pii: jc-17- 00147http://dx.doi.org/10.5664/jcsm.

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S LE E P M ED IC IN E PEARLS

Tympanic Membrane Perforation as a Complication of Continuous Positive

Airway Pressure
David W. Chou, BS1; Colin Huntley, MD2; David Rosen, MD2
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; 2Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University,
1

Philadelphia, Pennsylvania

A 74-year-old woman with obstructive sleep apnea (OSA) pre-
sented to our sleep center. Her split polysomnogram continu-
ous positive airway pressure (CPAP) titration study revealed
an apnea-hypopnea index of 31 and a respiratory disturbance
index of 36, consistent with severe OSA. She was titrated to
a CPAP pressure setting of 7 cm H2O, which eliminated all
respiratory events, and placed on an autotitrating CPAP set to
a range of 5 to 15 cm H2O.
One week after tolerating CPAP with a median pressure of
9.6 cm H2O, as determined by smart card analysis, the patient
noted acute right-sided otalgia and subsequent otorrhea. The
patient was seen at an acute care clinic and started on a 10-day
regimen of amoxicillin-clavulanic acid.
The patient presented to our office 1 week later with im-
proving but continued right-sided otorrhea, aural fullness, and
hearing loss. She denied otalgia, tinnitus, and vertigo and had
ceased CPAP use. Examination revealed purulence in the right
external auditory canal and a small central tympanic membrane
perforation. The left ear was normal. Nasal endoscopy showed
no evidence of a mass obstructing the eustachian tube orifice.
She was started on otic ciprofloxacin-dexamethasone drops.
At 1-week follow-up, the patient’s otorrhea had resolved,
and her tympanic membrane perforation had closed. A tympa-
nogram performed at this time revealed a type A pattern bilat-
erally with canal volumes of 0.9 mL on the right and 1.0 mL on
the left. Her audiogram showed bilateral sloping sensorineural
hearing loss, which had been present since 2005. She was seen
in the sleep disorders center, and her CPAP was set to a fixed
pressure of 7 cm H2O. The patient was fitted for hearing aids
1 week later.
QUESTION: What is the most likely reason for this patient’s
tympanic membrane perforation?

835 Journal of Clinical Sleep Medicine, Vol. 13, No. 6, 2017

DW Chou, C Huntley and D Rosen. Tympanic Membrane Perforation From CPAP
ANSWER: It was noted on smart card analysis that the
patient’s CPAP had ramped to 14.9 cm H2O at the time of
her injury, likely resulting in otic barotrauma.
D I SCUS S I O N
Although CPAP therapy has known benefits in the treatment of
OSA, CPAP is known to increase middle ear pressure with the
potential for otic barotrauma, including tympanic membrane
perforation.1-3 Patients with OSA have a higher baseline middle
ear pressure, presumably due to soft-tissue extrusion at the
level of the eustachian tube.2 Additionally, Sivri et al. showed
that patients who had used CPAP for longer than 6 months had
elevated middle ear pressure.3 Li et al. also correlated increas-
ing CPAP pressure with an increase in middle ear pressure,
which is augmented with swallowing.2
With the advent of autotitrating CPAP devices and their in-
creased use, there is an improved ability to control the varia-
tions in apnea that occur throughout the course of the night.
However, should the device encounter increased resistance,
such as from coughing, the pressure delivered throughout the
upper airway may acutely rise with the risk for otic barotrauma.
This case describes an example of tympanic membrane perfo-
ration as a result of excessive ramping of CPAP pressure.
S L E E P M E D I C I N E PE A R L S
1. Recognize the potential for otic barotrauma from an
acute rise in airway pressure while using CPAP.
2. Patients on long-term CPAP therapy are at an increased
risk for otic barotrauma as a result of increased middle
ear pressures.
Journal of Clinical Sleep Medicine, Vol. 13, No. 6, 2017
C I TAT I O N
Chou DW, Huntley D, Rosen D. Tympanic membrane perfora-
tion as a complication of continuous positive airway pressure.
J Clin Sleep Med. 2017;13(6):835–836.
R E FE R E N CES
1. McCormick JP, Hildrew DM, Lawlor CM, Guittard JA, Worley NK. Otic
barotrauma resulting from continuous positive airway pressure: case report
and literature review. Ochsner J. 2016;16(2):146–149.
2. Li J, Li K. Effects of continuous positive airway pressure on middle ear
pressure and acoustic stapedial reflex. Otolaryngol Head Neck Surg.
2016;155(2):301–311.
3. Sivri B, Sezen OS, Akbulut S, Coskuner T. The effect of continuous
positive airway pressure on middle ear pressure. Laryngoscope.
2013;123(5):1300–1304.
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication November 21, 2016
Submitted in final revised form March 22, 2017
Accepted for publication April 3, 2017
Address correspondence to: David W. Chou, BS, 1025 Spruce Street, Philadelphia,
PA 19107; Tel: (856) 278-3597; Email: dwc001@jefferson.edu
D I SCLO S U R E S TAT E M E N T
The authors have indicated no financial conflicts of interest.
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