Early CPAP use after anterior skull base surgery: A cautionary tale of postoperative CSF leak case report

Continuous positive airway pressure (CPAP) therapy is standard of care for obstructive sleep apnea (OSA) but is often discouraged after skull base surgery due to serious potential risks. Halting CPAP can negatively impact patients' quality of life and worsen postoperative cardiopulmonary complications. Identifying appropriate timing to resume CPAP following extended skull base approaches is essential, as recent literature mainly explores early CPAP safety after transsphenoidal surgery.

We report a 51-year-old male with OSA who developed a post-operative cerebrospinal fluid (CSF) leak from pre-emptive CPAP use following endoscopic anterior skull base inverted papilloma resection. Dura remained intact without an intraoperative CSF leak and bilateral nasoseptal flaps (NSF) were used for skull base coverage. Despite counseling on CPAP avoidance, the patient restarted CPAP on POD21 and developed clear rhinorrhea. Computed tomography showed mild pneumocephalus. Urgent exploration revealed a left dural tear and the NSFs had separated in the midline. This was repaired with abdominal fat and NSF repositioning. The patient recovered well and was cleared for CPAP use on day 57 after repair without further issues.

This case highlights the complexities and potential risks of resuming CPAP early after extended skull base approaches, for which standardized guidelines are lacking. Effective postoperative care is crucial for balancing CPAP benefits with risks, underscoring the need for further research on CPAP transmission to the anterior cranial fossa to optimize perioperative patient outcomes.