Current Management of CPAP After Otologic and Neurotologic Surgery

Immediate CPAP Use after Skull Base Reconstruction with Hydroxyapatite Bone Cement

OBJECTIVE

The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic medical center.

PATIENTS

Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022.

INTERVENTIONS

CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT).

MAIN OUTCOME MEASURES

Postoperative skull base defects on CT, pneumocephalus, or intracranial complications.

RESULTS

The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m 2 . Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively.

CONCLUSION

Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.

Acute pneumolabyrinth: a rare complication after cochlear implantation in a patient with obstructive sleep apnoea on CPAP therapy

Pneumolabyrinth is a condition characterised by the presence of air within the inner ear and is a rare complication after cochlear implant surgery. One of the causes of pneumolabyrinth may be the increase in pressure in the middle ear. The use of continuous positive airway pressure (CPAP) is an effective treatment strategy for obstructive sleep apnoea. According to a recent study, the use of CPAP should be delayed by 1 or 2 weeks in subjects undergoing middle ear surgery; however, there is currently no indication to delay the CPAP in subjects undergoing cochlear implant surgery. We report the case of a patient on CPAP who underwent left cochlear implantation and, in the early postoperative period, reported severe vertigo and tinnitus. Cone-beam CT of the temporal bone revealed the presence of pneumolabyrynth. We believe that the use of CPAP should be delayed in subjects undergoing cochlear implantation to avoid the development of acute pneumolabyrinth.

Predictive Patient Factors for Poor Outcomes Following Stapedotomy for Otosclerosis

OBJECTIVE

To assess patient-related risk factors associated with poor outcomes following stapedotomy for otosclerosis.

STUDY DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

METHODS

Retrospective chart review of 107 patients with otosclerosis who underwent stapedotomy between 2013 and 2020. Demographics, comorbidities, and smoking history were obtained. Preoperative and postoperative audiogram data, including air-bone gap (ABG), and complications were collected. Data were analyzed using t test and Fischer's exact test for continuous and categorical variables, respectively.

RESULTS

Among 107 patients, 29.5% were smokers and 70.1% non-smokers. Overall, the average ABG-gain 3-months postoperatively was 20.2 dB, and intraoperative and postoperative complications were 3.74 and 13.1%, respectively. Those with a history of otologic procedures had a lower mean ABG gain at 3 months compared with those without previous otologic surgery (14.4 dB versus 20.4 dB, p = 0.018). The average ABG gain at 3-months was not significantly different between those with current, former, or no smoking history, respectively (13.5 versus 18.1 versus 20.6, p = 0.08). Current smokers had 4.5 times greater odds of complications compared with non-smokers, although not statistically significant (95% CI 0.9-22.8, p = 0.1912).

CONCLUSION

Age and history of otologic procedures as independent risk factors did impact hearing outcomes among our patient cohort; however, smoking history did not. Future prospective studies are required to further investigate complication rates by various modifiable risk factors, such as smoking status, body mass index (BMI), and obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) use, for stapedotomy surgeries.

The Effect of CPAP on Middle Ear Pressure: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the effect of short-term and long-term continuous positive airway pressure (CPAP) use on middle ear pressure (MEP) in adult ears.

DATABASES REVIEWED

PubMed, Scopus, and Embase were searched through October 2020. Search strategies used a combination of subject headings (e.g., MeSH in PubMed) and keywords for CPAP and middle ear pressure.

METHODS

English-language articles studying changes in MEP as measured by tympanometry or tympanograms in patients using CPAP were selected for inclusion. Data extraction from included articles included demographics, baseline, and follow-up data.

RESULTS

A total of 7 articles representing 664 patients with weighted mean age of 42.5 years (range 34.9-57.8 yrs) were included. Meta-analysis of three qualifying studies demonstrated a positive correlation between higher CPAP pressures and degree of MEP rise during CPAP use compared to baseline with mean difference of 25.1 daPa (95% confidence interval [18.7, 31.4]) at 5 cm H2O and 81.9 daPa (95% confidence interval [60.2, 103.5]) at 10 cm H2O. Short-term effects of CPAP use were reviewed in four studies that showed a transient rise in MEP. Three separate studies examining the long-term effects of CPAP use showed resting MEP was higher in patients with severe obstructive sleep apnea (OSA), which might be related to progressive eustachian tube dysfunction as a complication of severe OSA.

CONCLUSION

Short-term CPAP use is associated with transient elevations of MEP in adult ears. Long-term CPAP use might produce beneficial MEP changes, especially in patients with OSA and eustachian tube dysfunction.

Subcutaneous Air Around Receiver-Stimulator Causing Open-Circuit Failures: An Uncommon But Readily Treatable Condition Related to CPAP Use After Cochlear Implant Surgery

OBJECTIVE

To raise awareness of a unique complication associated with continuous positive airway pressure (CPAP) use after cochlear implantation to improve early detection, prevent unnecessary testing, and facilitate treatment.

STUDY DESIGN

Case series.

SETTING

Tertiary referral center.

SUBJECTS

Patients who developed subcutaneous air around the receiver-stimulator device and the associated ground electrode in the setting of CPAP usage, which resulted in open-circuit electrode failures.

MAIN OUTCOME MEASURES

Clinical course and intervention.

RESULTS

Two patients were identified that fit this criterion. Both patients were noted to have poor implant performance secondary to high or open impedances and concomitant emphysema surrounding the cochlear implant receiver-stimulator. Manual massage offered transient improvement, but programming changes ultimately led to improved sound quality and resolution of impedance anomalies in both cases.

CONCLUSIONS

Subcutaneous air collection surrounding the cochlear implant receiver-stimulator in the setting of CPAP use is an uncommon but clinically relevant complication that can be recognized by characteristic physical examination findings and impedance changes. Early and accurate recognition of this event can prevent unnecessary testing and facilitate early effective treatment.