Risk of Postoperative Complications in Patients with Obstructive Sleep Apnea following Skull Base Surgery

Abstract

Objectives Obstructive sleep apnea (OSA) presents several challenges in skull base surgery, including increased intracranial pressure, worsened OSA with nasal packing, and avoidance of positive airway pressure (PAP) therapy postoperatively. The objective of this study was to examine the risk of postoperative complications in a skull base population with OSA in which PAP therapy is withheld. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Medical records of 414 adult patients undergoing anterior skull base procedures between January 1, 2014, and January 7, 2017, were retrospectively reviewed. Revision surgeries, skull base infections, sinus surgery, and orbital cases were excluded. Results Fifty-four (13.0%) patients with a diagnosis of OSA were identified. While the known patients with OSA were more likely to require postoperative supplemental oxygen (odds ratio [OR], 4.29; 95% confidence interval [CI], 2.38-7.75; P < .001), there was no increased risk of serious respiratory events or cerebrospinal fluid leak (CSF). To address the likely underdiagnosis of OSA in this cohort, subgroup analyses were performed of patients at high risk for OSA (body mass index >30 kg/m and hypertension) and demonstrated an increased risk of serious respiratory events (OR, 4.41; 95% CI, 1.24-15.7; P = .034) and CSF leak (13.6% vs 4.7%; P = .018). Conclusions Skull base patients with known OSA can be successfully managed with diligent care in the perioperative period when PAP therapy is withheld. However, OSA is likely underdiagnosed in the skull base population, and patients at high risk for undiagnosed OSA may be at the greatest risk for respiratory complications and CSF leak. Increased presurgical awareness and implementation of a perioperative management algorithm is needed.

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity

“…17 Specifically in patients who have undergone endonasal skull base surgery, those with OSA have a higher risk of hypoxia postoperatively. [18][19][20][21] There is clearly a need to identify a balance between the risks and benefits of postoperative CPAP, but the direct effect of CPAP on the intranasal cavity remains unknown. We acknowledge that there are many factors that contribute to the decision of when to reinitiate CPAP after endoscopic sinus and skull base surgery.…”

Evaluation of cranial base repair techniques utilizing a novel cadaveric CPAP model

“…Comorbid OSA in patients undergoing endonasal skull base surgery increases the risk of obstructive events and hypoxemia, as well as pulmonary and airway complications in the postoperative setting . As a result, management of these patients represents a significant clinical challenge.…”

Preoperative Screening for Obstructive Sleep Apnea Prior to Endoscopic Skull Base Surgery: A Survey of the North American Skull Base Society

“…7,8 Additionally, postoperative care of patients with skull base defects and underlying OSA is complicated by the risks of CPAP delivery to the sinonasal cavity which may lead to epistaxis, graft disruption, or pneumocephalus. 7,11,14,15 Practice guidelines for the perioperative management of patients with OSA have been developed by the American Society of Anesthesiologists. In the postoperative period, the guidelines recommend minimizing systemic opioids, monitoring with continuous pulse oximetry, non-supine positioning, and administering CPAP (if used by patient preoperatively and not contraindicated) or at least providing supplemental oxygen.…”

“…In addition, patients with idiopathic intracranial hypertension have a greater risk of cerebrospinal fluid leaks and OSA. [7][8][9] The perioperative timeframe is a period in which patients with OSA are at high risk for complications due to adverse effects from anesthesia, narcotics, and other sedatives. 6 The gold standard treatment of OSA is continuous positive airway pressure (CPAP) and some patients may require CPAP in the immediate postoperative period to manage OSA symptoms.…”

“…10 Positive airway pressure may present risks to postoperative patients with skull base defects and most recent research has focused on postoperative management of OSA in patients undergoing endoscopic skull base surgeryfrom timing of CPAP initiation to modification of skull base reconstruction. 7,[11][12][13][14][15] Preoperative screening of surgical patients for OSA has been identified as a way to anticipate and mitigate potential postoperative risks posed by OSA. 6,16,17 However, little is currently known about practice patterns by endoscopic skull base surgeons to screen for OSA in this patient population.…”