Original contributionMiddle ear pressure during sleep and the effects of continuous positive airway pressure☆
Introduction
Maintenance of normal middle ear pressure (MEP) by an appropriately functioning eustachian tube (ET) is vital to the health of the middle ear. ET dysfunction resulting in chronic negative MEP has been implicated in many significant otologic conditions including hearing loss, tympanic membrane (TM) retraction, and chronic otitis media. Prior studies evaluating middle ear and ET physiology have been performed on awake patients with normal or negative MEP [1], [2], [3]. To the authors’ knowledge, no study to date has specifically investigated MEPs during sleep despite the fact that the average individual sleeps nearly a third of their lifetime. Many organ systems have normal physiologic changes during sleep. In patients without middle ear disease, studies have shown that MEP is most commonly positive upon waking, but quickly normalizes toward zero after swallowing and chewing maneuvers [1], [2], [3]. These findings suggest that middle ear and ET physiology also change during sleep.
Continuous positive airway pressure (CPAP) therapy, a highly effective treatment for obstructive sleep apnea (OSA), provides a pneumatic stent for the upper airway and prevents apnea during sleep. It is highly plausible that positive pressure may be transmitted to the middle ear through the ET during CPAP use. This can occur during periodic ET opening or when nasopharyngeal airway pressures exceed the resting pressure keeping the ET closed. A recent study demonstrated a linear increase in MEP with increasing CPAP levels in awake patients [4]. We hypothesized that MEP would rise slowly with duration of sleep and that escalating CPAP levels would cause proportional elevations in MEP during sleep.
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Materials and methods
Following Institutional Review Board approval (IRB No. 12-005787), adult patients undergoing polysomnography at a tertiary academic referral center were prospectively enrolled. All research subjects were provided informed consent. Study participation was limited to patients without prior middle ear disease or a history of otologic surgery. Each eligible participant was further screened using otomicroscopy and tympanometry (Madsen OTOflex 100; GN Otometrics North America, Schaumburg, IL), and
Results
Ten patients, six men and four women, were included. The mean age at testing was 57.8 years (range 37.7–74.7 yrs). Monaural testing was performed in each patient including six left and four right ears. The mean MEP of all patients before sleep was + 3 daPa [range, − 12 to + 18 daPa; standard deviation (SD), ± 10]. The mean MEP at 1, 2, 3, and 4 hours following sleep onset were + 14 daPa (range, − 15 to + 40 daPa; SD, ± 24), + 22 daPa (range, − 1 to + 64 daPa; SD, ± 23), + 27 daPa (range, − 9 to + 53 daPa; SD, ±
Discussion
Using a novel method to record MEP during sleep, our results confirm the hypothesis that MEP predictably rises during sleep. We found that the mean MEP after 4 hours of sleep was 41 daPa, which corroborates two earlier studies measuring an average MEP of 29 and 48 daPa immediately upon waking [1], [2]. These values are significantly higher than the mean awake MEP of 3 daPa in the current study.
The mechanism of increased MEP during sleep is likely multifactorial and may result, in part, from
Conclusions
Middle ear pressure rises proportionately with duration of sleep. Furthermore, increasing CPAP levels result in predictable supraphysiologic elevations in MEP. Further research is needed to examine the long-term consequences of CPAP use on the middle ear and the potential therapeutic benefits for patients with tympanic membrane retraction and chronic ear disease.
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IRB Approval Number: 12-005787.