifestation of acromegaly. Early recognition is critical as urgent tracheostomy may be required for airway protection. The mechanisms underlying VF motion impairments in this setting remain unclear; potential causes include arthritic changes of the cricoarytenoid joints, cartilaginous enlargement, and recurrent laryngeal nerve stretch injury. Some reported cases suggest that VF immobility may be reversible with timely treatment of acromegaly, underscoring the importance of early diagnosis to both secure the airway and to optimize recovery of VF mobility.

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