The objective of this study is to illustrate prevention strategies and management of vascular complications from the jugular bulb (JB) and internal carotid artery (ICA) during middle ear surgery or cochlear implantation. The study design is retrospective case series. The setting is tertiary referral university hospital. Patients were included if presented pre- or intraoperative evidence of high-risk anatomical anomalies of ICA or JB during middle ear or cochlear implant surgery, intraoperative vascular injury, or revision surgery after the previous iatrogenic vascular lesions. The main outcome measures are surgical outcomes and complications rate. Ten subjects were identified: three underwent cochlear implant surgery and seven underwent middle ear surgery. Among the cochlear implant patients, two presented with anomalies of the JB impeding access to the cochlear lumen and one underwent revision surgery for incorrect positioning of the array in the carotid canal. Subtotal petrosectomy was performed in all cases. Anomalies of the JB were preoperatively identified in two patients with attic and external auditory canal cholesteatoma, respectively. In a patient, a high and dehiscent JB was found during myringoplasty, while another underwent revision surgery after iatrogenic injury of the JB. A dehiscent ICA complicated middle ear effusion in one case, while in another case, a carotid aneurysm determined a cholesterol granuloma. Rupture of a pseudoaneurysm of the ICA occurred in a child during second-stage surgery and required permanent balloon occlusion without neurological complications. Knowledge of normal anatomy and its variants and preoperative imaging are the basis for prevention of vascular complications during middle ear or cochlear implant surgery.
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Compliance with ethical standards
No funding sources were used for this study.
Conflict of interest
The authors (F. Di Lella, M. Falcioni, I. Iaccarino, S. Piccinini, A. Bacciu, E. Pasanisi, D. Cerasti, and V. Vincenti) declare no conflict of interest.
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Koesling S, Kunkel P, Schul T (2005) Vascular anomalies, sutures and small canals of the temporal bone on axial CT. Eur J Radiol 54(3):335–343CrossRefPubMedGoogle Scholar
Schutt C, Dissanaike S, Marchbanks J (2013) Case report: inadvertent carotid artery injury during myringotomy as a result of carotid artery dehiscence. Ear Nose Throat J 92(7):E35–E37PubMedGoogle Scholar
Takano K, Wanibuchi M, Ito F, Himi T (2016) Pseudoaneurysm of an aberrant internal carotid artery in the middle ear caused by myringotomy. Auris Nasus Larynx 43(6):698–701CrossRefPubMedGoogle Scholar
Welling DB, Glasscock ME 3rd, Tarasidis N (1993) Management of carotid artery hemorrhage in middle ear surgery. Otolaryngol Head Neck Surg 109(6):996–999CrossRefPubMedGoogle Scholar
Atmaca S, Elmali M, Kucuk H (2014) High and dehiscent jugular bulb: clear and present danger during middle ear surgery. Surg Radiol Anat 36(4):369–374CrossRefPubMedGoogle Scholar
Moore PJ (1994) The high jugular bulb in ear surgery: three case reports and a review of the literature. J Laryngol Otol 108(9):772–775CrossRefPubMedGoogle Scholar
Bilgen C, Kirazli T, Ogut F, Totan S (2003) Jugular bulb diverticula: clinical and radiologic aspects. Otolaryngol Head Neck Surg 128(3):382–386CrossRefPubMedGoogle Scholar
Moreano EH, Paparella MM, Zelterman D, Goycoolea MV (1994) Prevalence of carotid canal dehiscence in the human middle ear: a report of 1000 temporal bones. Laryngoscope 104(5 Pt 1):612–618CrossRefPubMedGoogle Scholar
Friedmann DR, Eubig J, McGill M, Babb JS, Pramanik BK, Lalwani AK (2011) Development of the jugular bulb: a radiologic study. Otol Neurotol 32(8):1389–1395CrossRefPubMedGoogle Scholar
Moret J, Delvert JC, Lasjaunas P (1982) Vascularization of the ear: normal variations, glomus tumors. J Neuroradiol 9(3):209–260PubMedGoogle Scholar
Young RJ, Shatzkes DR, Babb JS, Lalwani AK (2006) The cochlear–carotid interval: anatomic variation and potential clinical implications. AJNR Am J Neuroradiol 27(7):1486–1490PubMedGoogle Scholar
Lin YY, Wang CH, Liu SC, Chen HC (2012) Aberrant internal carotid artery in the middle ear with dehiscent high jugular bulb. J Laryngol Otol 126(6):645–647CrossRefPubMedGoogle Scholar
Brodish BN, Woolley AL (1999) Major vascular injuries in children undergoing myringotomy for tube placement. J Otolaryngol 20(1):46–50CrossRefGoogle Scholar
Hough JV (1963) Problems in stapedial surgery. Trans Indiana Acad Ophthalmol Otolaryngol 46:9–17PubMedGoogle Scholar
Henriksen SD, Kindt MW, Pedersen CB, Nepper-Rasmussen HJ (2000) Pseudoaneurysm of a lateral internal carotid artery in the middle ear. Int J Pediatr Otorhinolaryngol. 52(2):163–167CrossRefPubMedGoogle Scholar
Free RH, Falcioni M, Di Trapani G, Giannuzzi AL, Russo A, Sanna M (2013) The role of subtotal petrosectomy in cochlear implant surgery–a report of 32 cases and review on indications. Otol Neurotol 34(6):1033–1040CrossRefPubMedGoogle Scholar
Vincenti V, Pasanisi E, Bacciu A, Bacciu S (2014) Long-term results of external auditory canal closure and mastoid obliteration in cochlear implantation after radical mastoidectomy: a clinical and radiological study. Eur Arch Otorhinolaryngol 271(8):2127–2130CrossRefPubMedGoogle Scholar
Di Lella F, Falcioni M. Subtotal petrosectomy in middle ear and lateral skull base surgery. In: Takahashi (ed) Cholesteatoma and ear surgery—an update proceedings of the 9th international conference on cholesteatoma and ear surgery. June 3–7, 2012, Nagasaki, Japan (ISBN 13: 978-90-6299-237-9)Google Scholar
Pasanisi E, Vincenti V, Bacciu A, Guida M, Berghenti T, Barbot A, Zini C, Bacciu S (2002) Multichannel cochlear implantation in radical mastoidectomy cavities. Otolaryngol Head Neck Surg 127(5):432–436CrossRefPubMedGoogle Scholar
Vincenti V, Pasanisi E, Bacciu A, Bacciu S, Zini C (2014) Cochlear implantation in chronic otitis media and previous middle ear surgery: 20 years of experience. Acta Otorhinolaryngol Ital 34(4):272–277PubMedPubMedCentralGoogle Scholar
Sanghvi A, Bauer B, Roehm PC (2016) Hemostasis in otologic and neurotologic surgery. Otolaryngol Clin North Am 49(3):749–761CrossRefPubMedGoogle Scholar
Sanna M, Shin SH, De Donato G, Sivalingam S, Lauda L, Vitullo F, Piazza P (2011) Management of complex tympanojugular paragangliomas including endovascular intervention. Laryngoscope 121(7):1372–1382CrossRefPubMedGoogle Scholar
Piazza P, Di Lella F, Bacciu A, Di Trapani G, Ait Mimoune H, Sanna M (2013) Preoperative protective stenting of the internal carotid artery in the management of complex head and neck paragangliomas: long-term results. Audiol Neurootol 18(6):345–352CrossRefPubMedGoogle Scholar
Sahni D, Singla A, Gupta A, Gupta T, Aggarwal A (2010) Relationship of cochlea with surrounding neurovascular structures and their implication in cochlear implantation. Int J Pediatr Otorhinolaryngol 74(6):701–703CrossRefGoogle Scholar
Saleh EA, Aristegui M, Taibah AK, Mazzoni A, Sanna M (1994) Management of the high jugular bulb in the translabyrinthine approach. Otolaryngol Head Neck Surg 110(4):397–399CrossRefPubMedGoogle Scholar
Nevoux J, Loundon N, Leboulanger N, Roger G, Ducou Le Pointe H, Garabédian EN (2015) Cochlear implant in the carotid canal. Case report and literature review. Surg Radiol Anat 37(8):913–919CrossRefGoogle Scholar
Gastman BR, Hirsch BE, Sando I, Fukui MB, Wargo ML (2002) The potential risk of carotid injury in cochlear implant surgery. Laryngoscope 112(2):262–266CrossRefPubMedGoogle Scholar