Transsphenoidal Pituitary Surgery, Sleep Apnea, and Pneumocephalus: Is there a Link?

Objective: Patients undergoing transsphenoidal (TSS) pituitary tumor surgery are spared a large craniotomy but left with an anterior skull base defect, which prohibits the use of positive pressure ventilation. Obstructive sleep apnea (OSA) can be seen in patients with pituitary tumors and is treated with continuous positive airway pressure (CPAP). The objective of our study was twofold: (1) To document the incidence of OSA in patients undergoing TSS pituitary tumor surgery, and (2) to report the incidence of pneumocephalus in patients undergoing TSS pituitary tumor surgery and subsequent postoperative outcomes.

Methods: We conducted a single institution, retrospective review from 2008 to 2014 from a prospectively maintained surgical outcomes database. All database and electronic medical records were carefully reviewed, with a key emphasis on diagnosis of OSA and documented pneumocephalus. Descriptive statistics and a minimum of 3-month outcomes were documented.

Results: From July 2008 to July 2014, 350 patients underwent TSS for pituitary mass resection. A total of 194 patients (55%) were females and the average age was 50 years. Endocrine abnormalities were seen in 187 patients (53%), acromegaly in 21 patients (6%), and average BMI was 32.3 kg/m². All patients underwent a TSS approach, 19% of cases had binostril access, and septoplasty was performed in 68%. Our results showed that 71 patients (20%), or approximately 1 in 5, had documented OSA. Only 21 of 71 (30%) patients had a documented postoperative CPAP plan in chart, and average days off CPAP was 3.25 days. Of all the 350 patients, 4 had symptomatic pneumocephalus, all with headaches. Pneumocephalus resulted in an average of 4.5 days extra in the hospital. None of the four patients with pneumocephalus had sleep apnea.

Discussion: In our single institution, retrospective series, approximately one in five patients undergoing TSS for pituitary mass resection have OSA. Although a link between OSA and postoperative pneumocephalus was not seen in our population, a theoretical risk exists. OSA is a diagnosis commonly seen in patients undergoing TSS pituitary tumor surgery, and we recommend preoperative OSA screening and ensuring a cogent postoperative CPAP plan is in place to avoid potentially harmful pneumocephalus.