Table 3

 Prominent symptoms of acromegaly

• Growth of hands and feet: successive wedding ring enlargements and requirement for wider and sometimes longer shoe fittings is typical
• Coarsening of facial features: enlargement of distal nasal cartilage leading to a slightly globular nasal shape, prominence and eversion of the lower lip, and an increasing tendency to bite the tongue and cheeks
• Carpal tunnel syndrome: bilateral and recurrent in untreated disease
• Snoring and obstructive sleep apnoea: a major problem sometimes requiring continuous positive airways pressure or surgery
• Jaw growth: prognathism, separation of teeth, malocclusion, and temporal joint arthralgia are common; restoration of occlusion by advancement of the maxilla rather than recession of the mandible reduces the chance of exacerbating obstructive sleep apnoea
• Osteoarthritis and arthralgia: premature and widespread, this is often a significant ongoing problem for patients that once established is not ameliorated by effective control of acromegaly
• Headache: occasionally dramatically responsive to somatostatin analogues, headaches affect at least 50% of acromegalics and closely mimic classical migraine, lateralised or global headaches, and tension headache
• Excessive sweating: a prominent and inexplicable symptom in some patients
• Dysmorphophobia: a distressing preoccupation with defects in appearance