Introduction

An undiagnosed aberrant internal carotid artery (ICA) in the middle ear constitutes a life-threatening risk of injury during elective myringotomy. We report a case of a 4.5-year old undergoing elective myringotomy at an outpatient ENT practice"s surgery. The tympanic membrane was described as thickened, but without otherwise pathologic findings.

Methods[DTH1]

During surgery, the patient developed significant acute bleeding from the external auditory canal, which was controlled by ear canal packing. He remained intubated and was transferred to our tertiary center. We performed emergency CT angiography, which showed an aberrant ICA course through the right middle ear.

Results

As the bleeding had been controlled by initial ear canal packing (by the outpatient ENT consultant), we admittted the patient to the intensive care unit for 48h-monitoring. The packing was removed after repeated MR angiography. Bleeding had ceased by then. Therefore we initially refrained from embolization, and extubation was possible. As re-bleeding occurred two days later after spontaneous coughing, embolization of the ICA in the proximal petrous segment was necessary. Angiography revealed a posttraumatic pseudoaneurysm within the middle ear. The patient showed no neurological signs due to sufficient collateral brain circulation.

Conclusion

An aberrant ICA is a very rare but significant middle ear vessel abnormality, among differential diagnoses of glomus tumor and jugular bulb aberrations. Literature recommends CT and/or MRI in cases of tympanic membrane findings that are suspicious for vessel abnormalities[DAR2] . In case of aberrant ICA bleeding, endovascular stent placement for control of pseudoaneurysm vs. permanent ICA occlusion should be chosen based on individual case review[DAR3] .

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