From the Guidelines
Positive airway pressure (PAP) therapy is not directly associated with a risk of causing skull base fractures, but it may be contraindicated in patients with existing skull base fractures due to the potential for exacerbating complications such as pneumocephalus. The provided evidence 1 focuses on the management of obstructive sleep apnea (OSA) and the benefits of PAP therapy in improving morbidity, mortality, and quality of life, but it does not directly address the risk of skull base fractures associated with PAP therapy. However, based on general medical knowledge, the application of positive pressure to the airway can potentially force air through fracture lines into the cranial cavity in patients with existing skull base fractures, leading to serious complications. Key considerations for healthcare providers include:
- Evaluating patients for skull base fractures before initiating PAP therapy, especially following head trauma
- Considering alternative ventilation strategies for patients with known or suspected skull base fractures who require respiratory support
- Being aware of the potential risks and benefits of PAP therapy in patients with complex medical conditions. The primary goal is to prioritize patient safety and minimize the risk of complications, particularly in cases where PAP therapy may be contraindicated or require careful consideration, as supported by the principles of managing OSA and its associated risks 1.
From the Research
Risk of Skull Base Fractures with PAP Therapy
- The use of Positive Airway Pressure (PAP) therapy may carry a risk for skull base fractures, particularly in patients with pre-existing skull base defects or fractures 2.
- A study from 1980 reported a case of pneumocephalus, a potentially dangerous complication of continuous positive airway pressure (CPAP), which was caused by a fracture of the base of the skull that was not recognized despite neurologic and radiologic evaluation at admission 2.
- However, more recent studies suggest that the risk of skull base fractures or complications may be lower than previously thought, and that CPAP therapy can be safely resumed after endonasal skull base surgery in patients with obstructive sleep apnea (OSA) 3, 4.
- Cadaveric studies and small retrospective case series have shown that CPAP pressures are transmitted to the sphenoid sinus, but that common sellar reconstruction techniques can maintain their integrity and prevent transmission of pressure into the sella 3.
- Surveys of skull base surgeons have found that there is little consensus regarding the post-operative management of OSA, and that the use of postoperative CPAP and nasal saline rinses varies widely among surgeons 4.
Complications of Skull Base Fractures
- Skull base fractures can be complex and challenging to repair, and may require a multi-layered approach to achieve successful repair 5.
- The goal of successful anterior skull base repair involves creating a durable, watertight separation between intra and extracranial compartments to prevent cerebrospinal fluid (CSF) leak, protect intracranial structures, and minimize infection risk 5.
- CSF leaks are a common complication of skull base fractures, and can be predisposed by even small fractures and traumatic shear forces 6.
- The management of skull base fractures requires careful preoperative, intraoperative, and postoperative management to prevent complications and promote successful repair 6.