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The Effects of Positive Airway Pressure on the Middle Ear: Systematic Review and Meta-Analysis
Joseph Krivda1, Jessica Lewis-Cruz1, Zachary Nygren1
1Department of Otolaryngology-Head & Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, USA.
Objectives:
To systematically review the literature evaluating the effects of positive airway pressure (PAP) on the middle ear and to perform a meta-analysis of its impact on middle ear pressure (MEP), tympanic membrane (TM) morphology, and hearing outcomes.
Data Sources:
Pubmed, MEDLINE, OVID, Scopus, Web of Science, and the Cochrane Library.
Methods:
A systematic search was performed from database inception through November 1, 2025, following PRISMA guidelines. Studies reporting quantitative middle ear outcomes following PAP were included. Meta-analyses were performed using a random-effects model of MEP, TM retraction grade, and pure tone average (PTA).
Results:
Nine studies met inclusion criteria. PAP therapy demonstrated a significant dose-dependent increase in MEP (R2 = 0.9516, p < 0.0001). Meta-analysis of MEP at a setting of 10 cm H20 showed a pooled mean increase of 51.4 daPa (p < 0.00001). Swallowing was found to be a prerequisite for significant pressure transfer to the middle ear. In patients with Eustachian tube dysfunction and TM retraction, continuous PAP use was associated with significant morphological improvement in TM retractions (p = 0.002) and a mean improvement in PTA of 7.3 dB HL (95% CI 3.45, 11.17, p = 0.0002).
Conclusion:
PAP increases MEP in a dose-dependent manner, a finding of interest to otologic surgeons. In addition to its role in sleep medicine, PAP therapy may serve as a noninvasive treatment for chronic Eustachian tube dysfunction and TM retraction. Further prospective studies are needed to guide management conclusions for otologic patients utilizing PAP, particularly in the postoperative setting.
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