Jugular Bulb Research Articles

Computed Tomography Assessment of the Retrolabyrinthine Approach.

Introduction This study aimed to evaluate preoperative radiological assessments of the retrolabyrinthine approach to identify and describe anatomical constraints that may anticipate a more challenging situation for neurosurgeons and otolaryngologists specialized in skull base surgery. Materials and methods The study included 75 adult patients who underwent high-resolution computed tomography angiography scans of the head, with the aim of analyzing the side of the dominance of the sigmoid sinus (SS), the level of pneumatization of the mastoid portion of the temporal bone, and the height of the jugular bulb. Results The results showed that dominant SS and type 2 jugular bulbs were more common on the right side, while smaller type 1 bulbs were significantly more common on the left. Conclusions These findings provide valuable information for neurosurgeons and otolaryngologists in predicting the difficulty of the retrolabyrinthine approach based on preoperative radiological assessments.

Pre-Operative Evaluation of Petrous Temporal Bone Pathologies by CT and MRI in Cochlear Implant Candidates

Aim: To evaluate pathologies of the petrous temporal bone in cochlear implant candidates on CT and MRI preoperatively. Methods: A cross-sectional study was conducted at Combined Military Hospital Lahore from Jan 2014 to April 2016. 163 candidates were evaluated on CT and 149 were evaluated on MRI. All patients belonged to pediatric age group. Pathologies were grouped using classification of Sennaroglu & Saatci and every pathology was sought in all the cases ensuring that the pathologiesare not missed. Results: High-resolution CT scan temporal bone revealed 69.9% normal studies. Chronic otitis media with mastoiditis was major abnormality observed in 16.6% of cases. Unilateral mastoiditis was seen in 6.1% of patients. Bilateral CSOM without mastoiditis was seen bilaterally in 1.8% of cases. While unilateral CSOM was observed 0.6 % of patients. Among inner ear malformations, Mondini malformation was seen in 4 cases (2.5%). A high jugular bulb was seen in 2 cases (1.2%).93.3% of cases were labeled as normal study on MRI. Four cases showed Mondini malformation. Infective process of middle ear showed a cumulative frequency of 2.7%. Inner ear aplasia was found in one patient. Sclerosing labyrinthitis was also found in one case. Conclusion: Both CT and MRI have substantial role in pre-operative evaluation of petrous temporal bone in cochlear implant candidates. Preoperative evaluation of petrous temporal bone by CT scan and MRI successfully identifies pathologies which can be absolute or relative contraindications of the cochlear implant as well as conditions in which surgical procedure needs to be modified. Keywords: Cochlear implants, HRCT temporal bone, MRI cochlea, Mastoiditis, Mondini malformation

Developmental venous anomaly associated with dural arteriovenous fistula: Etiopathogenesis and hemorrhagic risk.

Developmental venous anomalies (DVAs) have traditionally been defined as non-pathological congenital lesions. Compared to isolated DVAs, the association of DVAs with arteriovenous shunts seems to have a more adverse clinical connotation. In this review, we describe the association between DVA and dAVF and discuss the hemorrhagic risk. We also advance a hypothesis about the potential de novo formation of a DVA and challenge the dogma about their "developmental" or "congenital" nature. A systematic review of the literature on the association of DVA and dAVF was performed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. A number of 678 papers was initially identified, but only 9 studies were included in the final qualitative analysis. Most of the patients presented with bleeding (56%), with a median GCS of 14 (range 10-15). In 56% of the cases the DVA had a supratentorial location. Supratentorial DVAs mostly drained in the superior sagittal sinus (80%), while all of infratentorial/combined DVAs drained in deep ependymal veins of the 4th ventricle. All the supratentorial dAVFs drained into the superior sagittal sinus, while the infratentorial/combined dAVFs mostly drained in the jugular bulb, Vein of Rosenthal, or transverse-sigmoid sinuses (75%). Most of the dAVFs were classified as Cognard type IIa + b (67%), while in a smaller number of cases type I (22%) and type V (11%). The dAVF was the target of treatment in each case and most patients underwent endovascular treatment (78%). The dAVF was completely occluded in 78% of cases and no periprocedural complications were reported. The clinical presentation, radiological findings, and treatment outcomes of DVAs and associated dAVFs have been discussed. Despite the general opinion that DVAs are benign congenital lesions, increasing epidemiological and radiological evidence supports a potential acquired origin, and the venous system seem to play a pivotal role in their post-natal genesis and development.

Role of High-resolution computed tomography (HRCT) in the detection of temporal bone pathology with Histopathological correlation

Background & objective: Pathology of ear is the third most common reason of visiting an Otorhinolaryngologist. Imaging plays an important role, especially in complicated and recurrent conditions and influence the treatment.Because of complicated anatomy radiographic assessment of temporal bone is difficult. An HRCT scan is useful for detail anatomical evaluation, assessment of different pathology, determining the extension and site of cholesteatoma and its sac, assessing the ossicles, evaluating the facial nerve, tegmen and sinus plate, and determining dural, sigmoid sinus, and jugular bulb positions. It is excellent in accurate assessment of pathology prior to surgical exploration regarding location, extent and complication of the disease.
 Method: A cross sectional study was carried out in the Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka in collaboration with the Department of Pathology and Department of ENT of BSMMU and ENT and Head Neck Cancer Hospital, Dhaka, during December 2016 to November 2017, to evaluate the extent of middle ear infections, benign and neoplastic conditions involving temporal bone according to compartment involved.For this purpose, a total of 65 patients having symptoms related to temporal bone pathology was included in this study. HRCT was done for every patient. HRCT findings and diagnoses of the pathologies were then correlated with the histopathological reports. Consecutive type of purposive sampling method was used in this study.
 Result: There was mild male preponderance.Majority (96.9%) patients had soft tissue lesion evaluated .by high-resolution computed tomography (HRCT) findings. Predominant findings are inflammatory, 52(80.0%) of the patients , followed by 11(16.9%) benign and 2(3.1%) malignant lesions. In histopathological evaluation 53(81.5%) of the patients had Inflammatory condition, followed by 11 (16.9%) benign and 1(1.5%) malignant lesions. The validity test of CT scan in the evaluation for benign lesion had sensitivity 81.8%, specificity 96.3%, accuracy 93.8% and positive predictive values 81.8% and negative predictive value 96.3%. CT in the evaluation for malignant lesion had sensitivity 100.0%, specificity 96.9%, accuracy 96.9%, positive predictive values 33.3% and negative predictive values 100.0%. CT in the evaluation for inflammatory lesion had sensitivity 94.3%, specificity 83.3%, accuracy 92.3%, positive predictive values 96.2% and negative predictive values 76.9%.
 Conclusion: In this study we found significant correlation between the histopathological diagnosis and HTCT of temporal bone pathology, where the validity tests are higher in evaluation of malignant lesion followed by inflammatory and benign. So it can be concluded that the high-resolution computed tomography is a useful diagnostic modality which enables characterization of a wide range of temporal bone pathology and can be used as a reliable tool.
 AKMMC J 2021; 12(2): 91-97

Abstract Number ‐ 119: Stent‐Coil Embolization Of A High Riding Jugular Bulb For Symptomatic Pulsatile Tinnitus

Introduction Tinnitus affects millions of people worldwide and in a significant number of people, tinnitus can be severe enough to impact day‐to‐day life. Various diseases can manifest with tinnitus, including atherosclerotic disease, AVMs, Meniere’s disease, IIH, medication toxicity, and neoplasms. Jugular bulb diverticula are a significant contributor to the incidence of persistent tinnitus. One study of 1579 temporal bone specimens, 8.2% were found to have high‐riding jugular bulbs. Other sources demonstrate a prevalence of 6% in the population. Another study demonstrated a high‐riding jugular bulb in 2.4‐7% of temporal bones, a 5 times higher prevalence of a high‐jugular bulb in patients with ear related symptoms, and tinnitus in 22% of patients in a 730 cohort who presented to otolaryngology. We present 3 cases of jugular bulb diverticula causing debilitating tinnitus and their subsequent treatment with stent‐assisted coiling. Methods Retrospective chart review of patients who presented with symptoms of pulsatile tinnitus, noted to have a jugular bulb diverticulum on cerebral venogram, who underwent stent‐assisted coil embolization. Results A 71‐year‐old male with a history of migraines presented with nausea and right‐sided tinnitus that worsened on lying down. The persistence of symptoms prompted further investigation with a catheter venogram which demonstrated a high‐riding right jugular bulb measuring 10.37 mm x 8.61 mm. The patient underwent stent‐assisted coiling and embolization with improvement in his symptoms. A 57‐year‐old male with recent history of right ischemic infarct secondary to intracranial atherosclerosis had worsening left sided pulsatile tinnitus over one year to the point where it prevented sleep, waking him hourly. A CT‐Venogram revealed a left jugular bulb diverticulum measuring 5.33×5.02 mm. A cerebral angiogram and venogram confirmed this diagnosis and ruled out an AVM/dAVF. Stent‐assisted coiling resulted in immediate relief. The above patients were treated with a Zilver stent (Cook Medical, Bloomington, IN) and Target Coils (Stryker Neurovascular, Kalamazoo, MI). A 40‐year‐old woman presented with severe abrupt‐onset pulsatile right‐sided tinnitus and associated hearing loss, without any associated relieving factors. Due to the severity of her symptoms, she goes to counseling. A cerebral venogram revealed a right internal jugular diverticulum measuring 6.73 mm x 14.5 mm, without any associated dural sinus stenosis. She is scheduled for stent assisted coil embolization. Conclusions High‐riding jugular bulb or jugular diverticulum should be suspected as a potential and treatable cause of pulsatile tinnitus when other diagnoses have been ruled out. Our case series demonstrates that stent assisted coil embolization is safe and effective in relieving tinnitus and hearing loss, which can be debilitating in many cases.

Abstract Number ‐ 12: First‐In‐Human Endovascular Treatment of Idiopathic Intracranial Hypertension Using a Miniature Biomimetic Transdural Shunt.

Introduction Successful percutaneous transvenous deployment of a miniature valved biomimetic transdural endovascular shunt (CereVasc eShunt, Auburndale, MA, USA) via an inferior petrosal sinus approach was recently described for treatment of post‐subarachnoid hemorrhage communicating hydrocephalus.The endovascular shunt replicates the function of the arachnoid granulation by draining cerebrospinal fluid (CSF) from the cerebello‐pontine angle cistern to the ipsilateral internal jugular vein. Idiopathic intracranial hypertension (IIH), usually resulting from venous transverse sinus stenosis, can be treated with pharmacological inhibition of CSF production, surgical ventriculoperitoneal shunting, or using venous stent angioplasty. In IIH, elevated CSF pressure can act to exacerbate venous sinus stenosis, resulting in worsening CSF reabsorption, thereby perpetuating a vicious cycle. The authors sought to evaluate the role of the minimally invasive eShunt approach in IIH management. Methods A 50‐year‐old male patient with history of dyslipidemia and IIH initially presented 6 years ago with diplopia initially treated with poorly tolerated acetazolamide and periodic lumbar punctures with subsequent symptom improvement. The patient was admitted following rapid evolution of sudden onset horizontal diplopia and headache. Brain magnetic resonance revealed flattening of the posterior sclera, partially empty Sella Turcica, enhancement of the prelaminar optic nerves and enlarged Meckel´s cave. Lumbar puncture was performed with opening pressure of 28 cmH2O. Cerebral angiography with 3D venography confirmed bilateral transverse sinus stenosis, though without a significant pressure gradient. Results The patient declined surgical ventriculoperitoneal shunting and was approved for compassionate use of eShunt by regulatory and bioethics committees.He underwent successful endovascular transdural deployment of the eShunt, which he tolerated well and was discharged at 48 hours post‐procedure with rapid symptomatic headache relief. Upon 30‐day follow‐up repeat brain MRI showed improvement of the prominent subarachnoid space around both optic nerves and sustained improvement of his pre‐procedural headache and diplopia.A repeat lumbar puncture revealed a lowed opening pressure of 20 cmH2O and MRI cisternography confirmed maintained patency of the biomimetic valve with accumulation of Gadolinium‐enhanced CSF drainage through the eShunt into the jugular bulb. Conclusions The current report describes the first‐in‐human use of the eShunt device for treatment of IIH resulting in sustained symptomatic relief along with decrease in CSF pressure and pre‐laminar optic nerve edema. The current results, which require confirmation in a larger cohort with longer follow‐up, are encouraging and suggest a possible role for minimally invasive endovascular transdural eshunt placement in the management of IIH.

Abstract Number ‐ 92: Successful thrombectomy with Indigo Aspiration System on diffuse cerebral sinus thrombosis

Introduction Endovascular treatment for venous sinus thrombosis is challenging. Commonly utilized aspiration catheters in neuro‐interventional procedures have diameters ranging from 2–3 mm and are much smaller than the average diameter of the major cerebral venous sinuses. Penumbra’s Indigo Aspiration System (Penumbra Inc., Place Alameda, CA) is a trackable, large‐lumen (Indigo System CAT7, 7F) catheter and aspiration system that is used for aspiration of thrombi and emboli involving the peripheral venous and arterial systems, as well as pulmonary emboli. Here, we show that this large‐lumen system may safely retrieve and successfully recanalize cerebral venous thrombosis (CVT), addressing the problem of available tools for complete thrombus removal. Methods Case report. I wanted to submit this abstract for: ‐Young Investigator Award ‐Best Scientific Abstract Award Results Here, we present the first reported case of successful endovascular thrombectomy of cerebral venous sinus thrombosis utilizing Penumbra’s Indigo System (Penumbra Inc., Place Alameda, CA), a minimally‐invasive system with a large‐lumen (Indigo System CAT7, 7F) catheter predominantly used for the removal of thrombi and emboli involving the peripheral arterial and venous systems and for the treatment of pulmonary embolism. A 30‐year‐old female presented with a hemorrhagic infarct of the left posterior temporal lobe secondary to an extensive cerebral venous thrombosis (CVT) extending from the left transverse sinus to the ipsilateral internal jugular bulb. In addition to a continuous heparin infusion, we performed an endovascular thrombectomy with the device mentioned above, resulting in a technically successful radiographic recanalization of the involved sinuses. The patient was discharged home in a stable condition. This case demonstrates that this trackable, atraumatic, large‐bore system can be safe and efficacious, permitting near complete thrombus removal. Conclusions Cerebral Venous Thrombosis (CVT) recanalization is an important outcome measure in trials investigating endovascular therapies for dural venous sinus clots.Most endovascular tools used for aspiration of CVT are designed for arterial, not venous, vasculature.Penumbra’s Indigo Aspiration System, a large‐lumen catheter can be considered as a valid, safe, and effective alternative for the treatment of diffuse CVT.

Abstract Number ‐ 116: Palliative Embolization on an Infantile Dural Sinus Malformation with Giant Lakes.

Introduction Dural Sinus Malformation (DSM) is a rare and high risk mortality vascular pathology identified early postnatal due to common clinical symptoms like macrocephaly, downward wandering eyes, bulging and pulsatile fontanels and heart failure. Most DSMs resolves prenatally. It is characterized by giant venous lake at the torcular region expanding towards the infratentorial and supratentorial spaces with usually existence of Dural arteriovenous fistulas (dAVF). Pathophysiology of DSMs are ballooning and malformation of the distal jugular bulb or persistence abnormal of the transverse sinus. Methods We performed the staged trans arterial Onyx‐18 embolization 5 times of a 3 mo infant boy with dural sinus malformation with multiple arteriovenous fistula using the 4 French GlideSim 2 Catheter, Headway Duo 167 micro catheter, and numerous microwires including Aristotle 014, Chikai Black Soft 014 and 010 and Synchro 014, 010 and 080 through alternated sides of transfemoral accesses. Embolizations were performed through the bilateral branches of the left and right middle meningeal arteries, posterior meningeal arteries and left occipital artery. Limitations during procedure are body weight to use contrast, fluoroscopy time and access sides. Results Post embolization injections demonstrated significant flow reduction into the malformation through ECA branches. No neurological complications occurred due to the procedures. MRI Brains in following weeks did not show large thrombus formation, hydrocephalus, or parenchymal injury. Patient showed clinical improvements with stable macrocephaly and decreased frontal pulsation and bulging. Conclusions Staged trans arterial embolization seems a safe approach on high mortality DSM. Thrombus is not formed all at once and mass effect from thrombosed sinus is avoided. Sinus has time to shrink.

Assessment of the distribution and volume of air chambers around the inner auditory canal on high-resolution computed tomography scans of the temporal bone.

Assessment of the distribution and volume of air chambers around the inner auditory canal on high-resolution computed tomography scans of the temporal bone.

Symptoms: Dizziness and Deafness

Symptoms: Dizziness and Deafness

Right Condylar Jugular Diverticulum: Contrast-enhanced Computed Tomography Findings of a Rare Anatomical Variant of Jugular Bulb.

This is the first description of condylar jugular diverticulum (CJD) by means of contrast-enhanced computed tomography scan in the medical literature. CJD is a rare anatomical variant of jugular bulb that should be known to avoid radiological and surgical errors and achieve an appropriate pre-surgical planning of skull base pathologies.

Influence of pneumatization on morphology of temporal bone-related vasculatures and their morphometric relationship with ear regions: a computed tomography study

Anatomical variations in the location and position of temporal bone-related vasculature are routinely encountered in clinical practice, contributing to clinical syndromes and complexities in ear-related and neurological surgeries. Pneumatization of the temporal bone (TB) is one of several factors that have been hypothesized to influence the variabilities and variations of these vessels. This study aimed to investigate the association between the degree of pneumatization and the morphologies of some TB-related vessels, as well as their morphometrical relationship with ear regions. Observational retrospective chart review of 496 TBs computed tomographic scans were examined. Different degrees of pneumatization were observed, with hyper-pneumatization being the most common and hypo-pneumatization being the least. Various anatomical variants of the sigmoid sinus (SS), jugular bulb (JB), and internal carotid artery (ICA) were observed. Distances of SS and JB to ear regions were observed to have significant differences (p < 0.05) in laterality. These distances increased relative to increased air cells, showing a significant association (p < 0.05). A significant association (p < 0.001) was also observed between the degree of pneumatization and variants of JB and ICA. High JB, JB dehiscence, and ICA dehiscence were significantly associated with increased pneumatization, while flat JB was significantly associated with decreasing pneumatization. However, no significant association (p = 0.070, p = 0.645) was observed between the degree of pneumatization and morphologies of SS. This study concludes that the degree of pneumatization influences only the jugular bulb variants and ICA dehiscence, as well as the distances of SS and JB to ear regions.

Assessment of jugular bulb variability based on 3D surface models: quantitative measurements and surgical implications

PurposeHigh-riding jugular bulbs (JBs) among other anatomical variations can limit surgical access during lateral skull base surgery or middle ear surgery and must be carefully assessed preoperatively. We reconstruct 3D surface models to evaluate recent JB classification systems and assess the variability in the JB and surrounding structures.Methods3D surface models were reconstructed from 46 temporal bones from computed tomography scans. Two independent raters visually assessed the height of the JB in the 3D models. Distances between the round window and the JB dome were measured to evaluate the spacing of this area. Additional distances between landmarks on surrounding structures were measured and statistically analyzed to describe the anatomical variability between and within subjects.ResultsThe visual classification revealed that 30% of the specimens had no JB, 63% a low JB, and 7% a high-riding JB. The measured mean distance from the round window to the jugular bulb ranges between 3.22 ± 0.97 mm and 10.34 ± 1.41 mm. The distance measurement (error rate 5%) was more accurate than the visual classification (error rate 15%). The variability of the JB was higher than for the surrounding structures. No systematic laterality was found for any structure.ConclusionQualitative analysis in 3D models can contribute to a better spatial orientation in the lateral skull base and, thereby, have important implications during planning of middle ear and lateral skull base surgery.

Analysis of Etiology, Diagnosis, and Treatment Strategy and Efficacy of Pulsatile Tinnitus Caused by Abnormal Vascular Anatomy.

To investigate the etiology, clinical characteristics, diagnosis, and treatment strategies and efficacy of pulsatile tinnitus (PT) caused by vascular anatomy abnormality. The clinical data of 45 patients with PT in our hospital from 2012 to 2019 were collected and retrospectively analyzed. All 45 patients had vascular anatomical abnormalities. The patients were divided into 10 categories according to the different locations of vascular abnormalities: sigmoid sinus diverticulum (SSD), sigmoid sinus wall dehiscence (SSWD), SSWD with high jugular bulb, pure dilated mastoid emissary vein, aberrant internal carotid artery (ICA) in the middle ear, transverse-sigmoid sinus (TSS) transition stenosis, TSS transition stenosis with SSD, persistent occipital sinus stenosis, petrous segment stenosis of ICA, and dural arteriovenous fistula. All patients complained of PT synchronous with heartbeat rhythm. Endovascular interventional therapy and extravascular open surgery were used according to the location of the vascular lesions. Tinnitus disappeared in 41 patients, was significantly relieved in 3 patients, and was unchanged in 1 patient postoperatively. Except for one patient with transient headache postoperatively, no obvious complications occurred. PT caused by vascular anatomy abnormalities can be identified by detailed medical history and physical and imaging examination. PT can be relieved or even completely alleviated after appropriate surgical treatments.

Imaging Study &amp; Surgical Perspective Of Cochlear Implantees

Introduction: A cross-sectional prospective clinical study was done to evaluate the inner ear anomalies in candidates undergoing cochlear implantation. Materials and Methods: Study was carried out over a period of 07 years (Jan 2013 to Dec 2019) at Cochlear Implant Centre, Combined Military Hospital Dhaka. A total 206 deaf candidates, both pre and post lingual, were included in convenient sampling method. Result: The sample consisted of 206 candidates, of whom 117 (56.80%) were female and 89 (43.20%) were male. All candidates had severe to profound bilateral deafness. 182 (88.35%) of them were pre and 24 (11.65%) were in post lingual group. All patients diagnosed audiologically as profound deafness underwent HRCT scan of temporal bone with 3D reconstruction of cochlea and MRI of internal auditory canal &amp; brain. Radiological examination revealed that 36 (17.47%) candidates had ear anomalies. Mondini deformity 14 (06.80%), cochlear ossification 11 (5.34%), large vestibular aqueduct 04 (1.94%), high jugular bulb 04 (1.94%) and anteriorly placed sigmoid sinus 03 (1.45%) were noted. During intervention, 42 (20.39%) candidates had anomalous intra operative findings. Among them CSF gusher 19 (9.23%), ossification of basal turn 12 (5.83%), isolated rotated Cochlea 02 (0.97%), high jugular bulb 04 (1.94%), anteriorly placed sigmoid sinus 03 (1.45%), and very high facial nerve 02 (0.97%) were observed. During surgery, electrode insertion difficulty due to high CSF gusher was experienced in19 (9.23%) cases, full length of electrode insertion was not possible due to ossified basal turn 12 (5.83%), difficult to find out round window membrane due to rotated cochlea 02 (0.97%), prevented direct visualization of the round window due to high jugular bulb 04 (1.94%), difficult to approach round window due to very high facial nerve 02 (0.97%). and approach to round window membrane was compromised due to anteriorly placed sigmoid sinus 03 (1.45%). Most of these difficulties were effectively managed during surgery. Conclusions: This study highlights the importance of preoperative radiological scanning in the assessment of patients undergoing cochlear implantation. It provides vital information on cochlear status and in ruling out non cochlear causes where cochlear implantation is not feasible. Detection of anatomical abnormalities with appropriate evaluation, specially imaging should be mandatory in every patient undergoing cochlear implantation. J Dhaka Med Coll. 2021; 30(2) : 167-175

CT evaluation of unilateral pulsatile tinnitus with jugular bulb wall dehiscence.

To investigate the imaging features of unilateral pulsatile tinnitus (PT) with jugular bulb wall dehiscence (JBWD). Computerized tomography angiography images of unilateral PT patients were reviewed between 2019 and 2021. Thirty-one symptomatic JBWD patients without sigmoid sinus wall dehiscence (SSWD) were included. Thirty-eight patients with SSWD were used as the control group. The prevalence of JBWD was calculated. The area and height of the jugular bulb, the extent of dehiscence, the presence of jugular bulb diverticulum, posterior condylar emissary vein (PCEV), oblique occipital sinus (OOS), venous outflow laterality (VOL), the degree of transverse sinus stenosis (TSS), and the pituitary height to sella turcica ratio were compared between the two groups. The prevalence of JBWD was 12.1%, and JBWD was established as a causative diagnosis in 5.0% of unilateral PT patients. There were no statistical differences in the gender, symptomatic side, or VOL between the two groups. The area of the jugular bulb was larger and the height was higher (parea < 0.001, pheight = 0.005). The prevalence of jugular bulb diverticulum was higher in the JBWD group (p = 0.002). The degree of symptomatic TSS was less severe (p < 0.001), and the prevalence of bilateral TSS was lower in the JBWD group (p < 0.001). The pituitary height to sella turcica ratio was greater (p = 0.004), the prevalence of PCEV (p = 0.014) was lower, and OOS (p = 0.015) was greater in the JBWD group. The correlating factors of PT with JBWD and PT with SSWD are significantly different. These findings can further facilitate early and efficient PT treatment. • The incidence of jugular bulb dehiscence (JBWD) accounted for approximately 12.1% in pulsatile tinnitus (PT) patients, and JBWD was established as a causative diagnosis in 5.0% of PT patients. • PT required large blood flows and abnormal flow patterns, whether in JBWD or sigmoid sinus wall dehiscence groups. • JBWD causing PT has some unique characteristic findings on CT.

Anterior occipital condyle screw placement through the endonasal corridor: proof of concept study with cadaveric analysis.

Odontoidectomy for ventral compressive pathology may result in O-C1 and/or C1-2 instability. Same-stage endonasal C1-2 spinal fusion has been advocated to eliminate risks associated with separate-stage posterior approaches. While endonasal methods for C1 instrumentationand C1-2 trans-articularstabilization exist, no hypothetical construct for endonasal occipital instrumentation has been validated. We provide an anatomic description of anterior occipital condyle (AOC) screw endonasal placement as proof-of-concept for endonasal craniocervical stabilization. Eight adult, injected cadaveric heads were studied for placing 16 AOC screws endonasally. Thin-cut CT was used for registration. After turning a standard inferior U-shaped nasopharyngeal flap endonasally, 4 mm × 22 mm AOC screws were placed with a 0° driver using neuronavigation. Post-placement CT scans were obtained to determine: site-of-entry, measured from the endonasal projection of the medial O-C1 joint; screw angulation in sagittal and axial planes, proximity to critical structures. Average site-of-entry was 6.88mm lateral and 9.74mm rostral to the medial O-C1 joint. Average angulation in the sagittal plane was 0.16° inferior to the palatal line. Average angulation in the axial plane was 23.97° lateral to midline. Average minimum screw distances from the jugular bulb and hypoglossal canal were 4.80mm and 1.55mm. Endonasal placement of AOC screws is feasible using a 0° driver. Our measurements provide useful parameters to guide optimal placement. Given proximity of hypoglossal canal and jugular bulb, neuronavigation is recommended. Biomechanical studies will ultimately be necessary to evaluate the strength of AOC screws with plate-screw constructs utilizing endonasal C1 lateral mass or C1-2 trans-articular screws as inferior fixation points.

Jugular foramen anatomy in lateral skull base paraganglioma surgery

To detalize the anatomy of the jugular foramen according to the comparison of cadaver dissections findings and the CT scans data that were performed before the dissections, for improvement of quality of treatment of patients with temporal bone paraganglioma (Fisch type C). The data of CT scans and the steps of the approaches to the jugular foramen (retrofacial and infratemporal approaches with opening of jugular bulb and identification of the anatomical structures of jugular foramen) were analyzed on 10 cadaver heads, 20 sides. Clinical implementation was demonstrated in case of temporal bone paraganglioma type C. Based on the detail study of the CTs data we revealed the individual features of the temporal bone structures. Due to the results of 3D rendering the average length of the jugular foramen in anterior-posterior direction was 10.1 mm. The length of vascular part was larger than the nervous part. The posterior part had the bigger height wherein the shortest part we detected between jugular ridges, which in some cases caused the dumbbell shape of jugular foramen. According to 3D multiplanar reconstruction the distances between jugular crests (3.0 mm) had the lowest measures and the largest was between internal auditory canal (IAC) and jugular bulb (JB) (8.01mm). At the same time, one of the largest variations of values was also identified between IAC and JB (from 4.39 to 9.84 mm). The distance between the facial nerve in the mastoid segment and JB was variable (from 3.4 to 10.2 mm) and determined by the volume and position of the JB. The results of the dissection corresponded to the measurements according to the CT scans, taking into account the 2-3 mm error due to the massive removal of temporal bone during performing of surgical approaches. The detailed knowledge of the surgical anatomy of the jugular foramen based on a thorough analysis of preoperative CT data is the key to an adequate surgical tactic for the removal of different types of temporal bone paraganglioma while preserving the function of vital structures and the quality of life. A larger study on the big data is needed to determine the statistical relationship between the volume of JB and the size of the jugular crest; the correlation between the dimensions of jugular crests and the tumor invasion in the anterior part of the jugular foramen.

Paraganglioma of External Auditory Canal: A Rare Entity Case Report

Paragangliomas are benign tumours originating from the paraganglia. In the ear paragangliomas are foundcommonly in middle ear or jugular bulb. Paragangliomas of external auditory canal are extremely rare. Our casedescribes a woman in her 5th decade presenting with difficulty in hearing since 6 months and swelling in theright ear. Physical examination revealed a red to pink swelling, non friable, bleeding on touch and obscuringthe external auditory canal completely. Differential diagnosis of granuloma/exostosis was considered. Patientunderwent excision biopsy. Hemorrhage during surgery was copious and suspicion of vascular lesion was raised.Histopathology and immunohistochemistry confirmed the diagnosis of paraganglioma. The aim of this article isto make clinicians aware of the entity for diagnosis and appropriate treatment.

Symptoms: Purple Ear Drum and Hearing Loss

Symptoms: Purple Ear Drum and Hearing Loss