Safety of restarting continuous positive airway pressure (CPAP) therapy following endoscopic endonasal skull base surgery. Issue 1 (31st March 2022)

• Record Type: Journal Article
• Authors: Chaskes, Mark B.; Rabinowitz, Mindy R.
• Other Names: Gudis David guestEditor.
• Is Part Of: World journal of otorhinolaryngology-head and neck surgery. Volume 8:Issue 1(2022)
• Page Start: 61
• Page End: 65
• Publication Date: 2022-03-31
• Subjects: Continuous positive airway pressure -- Endoscopic skull base surgery -- Obstructive sleep apnea -- Transsphenoidal surgery; Otolaryngology; Head -- Surgery; Neck -- Surgery; Periodicals; 617.51
• DOI: 10.1016/j.wjorl.2021.07.002
• Languages: English
• ISSNs: 2095-8811

Abstract

Abstract: Objectives: Patients with obstructive sleep apnea (OSA) are at increased risk of perioperative and postoperative morbidity. The use of continuous positive airway pressure (CPAP) in the perioperative period may be of potential benefit. However, among patients who have undergone endonasal skull base surgery, many surgeons avoid prompt re‐initiation of CPAP therapy due to the theoretical increased risk of epistaxis, excessive dryness, pneumocephalus, repair migration, intracranial introduction of bacteria, and cerebrospinal fluid (CSF) leak. The objective of this article is to review the most up‐to‐date literature regarding when it is safe to resume CPAP usage in the patient undergoing endonasal skull base surgery. Data Sources and Methods: This review combines the most recent literature as queried through PubMed regarding the safety of CPAP resumption following endonasal skull base surgery. Results: Recent surveys of skull base surgeons demonstrate little consensus regarding the post‐operative management of OSA. Recent cadaveric studies suggest that approximately 85% of delivered CPAP pressures are transmitted to the sphenoid sinus. Further, at frequently prescribed CPAP pressure settings, common sellar reconstruction techniques maintain their integrity while preventing very little transmission of pressure into the sella. In small retrospective case series, patients with OSA who received CPAP immediately following transsphenoidal pituitary surgery had similar rates of surgical complications as OSA patients who did not receive CPAP in the immediate post‐operative period. Concerns of re‐initiating CPAP too early, such as the development of pneumocephalus, rarely develop. Conclusions: There remains a paucity of objective data regarding when it is safe to resume CPAP following endonasal skull base surgery. Recent cadaveric studies and small retrospective case series suggest that it may be safe to resume CPAP earlier than is often practiced following endonasal skull base surgery. Key points: There is no consensus regarding the time course of when it is safe to resume CPAP therapy following endonasal skull base surgery. Following endonasal skull base surgery there are potentially unique risks of initiation of CPAP including epistaxis, excessive nasal crusting/drying, graft migration, pneumocephalus, CSF leak, and intracranial introduction of bacteria. Cadaveric modeling suggests that only a fraction of the delivered CPAP pressure is actually transmitted into the sella, and even the simplest sellar repair techniques can withstand low to moderate pressures. Small case series' do not demonstrate increased rate of post‐operative complications in patients with OSA who received CPAP immediately after surgery. The decision to start CPAP postoperatively must be tailored to each patient based on the severity of his/her OSA, intraoperative findings, and the type of skull base repair employed.