High jugular bulb and conductive hearing loss

Wave In in auditory brainstem response suggests a high possibility of a high jugular bulb

Background

Wave In, which refers to the negativity between waves I and II in auditory brainstem response (ABR), is an electrophysiological phenomenon observed in previous studies. The term "high jugular bulb" (HJB) describes a jugular bulb that is located in a high position in the posterior aspect of the internal acoustic canal. The present study aimed to explore the correlation between wave In and the possibility of a HJB.

Methods

This retrospective study included a cohort of pediatric patients diagnosed with profound hearing loss who were enrolled in a government-sponsored cochlear implantation program at an academic medical center between January 2019 and December 2022. The analysis involved examining the results obtained from the ABR test and high-resolution computed tomography (HRCT) of the temporal bone in the patients. The position of the jugular bulb was classified according to the Manjila and Semaan classification.

Results

A total of 221 pediatric patients were included in the study. Twenty-four patients, with a median age of 3 years and a range of 1-7 years, showed significant bilateral (n = 21) or unilateral (n = 3) wave In (mean latency: right ear, 2.16 ms ± 0.22 ms; left ear, 2.20 ms ± 0.22 ms). The remaining 197 patients showed an absence of ABR. The HRCT images revealed that 18 of the 24 patients (75%) had HJB, but only 41 of the 197 patients who lacked ABR (20.8%) showed signs of HJB. The ratio difference was considered statistically significant based on the chi-squared test (χ2 = 32.10, p < 0.01). More than 50% of the HJBs were categorized as type 4 jugular bulbs, which are located above the inferior margin of the internal auditory canal.

Conclusion

ABR wave In in pediatric patients with profound hearing loss suggests a high possibility of HJB. The physiological mechanism underlying this correlation needs further investigation.

Effect of High Jugular Bulb on the Hearing Loss Characteristics in Patients With LVAS: A Pilot Study

Objective

Both large vestibular aqueduct syndrome (LVAS) and high jugular bulb (HJB) are regarded as abnormalities commonly seen on the temporal bone CT. High jugular bulb has been found to erode the vestibular aqueduct, and there are several studies on jugular bulb vestibular aqueduct dehiscence. However, there is no study that specifically reports LVAS with concurrent HJB and its hearing loss relatedness. This study presents the pure tone audiometry differences between LVAS with HJB, and LVAS without HJB.

Methods

This was a case control study involving 36 bilateral LVAS with concurrent unilateral HJB patients, total of 72 ears. Intra-person comparison was done, by dividing ears into two groups: the case group, 36 ears (LVAS with HJB); and the control group, 36 ears (LVAS without HJB). Air conduction thresholds (250–4000 Hz), bone conduction thresholds (250–1000 Hz), and air bone gap (250–1000 Hz) were analyzed and compared between groups.

Result

There were statistically significant differences in AC thresholds at 250, 500, 2000, and 4000 Hz between the groups, p < 0.05. But there was no statistical significant difference at 1000 Hz, p > 0.05. There were statistical significant differences in BC thresholds at 250 and 500 Hz, p < 0.05, but there was no statistical difference at 1000 Hz. There were no significant differences in air bone gap at 250, 500, and 1000 Hz between the two groups.

Conclusion

LVAS with concurrent HJB was found to have higher air conduction thresholds, especially at 250, 500, 2000, and 4000 Hz. Bone conduction thresholds were higher at 250 and 500 Hz. Air bone gap at 250, 500, and 1000 Hz, were not significantly higher in LVAS with concurrent HJB.

Cholesteatoma Surgery With a Dehiscent High Jugular Bulb Treated With Surgery Assisted With Underwater Endoscopy: A Case Report

A dehiscent high jugular bulb would be a pitfall in middle ear surgery especially for cholesteatoma. We report a case of cholesteatoma attached to a dehiscent high jugular bulb successfully treated with surgery assisted with underwater endoscopy. To the best of our knowledge, no previous study has reported a case of cholesteatoma with dehiscent high jugular bulb treated with surgery assisted with underwater endoscopy. Owing to the risk of jugular bulb injury, underwater endoscopy is a good indication for middle ear cases with a dehiscent high jugular bulb to obtain a clear operative field and avoid an unexpected air embolism.

Dual retrotympanic aural mass

High-riding jugular bulb (HRJB), although rare, may pose a challenge as it may be mistaken for other non-alarming condition, such as middle ear effusion. Patients with HRJB classically present with pulsatile tinnitus. We report a unique case of a 26-year-old patient with underlying beta thalassaemia who presented with a 2-month history of intermittent epistaxis and rhinorrhoea. Otoscopic examinations revealed a pulsatile bluish mass behind the right tympanic membrane and a dull left tympanic membrane. Imaging performed revealed a finding of dual retrotympanic pathology, which consisted of a right dehiscent HRJB and left cholesterol granuloma. We highlight a rare case of dual retrotympanic mass as well as its management.

Tinnitus, Hyperacusis, Otalgia, and Hearing Loss

PURPOSE OF REVIEW

This article reviews the causes of tinnitus, hyperacusis, and otalgia, as well as hearing loss relevant for clinicians in the field of neurology.

RECENT FINDINGS

Important causes of unilateral and bilateral tinnitus are discussed, including those that are treatable or caused by serious structural or vascular causes. Concepts of hyperacusis and misophonia are covered, along with various types of neurologic disorders that can lead to pain in the ear. Hearing loss is common but not always purely otologic.

SUMMARY

Tinnitus and hearing loss are common symptoms that are sometimes related to a primary neurologic disorder. This review, tailored to neurologists who care for patients who may be referred to or encountered in neurology practice, provides information on hearing disorders, how to recognize when a neurologic process may be involved, and when to refer to otolaryngology or other specialists.

The Forgotten Second Window: A Pictorial Review of Round Window Pathologies

The round window serves to decompress acoustic energy that enters the cochlea via stapes movement against the oval window. Any inward motion of the oval window via stapes vibration leads to outward motion of the round window. Occlusion of the round window is a cause of conductive hearing loss because it increases the resistance to sound energy and consequently dampens energy propagation. Because the round window niche is not adequately evaluated by otoscopy and may be incompletely exposed during an operation, otologic surgeons may not always correctly identify associated pathology. Thus, radiologists play an essential role in the identification and classification of diseases affecting the round window. The purpose of this review is to highlight the developmental, acquired, neoplastic, and iatrogenic range of pathologies that can be encountered in round window dysfunction.

Transvenous Stent-assisted Coil Embolization for Management of Dehiscent High Jugular Bulb With Tinnitus and Contralateral Hypoplastic Venous Sinuses

OBJECTIVES

This study aimed to evaluate the safety and efficacy of transvenous stent-assisted coil embolization for dehiscent high jugular bulb (HJB) with tinnitus and contralateral hypoplastic venous sinus.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic medical center.

METHODS

From September 2008 to October 2018, a series of patients with dehiscent HJB presenting with intractable pulsatile tinnitus abated only by ipsilateral jugular vein compression were included. Patients underwent transvenous stent-assisted coil embolization for selective obstruction to the dome of the HJB due to hypoplastic contralateral transverse or sigmoid venous sinus. Technical safety and clinical efficacy were retrospectively analyzed. Clinical outcome measurements included pure-tone audiogram, tinnitus character, and tinnitus handicap inventory and evaluated based on the change during the first 6 months after the procedure.

RESULTS

Subjects included five patients with dehiscent HJB and troublesome pulsatile tinnitus who refused surgery (n = 4), or who experienced recurrence after surgical covering and reinforcement using autologous cartilage (n = 1). The mean age of the five patients (only female) was 45 years. Transvenous stent-assisted coil embolization was technically successful in all patients with symptomatic dehiscent HJB, with no procedure-related complications. Temporary postprocedural headache was observed in two patients, but resolved within 3 days. Symptoms were completely resolved in all cases. There was no recurrence or aggravation of tinnitus during follow-up period.

CONCLUSIONS

Transvenous stent-assisted coil embolization for dehiscent HJB with tinnitus and contralateral hypoplastic transverse or sigmoid venous sinus could be a technically safe and clinically effective treatment strategy while preserving cranial venous drainage.

A Revisit to High Jugular Bulb: A Newer Clinical Grading

A revisit to high riding jugular bulb with a newer classification. Observational study. Patients in the age group between 15 to 60 years, who underwent various Tympanomastoid and otosclerotic surgeries from April 2015 to 2018, have been included in the study. An analysis was made on high riding jugular bulb which encountered and different anatomical variations were noticed. A total of 531 patients underwent various tympanomastoid surgeries and 48 patients underwent otosclerotic surgeries. Out of which 8% of the cases (n = 49) were noticed to have high riding jugular bulb. In those 49 cases, 81% (n = 37) have Grade I, 11% (n = 5) have Grade II, 6% (n = 3) have grade III, 6% of the case (n = 3) have Grade IV and 2% (n = 1) has Grade V high riding Jugular bulb. Among these the prevalence of Grade I jugular bulb is high followed by Grade II. With the observation of our clinical study the authors have made a revisit to high riding jugular bulb and proposed a new clinical grading for high jugular bulb called BPH, that is Basava Prasad's grading clinical on High jugular bulb (Channa Basava Hubli and K. C. Prasad) as: Grade I high riding jugular bulb up to the level of inferior tympanic annulus. Grade II extending from the level of tympanic annulus up to the inferior margin of the round window niche. Grade III Completely obliterating the round window niche. Grade IV Lies between superior margin of round window niche and stapes. Grade V Abuting the Stapes Arch.

Dehiscent high-riding jugular bulb presenting as conductive hearing loss: A case report

RATIONALE

Jugular bulb anomalies are asymptomatic lesions commonly seen in routine practice. However, some patients with jugular bulb anomalies may present with symptoms such as tinnitus or conductive hearing loss (CHL).

PATIENT CONCERNS

A 9 year old boy complained right sided hearing disturbance without any vestibular symptoms. Pure tone audiometry (PTA) revealed a mild right sided conductive hearing loss. Otoscopy showed a red-purplish mass like lesion in his right middle ear cavity, which was regarded as hypervascular tumor.

DIAGNOSIS

Based on otoscopic findings, preliminary differential diagnoses included jugular bulb anomaly, hemotympanum, cholesterol granuloma and paraganglioma.

INTERVENTIONS

We performed contrast enhanced computed tomography of the temporal bone (TBCT).

OUTCOMES

CT scan showed and enhancing lesion which was bulging from his right jugular foramen to the middle ear with dehiscent jugular bulb. The lesion showed the same degree of contrast enhancement with the venous vasculature. This lesion contacted with the tympanic membrane, incudostapedial joint and round window, which might be attributable to interruption of sound transmission mechanics. Otherwise there was no evidence of mass or trauma related lesions in the temporal bone.

LESSONS

Although most of jugular bulb anomalies are asymptomatic, patients may present with conductive hearing loss due to the interference of sound transmission mechanics.

Topography of neurovascular structures in relation to round window and how it relates to cochlear implantation

PURPOSE

The purpose of this investigation was to evaluate the distances and angles on basal turn of cochlea in relation to round window at which the jugular bulb, internal carotid artery and facial nerve are at maximal risk and their implications in cochlear implantation (CI).

METHODS

Fifty-four cadaveric temporal bones were microdissected to expose the basal turn of cochlea, the carotid canal, the facial canal and the jugular fossa. The points were marked on the basal turn of cochlea, where there was minimum distance of basal turn of cochlea from the roof of the jugular fossa (point a), carotid canal (point b) and facial canal (point c). The distances and angles of these points from the round window were measured.

RESULTS

The points a, b and c were at mean (range) distances of 2.8 mm (1.3-4.1 mm), 8.4 mm (6.5-10.4 mm) and 16.4 mm (12.5-20.5 mm) and at mean angles of 30° (15°-45°), 111° (71°-136°) and 284° (255°-315°), respectively, from the round window.

CONCLUSIONS

This study highlights that 2.8 ± 0.5 mm (30 ± 5.40), 8.4 ± 1 mm (111 ± 12.70) and 16.4 ± 1.7 mm (284 ± 13.5) from the round window are the high-risk points on the basal turn of the cochlea for the jugular bulb, internal carotid artery and facial nerve, respectively. A wide range found for each parameter indicates that it is mandatory to evaluate these distances in each CI patient on preoperative radiographs to avoid intraoperative injury to these vital structures.

Complete morphometric analysis of jugular foramen and its clinical implications

INTRODUCTION

Tumors affecting structures in the vicinity of jugular foramen such as glomus jugulare require microsurgical approach to access this region. These tumors tend to alter the normal architecture of the jugular foramen by invading it. Therefore, it is not feasible to have correct anatomic visualization of the foramen in the presence of such pathologies. Hence, a comprehensive knowledge of the jugular foramen is needed by all the neurosurgeons while doing surgery in this region.

AIM

Due to the inadequate knowledge of the accurate morphology of the jugular foramen in different sexes, the aim of this osteological study was to provide a complete morphometry including gender differences and describe some morphological characteristics of the jugular foramen in an adult Indian population.

MATERIALS AND METHODS

The study was done on 114 adult human dry skulls (63 males and 51 females) collected from the osteology museum in the department. Various dimensions of both endo- and exocranial aspect of jugular foramen were measured. Presence and absence of domed bony roof of jugular fossa and compartmentalization of jugular foramen were also noticed. Statistical analysis was done using Chi-square test and Student's t-test in SPSS version 23.

RESULTS

All the parameters of right jugular foramen were greater than the left side, except the distance of stylomastoid foramen from lateral margin of jugular foramen (SMJF) which was greater on the left side. Gender differences between various measurements of jugular foramen, presence of dome of jugular fossa, and compartmentalization patterns were reported.

CONCLUSION

This study gives knowledge about the various parameters, anatomical variations of jugular foramen in both sexes of an adult Indian population, and its clinical impact on the surgeries of this region.

Imaging of the Posterior Skull Base

The posterior skull base can be involved by a variety of pathologic processes. They can be broadly classified as: traumatic, neoplastic, vascular, and inflammatory. Pathology in the posterior skull base usually involves the lower cranial nerves, either as a source of pathology or a secondary source of symptoms. This review will categorize pathology arising in the posterior skull base and describe how it affects the skull base itself and surrounding structures.

Radiological and audiometric evaluation of high jugular bulb and dehiscent high jugular bulb

Objective:

To inform on the incidence of high jugular bulb and dehiscent high jugular bulb, and the symptoms related to these vascular anomalies.

Methods:

A retrospective analysis was performed of temporal bone computed tomography scans of 3285 patients who attended our clinic with various symptoms. The medical records of patients with high jugular bulb and dehiscent high jugular bulb were analysed, and the clinical findings reviewed. Patients with dehiscent high jugular bulb were evaluated for hearing loss with pure tone audiometry.

Results:

High jugular bulb was evident in 730 patients (22 per cent) (510 right-sided, 220 left-sided; p < 0.01). Twenty-six high jugular bulb patients had dehiscent high jugular bulb. Ten of these 26 patients had vertigo, 15 had tinnitus and 1 had hearing disturbance. Ten dehiscent high jugular bulb patients had undergone pure tone audiometry: seven patients had conductive hearing loss, two had sensorineural hearing loss and one had mixed hearing loss.

Conclusion:

The incidences of high jugular bulb and dehiscent high jugular bulb were 22 per cent and 3.5 per cent, respectively. Tinnitus was the most common symptom of all patients. Dehiscent high jugular bulb was associated with various degrees of hearing loss, but not hearing disturbance.

A Rare Cause of Conductive Hearing Loss: High Lateralized Jugular Bulb with Bony Dehiscence

We present a rare case of pediatric conductive hearing loss due to a high lateralized jugular bulb. An 8-year-old boy with a right-sided conductive hearing loss of 40 dB was found to have a pink bulge toward the inferior part of the right eardrum. Computed tomography showed a high, lateralized right jugular bulb that had a superolaterally pointing diverticulum that bulged into the lower mesotympanum and posterior external auditory meatus. It was explained to the child's parents that it is important never to put any sharp objects into the ears because of the risk of injury to the jugular vein. A high, lateralized jugular bulb with a diverticulum is a rare anatomic abnormality. Correct diagnosis of this abnormality is important so that inappropriate intervention does not occur.

Single-center 10-year experience in treating patients with vascular tinnitus: diagnostic approaches and treatment outcomes

Objectives

Vascular tinnitus is the most common form of pulsatile tinnitus, particularly when the tinnitus corresponds with the pulse of patients. In this study, we reviewed the 10-year clinical data on vascular tinnitus of our tinnitus clinic to investigate the frequency of the underlying etiologies, to introduce a diagnostic protocol, and to evaluate the treatment outcomes.

Methods

We retrospectively collected the data of 57 patients who were diagnosed as vascular tinnitus between April 2001 and December 2011. Careful history taking, otoscopy, thorough physical examinations, audiometry, laboratory tests, as well as radiologic examinations were performed according to our diagnostic protocol to find the origin of pulsatile tinnitus. Treatment options were individualized based on the specific etiology, and the outcomes were assessed using patient's subjective reports at the follow-up interviews.

Results

High jugular bulb was the most common cause (47.4%) of vascular tinnitus, and venous hum was the next (17.5%). Dural arteriovenous fistula, intracranial aneurysm, atherosclerotic carotid artery disease, and hypertension were less common causes. Vascular tinnitus was alleviated in most patients after the appropriate treatment: surgical intervention, tinnitus retraining therapy, reassurance, and medications.

Conclusion

Vascular tinnitus can be successfully diagnosed by the regular use of the suggested protocol. Many patients with vascular tinnitus have treatable underlying etiologies. Treatment of those etiologies or at least counseling about the tinnitus itself can benefit the patients with troublesome vascular tinnitus.

Carotid artery-cochlear dehiscence: a review

This case report describes carotid-cochlear dehiscence, a rare and possibly fatal condition if missed or ignored on initial work-up of several otologic procedures. Thinning of the bony plate separating the carotid canal from other anatomic structures can occur anywhere along the course of the canal, including the carotid-cochlear bony plate. This condition should be recognized by all otolaryngologists in that it can mimic other otologic pathologies. The aim of this report was to call attention to this condition and its associated mimicking symptoms and inform on its proper management. The idea for this review was formed from the case of a patient who presented with pulsatile tinnitus and was found to have carotid-cochlear dehiscence. Carotid-cochlear dehiscence is a rare anatomic variation of which the neurotologic surgeon should be aware. This condition can mimic common otolaryngologic pathologies that regularly present themselves in clinical settings. We present what we believe to be the fourth reported case of carotid-cochlear dehiscence in the literature. The patient presented having only the complaint of pulsatile tinnitus and was later diagnosed with this rare condition. We advocate a thorough preoperative work-up, including high-resolution computed tomography and careful operative planning in a case-specific manner. This is especially important when common pathologies do not become apparent after careful investigation.

The relationship between jugular bulb-vestibular aqueduct dehiscence and hearing loss in pediatric patients

OBJECTIVE

To determine the prevalence of jugular bulb and vestibular aqueduct dehiscence (JBVAD) in pediatric patients undergoing temporal bone computed tomography (CT) scans and to assess the relationship between JBVAD and hearing loss.

STUDY DESIGN

Cross-sectional study with chart review.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

All patients 18 years of age or younger who had undergone temporal bone CT scans and audiometric testing between 2004 and 2009 were retrospectively reviewed. JBVAD was determined by blinded review of CT images. Hearing loss was determined by review of audiometric data and was correlated with imaging findings.

RESULTS

CT images and audiometric data were available for review in 927 patients (1854 ears). Overall prevalence of JBVAD was 8.6%, with a prevalence of 6.6% in right ears and 3.6% in left ears. JBVAD was present in 8.3% and 7.1% of patients with and without sensorineural or mixed hearing loss, respectively (95% confidence interval [CI], -2.3% to 4.6%; P = .51). Similarly, JBVAD was present in 5.5% of ears with and 4.6% of ears without sensorineural or mixed hearing loss (95% CI, -1.1% to 2.9%; P = .37).

CONCLUSION

The prevalence of JBVAD is 8.6% in pediatric patients undergoing temporal bone CT scans, 65% of which occur in the right ear. We were unable to identify any relationship between JBVAD and hearing loss. A major contribution to pediatric sensorineural hearing loss from JBVAD is therefore extremely unlikely.

A novel surgical technique for management of tinnitus due to high dehiscent jugular bulb

Objectives: To assess the effectiveness of middle ear floor reconstruction in management of vascular tinnitus due to high jugular bulb with dehiscent middle ear floor.

Study Design: Case series with chart review.

Setting: Tertiary academic medical center.

Subjects and Methods: We reviewed the medical records of seven patients with high dehiscent jugular bulb, presenting with incapacitating pulsatile roaring tinnitus that was abolished by digital compression of the ipsilateral jugular vein, from January 2002 to December 2006. The diagnosis was confirmed by CT scan of the temporal bone (bone window, coronal views). The seven patients were surgically explored, five under local anesthesia (to monitor the results with possible intraoperative revision) and two under general endotracheal anesthesia, for middle ear floor reconstruction that was done using bone dust, perichondrium, and tragal cartilage (mean follow-up 28 months).

Results: Of the seven patients, tinnitus disappeared in four (57%) and decreased in one. The overall improvement was five of seven (71%). One patient had postoperative increased intracranial pressure.

Conclusion: The preliminary results suggest that surgical reconstruction of the middle ear floor under local anesthesia offers valuable treatment for patients with incapacitating tinnitus due to dehiscent middle ear floor. However, the risk of sigmoid sinus thrombosis should be considered. To our knowledge, this is the first trial of multilayer reconstruction of the middle ear floor dehiscence to manage high jugular bulb causing tinnitus.

Clinical spectrum of patients with erosion of the inner ear by jugular bulb abnormalities

OBJECTIVES/HYPOTHESIS

Anatomic variants of the jugular bulb (JB) are common; however, abnormalities such as large high riding JB and JB diverticulum (JBD) are uncommon. Rarely, the abnormal JB may erode into the inner ear. The goal of our study is to report a large series of patients with symptomatic JB erosion into the inner ear.

STUDY DESIGN

Retrospective review in an academic medical center.

METHODS

Eleven patients with JB abnormality eroding into the inner ear were identified on computed tomography (CT) scan of the temporal bone.

RESULTS

Age at presentation was from 5 years to 82 years with six males and five females. The large JB or JBD eroded into the vestibular aqueduct (n = 9) or the posterior semicircular canal (n = 4). The official radiology report usually identified the JB abnormality; however, erosion into these structures by the JB was not mentioned in all but one case. All patients were symptomatic with five having conductive hearing loss (CHL) and three complaining of pulsatile tinnitus. Those with pulsatile tinnitus and four of five with CHL had erosion into the vestibular aqueduct. Vestibular evoked myogenic potential (VEMP) findings in three of six patients were consistent with dehiscence of the inner ear.

CONCLUSIONS

High riding large JB or JBD can erode into the inner ear and may be associated with CHL and/or pulsatile tinnitus. CT scan is diagnostic and should be examined specifically for these lesions. As patients with pulsatile tinnitus may initially undergo a magnetic resonance imaging scan, identification of JB abnormality should prompt CT scan or VEMP testing to evaluate for inner ear erosion.

Dehiscent high jugular bulb: a pitfall in middle ear surgery

OBJECTIVE

The aim of this study was to present our experience on facing the dehiscent high jugular bulb (HJB) during middle ear surgery in the past 2 decades.

STUDY DESIGN

Retrospective review.

SETTING

Secondary referral hospital.

PATIENTS

From January 1982 to June 2002, consecutive 1,657 patients underwent surgical intervention for middle ear cleft diseases, a total of 1,857 operations. Of them, 10 ears (0.5%) in nine patients were proven to have dehiscent HJB during operation for adhesive otitis media in four ears and for chronic otitis media with cholesteatoma in six ears.

MAIN OUTCOME MEASURES

Each patient underwent otoscopic examination, radiographic examination, and audiometry before and 6 months after operation.

RESULTS

Otoscopic examination revealed atrophic changes in the pars tensa with adhering to the promontory in two ears, attic retraction in one ear, and both findings in seven ears. All lesions were located beneath the basal turn of the cochlea and the round window niche at anteroinferior and/or posteroinferior quadrants. Active bleeding was encountered in two ears (20%) while elevating the tympanomeatal flap, which was treated by pressure compression associated with gelfoam sheet, then covered with an autologous cartilage to protect the dehiscent bulb. For the remaining eight ears, the bulbs were reinforced with fascia, perichondrium, or autologous cartilage. All 10 ears were allowed completion of the planned surgery without complications.

CONCLUSION

HJB is not a contraindication for middle ear surgery. Awareness of this pitfall may lessen the operation risk.

Surgical treatment of the high jugular bulb by compressing sinus sigmoideus: two cases

If the jugular bulb normally surrounded by a bony layer in jugular fossa is anatomically over the inferior surface of the bony annulus, in the middle ear or over the basal turn of cochlea, it is then named as high jugular bulb (HJB). It may be dehiscent or aberrant. It is reported to occur in 5% of the temporal bone specimens. In accordance with the literature jugular bulb compression, jugular vein ligation and embolization are suggested in such cases. In both of the presented cases, there was bleeding from jugular bulb during surgery and jugular bulb was compressed with bone wax and Surgicel, but sigmoid sinus has been compressed after failure to stop bleeding through jugular bulb compression. Venous MR angiographies showed no flow in postoperative controls. Although it is very rarely seen clinically, we present two HJB cases and different treatment perspectives accompanied by literature.

Dehiscence of the Jugular Bulb and Vestibular Aqueduct

OBJECTIVE

To determine the incidence of dehiscence between the vestibular aqueduct and the jugular bulb on computed tomography (CT) scans and assess its implication as a cause of dizziness or hearing loss.

METHODS

Two hundred temporal bone CT scans were evaluated for the prevalence of dehiscence between the jugular bulb and vestibular aqueduct. Correlation of the imaging findings and clinical data was performed.

RESULTS

A total of 11.5% of patients had dehiscence of the jugular bulb with the vestibular aqueduct; 75% of these cases occurred on the right side and in the setting of a high jugular bulb. Nine (39.1%) of 23 patients with dehiscence had dizziness, and 11 (47.8%) had hearing loss. The correlation between the incidence of dizziness, hearing loss, and dehiscence was not significant.

CONCLUSION

The incidence of a dehiscent jugular bulb with a vestibular aqueduct is 11.5%. The prevalences of vertigo and hearing loss associated with this finding are 39.1% and 47.8%, respectively. The depiction of dehiscent jugular bulb-vestibular aqueduct should be considered with caution as the sole cause of symptoms.

Management of hemorrhagic high jugular bulb with adhesive otitis media in an only hearing ear: transcatheter endovascular embolization using detachable coils

A 51-year-old woman had a hemorrhagic high jugular bulb protruding into the posterosuperior part of the tympanic cavity in her left ear. This (only hearing) ear had severe adhesive otitis media resulting in repetitive hemorrhage from the jugular bulb. Therefore, treatment to stop the bleeding was required. Since invasive middle ear surgery in an only hearing ear would involve a high risk of hearing loss and massive bleeding, transcatheter endovascular embolization using detachable coils was selected for this special case; it safely blocked the blood flow and preserved the patient's hearing level. This is the first such report in the otosurgical field, showing that transcatheter endovascular embolization using detachable coils was quite effective in a difficult case of a hemorrhagic high jugular bulb with severe adhesive otitis media in an only hearing ear.