Download PDF
J Neurol Surg B Skull Base 2020; 81(03): 237-243
DOI: 10.1055/s-0039-1688795
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Resumption of Positive-Pressure Ventilation Devices for Obstructive Sleep Apnea following Transsphenoidal Surgery: An Institutional Experience of a Surgical Cohort

Nicholas Gravbrot
1   Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Heidi Jahnke
1   Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
William L. White
1   Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
,
Andrew S. Little
1   Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
› Author Affiliations Funding This study received funding from the Barrow Neurological Foundation.
Further Information

Publication History

22 January 2018

26 March 2019

Publication Date:
17 May 2019 (online)

Also available at
   Permissions and Reprints

Abstract

Objectives Transsphenoidal surgery creates a skull base defect that may cause postoperative cerebrospinal fluid (CSF) leakage or pneumocephalus. This study reviewed the institutional experience of a pituitary center in managing patients who use positive-pressure ventilation (PPV) devices for obstructive sleep apnea (OSA) after transsphenoidal surgery, which risks disturbing the skull base repair.

Design Retrospective review.

Setting Pituitary referral center in a major metropolitan medical center.

Methods PPV was resumed at the discretion of the treatment team based on intraoperative findings and OSA severity. Perioperative complications related to resuming and withholding PPV were recorded.

Participants Transsphenoidal surgery patients with OSA using PPV devices.

Main Outcome Measures Intracranial complications before and after resuming PPV.

Results A total of 42 patients met the study criteria. Intraoperative CSF leakage was encountered and repaired in 20 (48%) patients. Overall, 38 patients resumed PPV (median: 3.5 weeks postsurgery; range: 0.14–52 weeks) and 4 patients did not resume PPV. Postoperatively, no patient experienced CSF leakage or pneumocephalus before or after resuming PPV. Four (10%) patients required temporary nocturnal supplemental oxygen at home, one patient was reintubated after a myocardial infarction, and one patient had a prolonged hospital stay due to chronic obstructive pulmonary disease exacerbation.

Conclusions Resuming PPV use after transsphenoidal surgery did not result in intracranial complications. However, delay in resuming PPV resulted in four patients requiring oxygen at home. We propose a preliminary PPV device management algorithm based on the size of the intraoperative CSF leak to facilitate future studies.

Keywords

CPAP - obstructive sleep apnea - positive-pressure ventilation - transsphenoidal surgery

Disclosures

Dr. Little is a stockholder in Kogent Surgical. None of the authors have anything to disclose.


 

  • References

  • 1 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 2007; 60 (04) (Suppl. 02) 295-303 , discussion 303–304
    PubMedGoogle Scholar
  • 2 Kassam AB, Prevedello DM, Carrau RL. , et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 2011; 114 (06) 1544-1568
    Google Scholar
  • 3 Zaidi HA, Awad AW, Bohl MA. , et al. Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma. J Neurosurg 2016; 124 (03) 596-604
    Google Scholar
  • 4 Altinörs N, Arda N, Kars Z. , et al. Tension pneumocephalus after transsphenoidal surgery: case report. Neurosurgery 1988; 23 (04) 516-518
    CrossrefPubMedGoogle Scholar
  • 5 Haran RP, Chandy MJ. Symptomatic pneumocephalus after transsphenoidal surgery. Surg Neurol 1997; 48 (06) 575-578
    CrossrefPubMedGoogle Scholar
  • 6 Sawka AM, Aniszewski JP, Young Jr WF, Nippoldt TB, Yanez P, Ebersold MJ. Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976-1998. J Clin Endocrinol Metab 1999; 84 (12) 4731-4734
    PubMedGoogle Scholar
  • 7 Yüceer N, Cakíroğlu K, Erdoğan A, Gökalp HZ, Bağdatoğlu C. Tension pneumocephalus after transsphenoidal surgery: two case reports. Acta Neurochir (Wien) 1995; 137 (1-2): 58-61
    CrossrefPubMedGoogle Scholar
  • 8 Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 2008; 5 (02) 136-143
    CrossrefPubMedGoogle Scholar
  • 9 Barbosa FR, Silva CM, Lima GA. , et al. Prevalence of obstructive sleep apnea in patients with prolactinoma before and after treatment with dopamine agonists. Pituitary 2014; 17 (05) 441-449
    CrossrefPubMedGoogle Scholar
  • 10 Smith M, Hirsch NP. Pituitary disease and anaesthesia. Br J Anaesth 2000; 85 (01) 3-14
    CrossrefPubMedGoogle Scholar
  • 11 Banu MA, Szentirmai O, Mascarenhas L, Salek AA, Anand VK, Schwartz TH. Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks. J Neurosurg 2014; 121 (04) 961-975
    Google Scholar
  • 12 Bottini P, Tantucci C. Sleep apnea syndrome in endocrine diseases. Respiration 2003; 70 (03) 320-327
    CrossrefPubMedGoogle Scholar
  • 13 Colao A, Ferone D, Marzullo P, Lombardi G. Systemic complications of acromegaly: epidemiology, pathogenesis, and management. Endocr Rev 2004; 25 (01) 102-152
    CrossrefPubMedGoogle Scholar
  • 14 Sze L, Schmid C, Bloch KE, Bernays R, Brändle M. Effect of transsphenoidal surgery on sleep apnoea in acromegaly. Eur J Endocrinol 2007; 156 (03) 321-329
    CrossrefPubMedGoogle Scholar
  • 15 Epstein LJ, Kristo D, Strollo Jr PJ. , et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5 (03) 263-276
    CrossrefPubMedGoogle Scholar
  • 16 Morgenthaler TI, Kapen S, Lee-Chiong T. , et al; Standards of Practice Committee; American Academy of Sleep Medicine. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006; 29 (08) 1031-1035
    CrossrefPubMedGoogle Scholar
  • 17 Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P. ; Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2013; 159 (07) 471-483
    PubMedGoogle Scholar
  • 18 Venkatraghavan L, Perks A. Postoperative management of obstructive sleep apnea after transsphenoidal pituitary surgery. J Neurosurg Anesthesiol 2009; 21 (02) 179-180
    PubMedGoogle Scholar
  • 19 Jarjour NN, Wilson P. Pneumocephalus associated with nasal continuous positive airway pressure in a patient with sleep apnea syndrome. Chest 1989; 96 (06) 1425-1426
    CrossrefPubMedGoogle Scholar
  • 20 Kopelovich JC, de la Garza GO, Greenlee JD, Graham SM, Udeh CI, O'Brien EK. Pneumocephalus with BiPAP use after transsphenoidal surgery. J Clin Anesth 2012; 24 (05) 415-418
    CrossrefPubMedGoogle Scholar
  • 21 Kuzniar TJ, Gruber B, Mutlu GM. Cerebrospinal fluid leak and meningitis associated with nasal continuous positive airway pressure therapy. Chest 2005; 128 (03) 1882-1884
    CrossrefPubMedGoogle Scholar
  • 22 Yared J, El Annan J. Cerebrospinal fluid leak associated with nasal continuous positive airway pressure treatment for obstructive sleep apnoea. BMJ Case Rep 2010; 2010: 201
    PubMedGoogle Scholar
  • 23 Zlotnik D, Taylor G, Simmoneau A, Viot-Blanc V, Devys JM. Two cases of pneumocephalus following noninvasive continuous positive airway ventilation after transsphenoidal neurosurgery [in French]. Ann Fr Anesth Reanim 2014; 33 (04) 275-278
    CrossrefPubMedGoogle Scholar
  • 24 Abdelsattar ZM, Hendren S, Wong SL, Campbell Jr DA, Ramachandran SK. The impact of untreated obstructive sleep apnea on cardiopulmonary complications in general and vascular surgery: a cohort study. Sleep (Basel) 2015; 38 (08) 1205-1210
    CrossrefPubMedGoogle Scholar
  • 25 Nagappa M, Mokhlesi B, Wong J, Wong DT, Kaw R, Chung F. The effects of continuous positive airway pressure on postoperative outcomes in obstructive sleep apnea patients undergoing surgery: a systematic review and meta-analysis. Anesth Analg 2015; 120 (05) 1013-1023
    CrossrefPubMedGoogle Scholar
  • 26 Little AS, Kelly DF, Milligan J. , et al. Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study. J Neurosurg 2015; 123 (03) 799-807
    Google Scholar
  • 27 Gross JB, Bachenberg KL, Benumof JL. , et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104 (05) 1081-1093 , quiz 1117–1118
    CrossrefPubMedGoogle Scholar
  • 28 Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet 2014; 383 (9918): 736-747
    CrossrefPubMedGoogle Scholar
  • 29 Jonas DE, Amick HR, Feltner C. , et al. Screening for obstructive sleep apnea in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2017; 317 (04) 415-433
    CrossrefPubMedGoogle Scholar
  • 30 Javaheri S, Barbe F, Campos-Rodriguez F. , et al. Sleep apnea: types, mechanisms, and clinical cardiovascular consequences. J Am Coll Cardiol 2017; 69 (07) 841-858
    PubMedGoogle Scholar
  • 31 Xie YJ, Shargorodsky J, Lane AP. , et al. Perioperative continuous cerebrospinal fluid pressure monitoring in patients with spontaneous cerebrospinal fluid leaks. Int Forum Allergy Rhinol 2015; 5 (01) 71-77
    CrossrefPubMedGoogle Scholar
  • 32 Jennum P, Børgesen SE. Intracranial pressure and obstructive sleep apnea. Chest 1989; 95 (02) 279-283
    CrossrefPubMedGoogle Scholar
  • 33 Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth 2014; 26 (08) 591-600
    CrossrefPubMedGoogle Scholar
  • 34 White-Dzuro GA, Maynard K, Zuckerman SL. , et al. Risk of post-operative pneumocephalus in patients with obstructive sleep apnea undergoing transsphenoidal surgery. J Clin Neurosci 2016; 29: 25-28
    CrossrefPubMedGoogle Scholar
  • 35 Rahimi E, Mariappan R, Tharmaradinam S, Manninen P, Venkatraghavan L. Perioperative management and complications in patients with obstructive sleep apnea undergoing transsphenoidal surgery: our institutional experience. J Anaesthesiol Clin Pharmacol 2014; 30 (03) 351-354
    CrossrefPubMedGoogle Scholar
  • 36 Wanamaker JR, Mehle ME, Wood BG, Lavertu P. Tension pneumocephalus following craniofacial resection. Head Neck 1995; 17 (02) 152-156
    CrossrefPubMedGoogle Scholar