High Jugular Bulb Research Articles

A Convenient Sonographic Technique for Diagnosis of Pulsatile Tinnitus Induced by a High Jugular Bulb

The purpose of this report is to describe our experience with sonography in a case of pulsatile tinnitus (PT) due to a high jugular bulb (HJB). A 71-year-old woman came to our hospital with a 1-year history of right PT. A right HJB was shown on cerebral angiography, and enlargement of the right jugular blub compared with the left side was found. First, the ultrasound probe was placed on the anterior right upper neck at the anterior edge of the sternocleidomastoid muscle to identify the ipsilateral internal jugular vein (IJV) and measure the flow velocity. After the measurement, the ultrasound probe gradually compressed the skin until the flow in the IJV decreased. The patient reported that her PT decreased after the flow in the IJV decreased. We decided that the PT in this case was induced by the HJB. This technique is less invasive and convenient for the diagnosis of PT caused by an HJB.

A Case of Pulsatile Tinnitus from Dehiscent High Jugular Bulb Treated by Reconstruction of the Hypotympanum

Vascular tinnitus, a sort of pulsatile tinnitus, should be differentiated with other sensorineural tinnitus because it is possible to be cured by correction of underlying systemic disease or surgery. The dehiscent high jugular bulb, a common cause of venous pulsatile tinnitus, can be cured by reconstruction of hypotympanum. We present a case of pulsatile tinnitus with dehiscent high jugular bulb which has been treated by surgery. Preoperative microscopic finding showed dark bluish pulsating mass in posteroinferior portion of tympanic membrane. Temporal bone CT showed high jugular bulb with bone defect of hypotympanum. The hypotympanum was reconstructed and high jugular bulb lowered using the harvested bony fragment from mastoid cortical bone. The pulsatile tinnitus disappeared immediately after surgery. (Korean J Otorhinolaryngol-Head Neck Surg 2008;51:751-4)

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.

Morphological and positional relationships between the sigmoid sinus and the jugular bulb

The purpose of this study was to determine the quantitative relationships between the positions of the sigmoid sinus (SS) and jugular bulb (JB) and the influence of mastoid pneumatization upon these structures. The investigations were carried out on 116 healthy adult ears based on the axial images of computed tomography (CT). The reference system locating the displacements of the SS and JB was established and the shape and position of the SS and JB were measured. The volume of pneumatization was quantitatively measured based on the serial digital images of CT. The method of partial correlation analysis was used to find the real relationship of two variables from the complicated dependence relationships. There was a tendency for the SS in the males to be situated more laterally and more backwardly, and the JB in the males was situated more laterally with thicker lateral bone wall when compared to the females. When compared to the left side, the SS on the right side tended to protrude more deeply and was situated more laterally and with less thickness of the lateral bone wall. In male, the right SS was situated more anteriorly than the left SS. In female, the right JB was situated more posteriorly than the left JB. There was a tendency for the SS to be situated more medially, to have a thicker lateral bone wall, and to protrude more superficially in the well-pneumatized bones. When the pneumatization was well, the JB tended to be situated more backwards and have a thicker lateral bone wall. However, there was no significant difference of pneumatization between the high JB group and the low JB group. The SS position and JB position changed synchronously in forward-backward or medial-lateral directions. The results suggest that the factors that influence the shape and position of the SS and JB are multiple. The results suggest that the morphological and positional relationships between the SS and the JB are complicated but could be grasped. The development of the cranial base, the temporal bone pneumatization and non-synchronous dural venous development between the right and left sides are considered to contribute to the morphological and positional changes of the SS and JB.

소아에서 전음성 난청을 동반한 고위 경정맥구 1예

소아에서 전음성 난청을 동반한 고위 경정맥구 1예

Dehiscent High Jugular Bulb

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. Retrospective review. Secondary referral hospital. 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. Each patient underwent otoscopic examination, radiographic examination, and audiometry before and 6 months after operation. 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. HJB is not a contraindication for middle ear surgery. Awareness of this pitfall may lessen the operation risk.

High jugular bulb in the translabyrinthine approach to the cerebellopontine angle: anatomical considerations and surgical management

Evidence of a high jugular bulb position (HJBP) during the translabyrinthine approach may compromise the surgical removal of cerebellopontine angle (CPA) tumours. We report a simple surgical procedure to safely manage this frequent normal variation and comment on various alternative options. The translabyrinthine approach included a complete skeletonization of the sigmoid sinus and of the presigmoid dura. A thin eggshell bone was left at the jugular bulb surface. The dome of the jugular bulb was gently dissected from the jugular fossa and gradually retracted downward in a tailored way, allowing the surgeon to drill below the internal auditory meatus. A small piece of bone was wedged over the jugular dome in order to maintain its lowered position. Among 178 consecutive translabyrinthine approaches performed for the removal of large CPA tumors, the use of this procedure was required in 44 cases of HJBP. Excepting minimal venous bleeding easily controlled in several cases, we never observed any complication from this procedure nor failure to expose the inferior compartment of the CPA. The HJBP can be systematically diagnosed with the preoperative CT-scan using bone window imaging. Our results demonstrate that the described procedure is safe and effective to widen the operative corridor that is required for the exposure of the inferior compartment of the CPA in this anatomical situation.

内頚動脈走行異常部の動脈りゅうからの耳出血例

We experienced right middle ear bleeding from an aneurysm in an aberrant internal carotid artery in a 68 year-old female. Her chief complaint was a slight right ear hemorrhage and mild hearing loss. She had a past history of cirrhosis and hepatocellular carcinoma, and was treated at the department of internal medicine in our hospital. On first examination, slight pulsation was observed in the inferior quadrant tympanic membrane of her right ear. High jugular bulb and glomus jugulare tumor were not revealed by computed tomography. Brain angiography was performed and the rupture of an aneurysm in an aberrant internal carotid artery in the middle ear was suspected as the cause. The observation was done because of the impaired liver function. However, transcatheter embolization was planned because of the massive successive bleeding episodes. Almost 100 percent embolization was obtained. After the operation, the aneurysm disappeared and there were no severe side effects except for slight sensorineural hearing loss. Pulsation of the tympanic membrane disappeared. Although it is a very rare disease, it is important as a cause of extensive bleeding from the middle ear.

Cerebral Venous Sinus Thrombosis Following Jugular Bulb Decompression

A 7-year-old boy was found to have hearing loss on the left side on school screening. On otolaryngology examination he was noted to have a vascular mass behind the tympanic membrane, located inferiorly. Computerized tomography (CT) scan and magnetic resonance imaging (MRI) revealed a dehiscent high jugular bulb. He underwent surgical decompression of the jugular bulb. Two weeks after surgery, he complained of headache and diplopia and was noted to have papilledema and a sixth nerve palsy without visual loss. Cranial MRI scan revealed thrombosis of the left internal jugular vein, transverse and sigmoid sinus. There was no cerebral venous infarct. He was treated with oral acetazolamide and anticoagulation. Two months later he was symptomatically better, neurologically intact with resolved sixth nerve palsy and markedly improved optic disc edema. To our knowledge this is the first reported case of venous thrombosis following jugular bulb surgery in the English language ophthalmologic literature.

A case with an auditory tumor case which was difficult to remove due to the presence of a high jugular bulb

A case with an auditory tumor case which was difficult to remove due to the presence of a high jugular bulb

Otologische Manifestationen des Apert-Syndroms

The Apert syndrome (Acrocephalosyndactyly) is one of the craniosynostotic syndromes, which is often associated with congenial malformation in the temporal bone. We present a case of a 13 year old girl with Apert syndrome. By planning a tympanoplasty we arranged a CT-scan of the temporal bones. It demonstrated next to some other malformations a high jugular bulb on both sides, on the right side just with a membraneous bound to the external ear canal. In a recherche we did not find a higher incidence of high jugular bulb in Apert-syndrome and other craniosynostotic syndromes. However as we expect different malformations of the temporal bone in Apert syndrome we recommend an otorhinolaryngeal examination in each of these patients and a ct scan of the temporal bone before any operation of the middle ear.

The High Jugular Bulb in Lateral and Posterolateral Skull Base Surgery

The High Jugular Bulb in Lateral and Posterolateral Skull Base Surgery

Dehiscence of the Jugular Bulb and Vestibular Aqueduct

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. 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. 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. 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.

Relationship between Tinnitus Loudness Level and Internal Jugular Venous Flow Rate Measured by Coloured Doppler Ultrasonography in Patients with a High Jugular Bulb

The aim of this study was to investigate the relationship between tinnitus loudness level (TLL) and internal jugular venous flow rate (IJVFR) in tinnitus patients with a unilateral high jugular bulb detected by temporal bone high-resolution computed tomography (HRCT). The study group consisted of 24 adult patients (13 male, 11 female) with a unilateral high jugular bulb. One ear suffered from tinnitus with a high jugular bulb was included into the study group. The ears without tinnitus and no high jugular bulb on temporal bone HRCT comprised the control group. All patients were evaluated with a history and physical and otolaryngologic examinations, and, using a questionnaire, TLLs were detected. The patency and flow rates in the internal jugular veins were measured by right and left internal jugular venous Doppler ultrasonography. The TLLs were "very quiet" in 1 (4.1%) patient, "intermediate loud" in 17 (70.9%) patients, and "very loud" in 6 (25.0%) patients. IJVFRs were not different in the study and control groups. In the study group, IJVFRs were not correlated with age. There was no relationship among TLLs and IJVFRs, dominance, dehiscence, and bony septum thickness between the high jugular bulb and the middle ear. TLLs were not affected by IJVFRs, dominance, dehiscence, and bony septum thickness in patients with a high jugular bulb. More detailed studies should be undertaken to determine the reason for the different TLLs in patients with a high jugular bulb.

Infralabyrinthine approach to the petrous apex

This study measures the anatomical dimensions of the path to the petrous apex (PA) via the infralabyrinthine approach in temporal bones of adult Indian subjects, and studies the anatomical variation encountered in this approach. Forty-two temporal bones were dissected to gain access to the PA via the infralabyrinthine approach. The horizontal and vertical dimensions of the access window created as well as the length of the track to the PA from the vertical portion of facial nerve were measured with two-point calipers. Complete dissection was possible in only 21 bones (50%). In the remainder, after preliminary cortical mastoidectomy, an access window to the PA could not be created due to a high jugular bulb. The mean dimensions of the window in dissected bones were 4.60 mm vertically (SD = 0.94 mm) and 6.45 mm (SD = 1.44 mm) horizontally, and the depth of the track to the PA was 30.26 mm (SD = 3.62 mm). The infralabyrinthine approach to the PA provides wide access to lesions of the posterior and inferior PA. In up to 50% of temporal bones, as evidenced by this series, access may be limited by a high jugular bulb. The possibility of this anatomical variation should be considered when the surgical approach to a PA lesion via the infralabyrinthine approach is being planned.

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.

Vascular anomalies, sutures and small canals of the temporal bone on axial CT

Purpose: Subtle bony structures, small canals and fine sutures cause sometimes problems in the analysis of CTs of the temporal bone. The aim of this study was: to analyze the visibility of subtle structures and to estimate the incidence of vascular anomalies. Patients and method: We retrospectively analyzed axial scans of 223 high-resolution CTs of the temporal bone obtained as single slice or spiral CT with 1 mm slice thickness. All CTs had clinical indications. Two experienced radiologists studied CTs regarding the visibility of the fine sutures, fissures and small canals and the occurrence of vascular anomalies. Results: The following structures were seen commonly: sphenosquamosal suture (76%), arcuate artery canal (93%), vestibular aqueduct (89%), mastoid emissary vein (82%), singular canal (56%). Not so commonly were observed: tympanosquamosal suture (31%), mastoid canaliculus (28%), lateral sigmoid sinus (28%), petrotympanic fissure (24%), tympanomastoid suture (10%). Seldom we identified: the inferior tympanic canaliculus (6%), high jugular bulb (6%), anterior sigmoid sinus (5%), dehiscent internal carotid artery canal (2%), persistent petrosquamosal sinus (1%), dehiscent jugular bulb (1%). Persistent stapedial artery, aberrant internal carotid artery, dehiscent jugular bulb, high jugular bulb with diverticulum, anterior and dehiscent sigmoid sinus were detected in below 1% of the analyzed temporal bones. The frequency of asymmetry of the jugular foramen, which varied between 3% and 42%, depended on different criterions of size. Conclusion: A profound knowledge of normal anatomy and anomalies of the temporal bone avoids misinterpretation as pathological lesions and iatrogenic bleedings.

The PACS and three-dimensional reconstruction of temporal bone in middle ear surgery

Objectives: The goal of this study was to investigate the advantages of the three-dimensional (3-D) reconstruction of temporal bone during middle ear surgery and also its application to PACS (Picture Archiving and Communication System). Methods: 3-D images of 2 cases were reconstructed from spiral high-resolution temporal bone CT. One was a case of recurrent chronic otitis media with cholesteatoma that needed a revisional modified radical mastoidectomy, and the other case was of chronic otitis media with high jugular bulb. 3-D reconstruction was performed by segmentation, and surface-rendering algorithm on a personal computer. As this computer was linked to PACS (m-view 5.0, marotech, Korea) of the hospital, image data from spiral high resolution CT were directly downloaded from PACS and reconstructed images were then saved to PACS. A software (Vwork 4.0, CyberMedtm, Korea) was used for image reconstruction. Results: We were able to demonstrate the 3-D display of status of middle ear and mastoid, as well as various structures in them. We could focus on the relationship of high facial ridge and underlying facial nerve, especially helpful in cases of revisional modified radical mastoidectomy, and in cases of high jugular bulb, we could estimate the extent of high jugular bulb to middle ear space on the monitor in operation room. Computer-assisted measurement of reconstructed structures demonstrated comprehensively the anatomic details, improved surgeon’s understanding of their spatial relationship, and so, was helpful for surgery itself and for preventing unexpected complications. Conclusion: The 3-D reconstruction of temporal bone CT associated with PACS can be useful for anatomical understanding of temporal bone and also help to avoid an iatrogenic complication by monitoring during surgery.

伝音難聴を呈した高位頚静脈球症の２例

We report two cases of high jugular bulb presenting with conductive hearing loss. Although patients with high jugular bulb are frequently asymptomatic, it should be recognized that high jugular bulb can occasionally cause tinnitus, hearing loss and dizziness.

Jugular Bulb Diverticulum Combined with High Jugular Bulb: A Case Report with CT and MRA Findings

Jugular Bulb Diverticulum Combined with High Jugular Bulb: A Case Report with CT and MRA Findings