Abstract
Background
Concerns with barotrauma after otologic surgery are well-established, but rarely is continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) considered despite evidenced impacts on middle ear pressure. With increasing CPAP use, it is vital to investigate CPAP’s role in middle ear physiology and otologic barotrauma.
Case presentation
A 47-year-old male presented with sudden complete right hearing loss. He had a history of bilateral otosclerosis treated with bilateral stapedotomies years prior. His right ear required revision complicated by otitis media and bacterial labyrinthitis. His hearing had been stable for years prior to the sudden loss. Initial treatment was antibiotics and nasal steroids for presumed otitis media. Medical history confirmed OSA treated with CPAP.
Otoscopy demonstrated intact ear drums without middle ear fluid. No nystagmus was observed. An audiogram demonstrated worsened right mixed hearing loss. Oral corticosteroids were prescribed, and a temporal bone computed tomographic (CT) scan was ordered. The patient’s hearing did not improve, and the CT scan demonstrated a well-positioned stapes prosthesis and air in the vestibule consistent with pneumolabyrinth.
The patient was offered hearing aids, exploratory middle ear surgery, or cochlear implantation. He elected for cochlear implantation. CPAP was suspended postoperatively. After activation, his hearing improved dramatically. Six-month postoperative CT scan demonstrated no pneumolabyrinth.
Conclusions
Postoperative CPAP utilization confers increased risk of barotrauma and warrants prolonged vigilance for complications in patients undergoing stapedotomy. Otologists should consider CPAP’s role in sudden hearing loss after otologic surgery. Further investigation into the physiology of CPAP and pneumolabyrinth is warranted.
Highlights
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Continuous positive airway pressure is a risk for postoperative ear barotrauma.
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Postoperative perilymphatic fistula formation can occur many years postoperatively.
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Postoperative continuous positive airway pressure suspension should be considered.
Introduction
Perilymphatic fistulae (PLF) are abnormal communications between the perilymph-filled inner ear and the air-filled middle ear and mastoid or cranial spaces, and etiologies include head trauma, otic capsule dehiscence, and barotrauma [ ]. Barotrauma-induced PLFs result from increased middle ear pressure from activities associated with increased external pressures, such as SCUBA diving, or internal pressures, such as Valsalva [ , ]. The pressure is transmitted through points of weakness such as the fissula ante fenestrium or weakness related to middle ear surgery as in stapedectomy. Continuous positive airway pressure (CPAP), a common treatment for obstructive sleep apnea (OSA), can elevate middle ear pressures to supraphysiologic levels in patients with normal eustachian tube function [ ]. However, contemporary literature investigating the relationship between CPAP and PLFs is scarce [ ]. Furthermore, the risk of CPAP use after middle ear surgery is unknown. We present a patient who developed a PLF many years after stapedotomy while on CPAP treatment, illustrating CPAP as a potential cause of PLF.
Case Presentation
A 47-year-old male with a history of bilateral otosclerosis treated with bilateral stapes surgery presented to the otolaryngology clinic with a history of recent sudden complete right hearing loss. Two weeks earlier he had presented to the emergency department for the hearing loss and associated otalgia and was treated with oral antibiotics and nasal steroids for presumed otitis media without benefit. He denied any history of rapid pressure changes, such as sneezing. Surprisingly, he denied vertigo. His complete otologic surgical history starts with a successful right stapedotomy twelve years prior, followed by right revision stapedotomy for a displaced prosthesis ten years prior complicated by acute otitis media and bacterial labyrinthitis, and then successful left stapedotomy four years prior. His past medical history includes OSA treated with CPAP. After right ear revision stapedotomy and left ear stapedotomy, his hearing became stable. The most recent audiogram five months earlier demonstrated right ear mild to severe high frequency sensorineural hearing loss and left ear mild to moderate mixed hearing loss ( Fig. 1 a).
