A pea-sized gland that sits snug at the base of the skull plays crucial enough a role to cause havoc if disturbed. Thankfully, modern medicine now allows for us to reach it effortlessly through the nose
This picture has been used for representation purpose
My wedding ring doesn't fit anymore, doctor!" said David, 47, a prosperous banker. Before he completed his story, his chatty wife downplayed the symptoms: "I think it's his excuse to want to appear single again!" I smiled.
"Every few months, he says his shoes don't fit. He gets jazzier pairs, and also says he can't see clearly. So, he goes and buys a new set of glasses. His jaw is now prominent and he walks around like John Travolta. He speaks in this hoarse voice, trying to sound hot and all," she concluded, placing her palms on the table to give me her final diagnosis.
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Just when I thought she was done, she added, "Please ask him to lose weight."
"Let me know if you remember anything else you're missing," I said, turning my attention to the patient.
"My head hurts and I get tired soon," David said, "And my vision is a bit blurry. I've suddenly grown all over and look like a giant in the mirror."
I held his hands as he outstretched them to gesticulate what he was describing.
The wife pulled out a picture of their wedding day from 15 years ago. He looked like another man. The difference was like between David and Goliath, but they were the same person.
"You've got acromegaly," I said, going straight to the point after an examination. The hormonal disorder develops when the pituitary gland produces excessive amounts of the growth hormone during adulthood. The bones and soft tissues increase in size, leading to the symptoms David described.
The pituitary or hormone-producing gland is the size of a pea and receives messages from the hypothalamus to stimulate all other hormone-producing glands. It for instance, controls the thyroid, and tells the kidneys how much water to conserve by producing the vasopressin hormone.
I asked for an MRI of the brain, an eye check-up, and a battery of blood tests to see if any other hormone was affected. As he rose, David asked calmly, "What do I do about the headache?
"Stay away from her for a while!" I wanted to say, as I scribbled a prescription. They returned with the reports in a few days, hand-in-hand. As expected, the scan revealed a 3-cm tumour in the pituitary gland, pressing on his optic nerves, causing the diminution in vision. "This tumour is producing the excess growth hormone," I pointed out on the MRI, "and we have to remove it with an operation because it is also pressing on your optic nerves." The good bit was that we didn't need to open his head like neurosurgeons would've done a few decades ago. We could remove it using a specialised endoscope from the nose.
Multiple questions later, they agreed to the surgery.
Medical experts believe that Goliath, the Philistine giant mentioned in the biblical Book of Samuel, also had pituitary adenoma, leading to his size.
The endoscope, when manoeuvred through the small structures of the nose that clean and humidify air, allows you to reach the base of the skull, where, in a small depression of the bone resides the pituitary gland smack between the carotid arteries, the main arteries supplying blood to the entire brain. Through the nostrils, we got a panoramic view as we took multiple pieces of the tumour and removed them completely, making sure we preserved the normal gland, which looked a little firmer and more pinkish.
Each time I perform this operation, I think of Dr Ari Chacko, my mentor who trained me in this surgery. His exuberant enthusiasm on seeing the normal pituitary gland after removing the tumor, flashes before my eyes. I secretly wish that I can operate like him one day.
We reconstructed the base of the skull and within a few hours after surgery, David confirmed that his vision appeared brighter.
Three months later, he had lost the weight and his wife was delighted that the ring fit again. His growth hormone levels came back to normal. I told him he was cured but had to continue following up with me for the rest of his life. "My headache is gone," he said. I looked at the wife wondering if she had anything to say. "I'm happy he's my David again, not Goliath."
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals. You can reach him at mazdaturel@gmail.com
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