Management of Obstructive Sleep Apnea Following Endoscopic Skull Base Surgery

Objective: Obstructive sleep apnea (OSA) is associated with an increased risk of postoperative complications following general anesthesia due to the collapse of the pharyngeal airway, resulting in frequent apneic or hypopneic episodes. The presence of OSA in patients undergoing endoscopic skull base surgery imparts unique considerations that require careful management. There is strong support in the anesthesia literature for the maintenance of the nasopharyngeal airway in OSA patients during emergence from general anesthesia, but management of this population following endoscopic skull base surgery is not well characterized. The purpose of this study is to examine our experience with OSA patients undergoing endoscopic skull base surgery and to provide recommendations for management.

Methods: Medical records of all patients undergoing endoscopic skull base surgery at a tertiary care center between November 1, 2009, and September 15, 2012, were reviewed, and patients with a preoperative diagnosis of sleep apnea as well as patients reporting snoring were identified.

Results: A total of 279 patients underwent endoscopic skull base surgery during this time period. Of these, 31 patients either had a preoperative diagnosis of OSA based on nocturnal polysomnography or were suspected of having OSA based on history, body habitus, and airway evaluation. There were 27 men and 4 women, with age range of 23-80 years and BMI range of 22-56 kg/m² (average, 36 kg/m²). Twelve patients (39%) used CPAP preoperatively. Types of lesion included pituitary adenomas (23, 74%), Rathke's cleft cysts (3, 10%), and others (5, 16%). Acromegaly was present in 6 (19%) and Cushing's disease in 1 (3%). A nasal trumpet was placed under direct endoscopic visualization immediately prior to emergence from anesthesia in 30 patients (97%). Except for one patient, in whom the nasal trumpet fell out prematurely a few hours after placement, the nasal trumpet was removed the first postoperative day. There were no incidents of documented respiratory distress or oxygen desaturation.

Conclusion: Patients with OSA undergoing endoscopic skull base surgery provide a unique set of challenges while emerging from general anesthesia. The nasal airway may be compromised by the presence of edema, blood, and surgical packing. In addition, the increased incidence of acromegaly and macroglossia in these patients further impacts pharyngeal patency negatively. A careful history and examination can identify patients at risk for OSA, even without a formal sleep study, to plan perioperative management. The use of a nasal trumpet to secure the nasopharyngeal airway in patients with OSA undergoing endoscopic skull base surgery is well-tolerated and safe, and may decrease the incidence of perioperative OSA-related complications.