The main side effects of CPAP therapy are typically mild and include dryness of the nasal and oral mucosa, sneezing, congestion, aerophagia, sinusitis, and epistaxis. The risks of CPAP therapy should also be considered when evaluating treatment options for patients with OSA. The recommendations state that the minimum starting CPAP should be 4 cm H 2O in adult patients and should be titrated to the lowest possible pressure at which apneic/hypopneic events are eliminated, to a maximum pressure of 20 cm H 2O. 2 This was the first set of clinical guidelines created in an effort to standardize the manual titration of CPAP. In 2008, the Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine published clinical guidelines for the manual titration of CPAP in patients with OSA. A perilymph fistula was suspected however, the patient elected not to undergo exploratory tympanotomy because of the improvement in his hearing loss. At follow-up 2 weeks after presentation, a repeat audiogram demonstrated more significant improvement in hearing ( Figure 1D), and the patient was followed on an as-needed basis thereafter. A repeat audiogram performed 1 week after initial presentation revealed modest improvement in hearing ( Figure 1C). The patient was started on a prednisone taper and ciprofloxacin but had no improvement in hearing or tinnitus at follow-up 3 days later. The ossicles appeared to be intact, and the inner ear structures appeared to be normal. A computed tomography scan of the temporal bones showed complete opacification of the right middle ear cavity and right mastoid air cells ( Figure 2). Audiometry revealed significant mixed hearing loss in the right ear ( Figure 1B). On the day his hearing loss began, he recalled turning the CPAP up to the maximum allowed setting.Īudiograms were performed and compared with baseline audiograms performed in 2007 ( Figure 1A). Further questioning revealed a history of weight gain and subjective improvement in his OSA symptoms as he systematically increased the pressure on his CPAP machine. During examination, no perforation of the tympanic membrane was observed however, there was evidence of a significant clear serous effusion. He also reported sudden onset tinnitus but denied any symptoms of vertigo. The patient was seen intermittently during the next 4 years until 2011, when he presented to the clinic with a 1-week history of sudden hearing loss with the sensation of aural fullness, pain, and a pop sound in the right ear that had begun suddenly after excessive self-titration of CPAP. Snoring and apneic events were eliminated at a pressure of 15 cm H 2O. The patient subsequently underwent a CPAP titration study. He had never been titrated for CPAP therapy and had returned to the clinic at this time because of worsening symptoms. Polysomnography at the time of diagnosis revealed an apnea-hypopnea index of 57.5 with oxygen desaturations to 84%. He reported that in 2005 he was diagnosed with OSA. 3 We present a case of otic barotrauma resulting from excessive self-titration of CPAP in an in-home setting.Ī 50-year-old obese male presented in 2007 with a concern of snoring. 2Īdverse effects from CPAP use are numerous and most commonly include congestion, dryness of the oral and nasal cavities, aerophagia, epistaxis, sneezing, and sinusitis. The goal of the titration study is to establish the minimal pressure at which snoring ceases and apneic or hypopneic events are absent. The pressure required for individual patients is variable and is determined by careful manual titration of pressures during a CPAP titration study. 2 CPAP prevents the collapse of the upper airway by providing continuous positive pressure to the oropharynx and nasopharynx. The traditional treatment for patients with OSA is continuous positive airway pressure (CPAP). This collapse causes the characteristic apneic or hypopneic events that define the diagnosis of OSA. The pathophysiology of OSA is postulated to be related to decreased parasympathetic activity during sleep, leading to decreased muscle tone in the upper airway that can in turn lead to repetitive collapse of the upper airway. 1 Throughout the years, this number has consistently increased, possibly secondary to the rising prevalence of obesity in the population. Some form of OSA affects approximately 17% of the adult population. Obstructive sleep apnea (OSA) is a common yet underrecognized condition.
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