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Original Investigation
June 2018

Association of Obstructive Sleep Apnea With Calvarial and Skull Base Thinning

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis
  • 2Indiana University School of Medicine, Indianapolis
  • 3Section of Pulmonary, Department of Medicine, Critical Care and Sleep Medicine, Indiana University School of Medicine, Indianapolis
  • 4Department of Neurosurgery, Indiana University School of Medicine, Indianapolis
JAMA Otolaryngol Head Neck Surg. 2018;144(6):513-518. doi:10.1001/jamaoto.2018.0347
Key Points

Question  Do patients with moderate to severe obstructive sleep apnea have thinner calvaria and skull bases compared with those without obstructive sleep apnea?

Findings  In this cohort study, obstructive sleep apnea was independently associated with calvarial and skull base thinning compared with obese, age-matched patients without obstructive sleep apnea. The patients with obstructive sleep apnea had a higher rate of tegmen dehiscence than those without obstructive sleep apnea.

Meaning  Obstructive sleep apnea may mechanistically contribute to the development of disorders related to skull thinning, such as spontaneous cerebrospinal fluid leaks.

Abstract

Importance  Spontaneous cerebrospinal fluid leaks (sCSF-L) of the temporal bone are associated with obesity, calvarial thinning, and obstructive sleep apnea (OSA), and the incidence has doubled in the past decade. It is currently unknown if OSA is independently associated with skull thinning.

Objective  To determine if patients with OSA have thinner skulls than patients without OSA.

Design, Setting, and Participants  A retrospective cohort study of patients who underwent a level 1 polysomnogram (PSG) and also had high-resolution computed tomographic (CT) imaging of the head from January 2010 to March 2017 at Indiana University was carried out. Patients with moderate to severe OSA (apnea-hypopnea index [AHI]≥25/h) and without OSA (AHI<5/h) were matched for age and body mass index (BMI, calculated as weight in kilograms divided by height in meters squared).

Interventions  Measurement of calvarial thickness, extracranial zygoma thickness, skull base height and tegmen dehiscence (>4 mm) when blinded to OSA status.

Main Outcomes and Measures  Primary outcomes were calvarial, skull base, and zygoma thickness differences between patients with OSA vs those without OSA.

Results  A total of 22 933 patients had a PSG and 1012 also had head CT imaging. Of the 1012 patients with both PSG and CT, the mean (SD) age was 50.8 (16.2) years and 624 (61.7%) were women. Those patients with moderate to severe OSA (56) and without OSA (58) were matched for mean (SD) age (50.3 [6.5] vs 49.8 [6.1] years]) and BMI (37.4 [8.1] vs 38.6 [6.8]). Patients with OSA had thinner mean (SD) calvaria (2.73 [0.67] vs 2.47 [0.52] mm; difference, −0.26 mm; 95% CI, −0.49 to −0.04; Cohen d, 0.44) and thinner skull bases (5.03 [1.40] vs 4.32 [1.28] mm; difference, −0.71; 95% CI, −1.23 to −0.19; Cohen d, 0.53). The mean (SD) extracranial zygoma thickness was the same (4.92 [0.87] vs 4.84 [0.84] mm; difference, −0.07 mm; 95% CI, −0.39 to 0.24). The tegmen mastoideum was dehiscent in nearly twice as many patients with OSA as those without (37% vs 20%; difference, 17%; 95% CI, 0.4-32).

Conclusions and Relevance  Obstructive sleep apnea was independently associated with intracranial bone (calvaria and skull base) thinning and not with extracranial (zygoma) thinning. These findings support a possible role of OSA in the pathophysiologic development of sCSF-L.

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