Stapedial Artery Research Articles

Persistence of Stapedial Artery, Our Experience – A Case Report

Stapedial artery persistence is an uncommon issue to encounter in ordinary ear, nose, and throat practice. If they are, they typically show up as a pulsatile mass or as a sneaky discovery. Due to the condition’s rarity, most individuals are asymptomatic, but occasionally it can induce vertigo, pulsatile tinnitus, or conductive hearing loss in certain people. We hereby present a case of incidental discovery of a persistent stapedial artery in a patient with complaints of nasal obstruction.

The Many Faces of Persistent Stapedial Artery: CT Findings and Embryologic Explanations.

Persistent stapedial artery is a vascular anomaly with both clinical and surgical implications. Because of its scarcity, however, it remains underrecognized on imaging. Presented here is a series of 10 cases, demonstrating characteristic CT findings associated with this vascular anomaly and its most common pathognomonic imaging signs. The variable morphologic configurations and their corresponding embryologic underpinnings are described. Clinical and surgical implications of this rare anomaly are discussed.

Stapedial Artery: From Embryology to Different Possible Adult Configurations.

The stapedial artery is an embryonic artery that represents the precursor of some orbital, dural, and maxillary branches. Although its embryologic development and transformations are very complex, it is mandatory to understand the numerous anatomic variations of the middle meningeal artery. Thus, in the first part of this review, we describe in detail the hyostapedial system development with its variants, referring also to some critical points of ICA, ophthalmic artery, trigeminal artery, and inferolateral trunk embryology. This basis will allow the understanding of the anatomic variants of the middle meningeal artery, which we address in the second part of the review.

Stapes surgery with a persistent stapedial artery.

To review surgical outcomes of stapes surgery for otosclerosis with persistence of the stapedial artery. A retrospective case review of a tertiary neurotology referral center of patient with otosclerosis undergoing primary stapes surgery between 2010 and 2017 found to have a persistent stapedial artery. Stapedectomy was performed with or without cauterization of the stapedial artery. The primary outcome measures include pre- and postoperative hearing as well complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Neurologic complications, including facial nerve function, were assessed. Four patients out of 853 with otosclerosis undergoing stapedectomy were found to have a persistence of the stapedial artery. Mean AC PTA was 55dB preoperatively, and 24dB postoperatively (p=.0041), while the ABG improved on average from 31dB to 6dB (p=.0014). Mean follow-up time was 32months, and there were no significant complications. Facial nerve function was preserved in all patients (House-Brackmann grade I/VI). In the case of a persistent stapedial artery, excellent hearing outcomes are achievable for otosclerosis via stapedectomy without an apparent increased risk of neurologic complication.

CXCL12 is required for stirrup-shaped stapes formation during mammalian middle ear development.

The mammalian middle ear comprises a chain of three ossicles-the malleus, incus, and stapes-each of which has a unique morphology for efficiently transmitting sound information. In particular, the stapes, which is attached to the inner ear, is stirrup-shaped with a head and base connected by two crural arches, forming the stapedial foramen, through which the stapedial artery passes. However, how the stapes acquires this critical stirrup shape for association with the stapedial artery during development is not clear. C-X-C motif chemokine ligand 12 (CXCL12) is a chemoattractant essential for cellular movement and angiogenesis. In Cxcl12 -/- embryos, migration of neural crest cells into the prospective middle ear regions and their mesenchymal condensation to form the three ossicles proceed normally in correct alignment with each other and the inner ear. However, in the absence of CXCL12, the stapes loses its stirrup shape and instead exhibits a columnar shape lacking the crural arches and central hole. In addition, although the stapedial artery initially forms during early mesenchymal condensation of the stapes, it degenerates without CXCL12 function. CXCL12 plays an essential role in establishing the stirrup-shaped architecture of the stapes, possibly by maintaining the stapedial foramen and stapedial artery throughout development.

Bilateral Persistent Stapedial Arteries Associated With Abnormal Lower Extremity Bone Growth.

Bilateral Persistent Stapedial Arteries Associated With Abnormal Lower Extremity Bone Growth.

Extratympanic Observation of Middle and Inner Ear Structures in Rodents Using Optical Coherence Tomography.

ObjectivesThis study aimed to investigate whether optical coherence tomography (OCT) provides useful information about the microstructures of the middle and inner ear via extratympanic approach and thereby could be utilized as an alternative diagnostic technology in ear imaging.MethodsFive rats and mice were included, and the swept-source OCT system was applied to confirm the extent of visibility of the middle and inner ear and measure the length or thickness of the microstructures in the ear. The cochlea was subsequently dissected following OCT and histologically evaluated to compare with the OCT images.ResultsThe middle ear microstructures such as ossicles, stapedial artery and oval window through the tympanic membrane with the OCT could be confirmed in both rats and mice. It was also possible to obtain the inner ear images such as each compartment of the cochlea in the mice, but the bone covering bulla needed to be removed to visualize the inner ear structures in the rats which had thicker bulla. The bony thickness covering the cochlea could be measured, which showed no significant differences between OCT and histologic image at all turns of cochlea.ConclusionOCT has been shown a promising technology to assess real-time middle and inner ear microstructures noninvasively with a high-resolution in the animal model. Therefore, OCT could be utilized to provide additional diagnostic information about the diseases of the middle and inner ear.

Improved postauricular surgical approach to the round window of rats

ObjectivesResearch using rat as an in-vivo model has played an important role in otological research. The rat ear anatomy has been described; however, detailed surgical procedures to access the temporal bone are limited. The authors present a technique to approach the inner ear of rat that was standardized by cadaveric dissections and later replicated in living animals. MethodsAdult Wistar albino rats were dissected via the post-auricular approach. The emphasis was on early identification of the facial nerve that formed a reliable landmark for the tympanic bulla, which in turn houses the round window and stapedial artery. The point of identification of facial nerve was postero-inferior to the external auditory meatus. The procedure was then repeated in living animals. ResultsSeventeen cadaveric rats were dissected. Initially, the investigators attempted to identify the facial nerve at its crossing over the external auditory meatus. However, that method was found to be unsatisfactory. The facial nerve was then attempted to be identified in its course postero-inferior to the external auditory meatus. The technique improved drastically, and the facial nerve was identified promptly and reliably. The procedure was then repeated in seven living rats under general anaesthesia. The major issues encountered were bleeding from the stapedial artery, hematoma of the pinna in one rat. ConclusionThis study suggests that the post-auricular approach is a feasible and less time consuming route for round window drug delivery experiments in Wistar albino rats. Recognition of anatomical landmarks, particularly the facial nerve is the key to surgery.

Persistent stapedial artery in PHACE syndrome

IntroductionPHACE syndrome is characterized by posterior fossa malformations, haemangioma, arterial anomalies, coarctation of the aorta, and eye abnormalities. Case reportWe present the case of a 6-year-old girl followed since birth for PHACE syndrome and left hemifacial haemangioma, who presented with left hearing loss. Computed tomography scan showed left persistent stapedial artery (PSA). DiscussionTwo types of arterial anomalies may be observed in PHACE syndrome: persistence of embryonic arteries and anomalies of cerebral arteries. PSA can be observed in the context of PHACE syndrome. Children with PHACE syndrome require regular audiometric follow-up to detect hearing loss and avoid its consequences on speech and language development.

Arterial Anomalies of the Middle Ear: A Pictorial Review with Clinical-Embryologic and Imaging Correlation.

The differential diagnosis of a red and/or pulsatile retrotympanic mass includes aberrant internal carotid artery, persistent stapedial artery (PSA), glomus tympanicum, and dehiscent jugular bulb. By recognizing the features of aberrant internal carotid artery and PSA on high-resolution computed tomography, these entities can be assessed by the radiologist. PSA is further classified by type because each type demonstrates a unique set of imaging features in addition to features common to all types. Although rarely encountered, it is important to reliably and consistently detect these anomalies because failure to do so can lead to disastrous surgical outcomes.

Pulsatile Tinnitus Due to a Sigmoid Sinus Diverticulum and/or Dehiscence

In 2009, a 52-year-old man presented with a two year history of intermittent right-sided pulse-synchronous tinnitus. He noted that the tinnitus worsened when his blood pressure was elevated. Otologic exam was unremarkable, with no obvious middle ear fluid or mass. There was no neck bruit, and the tinnitus diminished on manual compression of the ipsilateral internal jugular vein. In keeping with the recommendations for clinical imaging at that time, a non-contrast CT of the temporal bone was performed. This was to evaluate for conditions such as : a middle ear glomus, an aberrant internal carotid artery, a jugular bulb variant (e.g. a high-riding jugular bulb), otosclerosis, superior semicircular canal dehiscence syndrome, a persistent stapedial artery, or a hemangioma of the temporal bone.1 No evidence of these conditions was found. An MRI of the brain, with MR angiography and venography of the intracranial vasculature also performed to evaluate for conditions such as: idiopathic intracranial hypertension, a dural arteriovenous fistula, an arteriovenous malformation, vascular loop syndrome, and dural sinus stenosis or thrombosis.2 All of these conditions were excluded. As no definite pathology was identified, no firm treatment reommendations were initiallly made.
 In 2011, Eisenman reported on a series of 13 patients with pulsatile tinnitus due to a sigmoid sinus diverticulum and/or dehiscence who were successfully treated surgically via an extraluminal transmastoid approach.3 This was the first relatively large series published in the otologic literature. This publication likewise reported on the subtle radiologic signs that signify the presence of a sigmoid sinus diverticulum and/or dehiscence, such as an irregularity of the normal semicircular contour of the bony sinus wall, focal thinning of the calvarial cortex overlying the adjacent sinus wall, absence of the normal thin layer of cortical bone overlying the sinus, and the "air-on-sinus" sign, where mastoid air cells directly contact the sinus wall, without overlying bone.3
 In light of this new information, the patient's imaging studies were re-evaluated, and evidence of a right-sided sigmoid sinus diverticulum and/or dehiscence was identified. The images below show the findings on an axial slice of the patient's temporal bone CT study.
 How significant is this condition ? Sigmoid sinus diverticulum and/or dehiscence is being increasingly recognized as a common cause of pulsatile tinnitus. In fact, a recent study by Schoeff et al. found its prevalence to be 23% in patients with pulsatile tinnitus.4 As such, the identification of this condition is highly relevant, particularly because effective surgical management is available for its alleviation.

Endoscopic evaluation of middle ear anatomic variations in autopsy series: analyses of 204 ears

IntroductionMicrosurgery of the ear requires complete evaluation of middle ear surgical anatomy, especially the posterior tympanic cavity anatomy. Preoperative assessment of the middle ear cavity is limited by the permeability of eardrum and temporal bone density. Therefore, middle ear exploration is an extremely useful method to identify structural abnormalities and anatomical variations. ObjectiveThe aim of this study is to determine anatomic variations of the middle ear in an autopsy series. MethodsAll evaluations were performed in the Forensic Medicine Institute Morgue Department. The cases over 18 years of age, with no temporal bone trauma and history of otologic surgery included in this study. ResultsOne hundred and two cadavers were included in the study. The mean age was 49.08±17.76 years. Anterior wall prominence of the external auditory canal was present in 27 of all cadavers (26.4%). The tympanic membrane was normal in 192 ears (94%) while several eardrum pathologies were detected in 12 ears (6%). Agenesis of the pyramidal eminence and stapedial tendon was found in 3 ears. While the ponticulus was bony ridge-shaped in 156 of 204 ears (76.4%), it was bridge-shaped in 25 ears (12.3%). The ponticulus was absent in 23 ears (11.3%). While complete subiculum was present in 136 of all ears (66.7%), incomplete subiculum was present in 21 ears (10.3%). Subiculum was absent in 47 ears (23%). Facial dehiscence was found in 32 ears and the round window niche was covered by a pseudomembrane in 85 ears (41.6%). A fixed footplate was present in 7.4% of all ears, and no persistent stapedial artery was seen in any cases. ConclusionThe pseudomembrane frequency covering the round window niche was found different from reports in the literature. In addition, the frequency of the external auditory canal wall prominence has been reported for the first time.

Persistent Stapedial Artery with Ankylosis of the Stapes Footplate

When cochlear implantation was first introduced, the mastoidectomy and posterior tympanotomy approach was the most frequently used technique to gain access to the middle ear and the cochlea. Since 2000, several authors have routinely used a non-mastoidectomy nonposterior tympanotomy technique, which has undergone several modifications. Alternative surgical techniques for cochlear implantation have recently been introduced, such as endomeatal-alone or suprameatal-alone and combined posterior tympanotomy/endomeatal approaches. The goal of this study was to describe another modification of this less invasive technique to perform cochlear implantation. Cochlear implantations were performed between January 1, 2002, and December 31, 2012, in 220 patients through the posterior suprameatal approach. In reviewing our experiences, we have concluded that this approach, which eliminates the need for mastoidectomy, is considered safe, time-efficient, and minimally invasive. The possible pitfalls and the microsurgical relevance of anatomic structures of this technique are discussed in detail. Using this technique, not all classical anatomic orientation points are identified. However, certain landmarks predict the depth and the three-dimensional location of invisible anatomic structures.

The Stapedial Artery in the Mongolian Gerbil (Meriones unguiculatus).

The persistent stapedial artery is a component of the main arterial roads of the head in some animal groups (Frąckowiak: Roczn Akad Roln Poznań 336 (2003) 1-81). This type of vascularization occurs in the Mongolian gerbil, among others. The stapedial artery is common in a variety of forms in rodents. It has been described, for example, in Sciuridae, Muridae, Heteromyidae, Geomyidae, Splacidae, Cricetidae, Arvicolinae, and in genus Jaculus (Cox and Hautier: Evolution of the Rodents: Advances in phylogeny, Functional Morphology and Development, 2015). The aim of this study was the analysis of morphology, and of course, of the stapedial artery in this species. Investigations were performed on 10 animals of both sexes, weighing 50-60 g. After lethal anesthesia, the vascular system of every animal was filled with colored latex. After latex coagulation and decalcification of skull bones, fixed tissues were delicately prepared, and the head vascular system was exposed. The stapedial artery separates from the internal carotid artery, runs toward the auditory bulb and passes through the stapes. After the branching of the medial meningeal artery, the stapedial artery runs rostrally, forming its infraorbital branch. This branch, in the further course, gives the branch forming the short trunk of the ophthalmic artery, which supplies orbital structures (muscles, lacrimal gland, Harderian gland, and eyeball). The performed investigations revealed that the maintained infraorbital branch of the stapedial artery is the only source of arterial supply of the orbit in this species. Anat Rec, 301:1131-1137, 2018. © 2018 Wiley Periodicals, Inc.

Monitoring blood-flow in the mouse cochlea using an endoscopic laser speckle contrast imaging system.

Laser speckle contrast imaging (LSCI) enables continuous high-resolution assessment of microcirculation in real-time. We applied an endoscope to LSCI to measure cochlear blood-flow in an ischemia–reperfusion mouse model. We also explored whether using xenon light in combination with LSCI facilitates visualization of anatomical position. Based on a previous preliminary study, the appropriate wavelength for penetrating the thin bony cochlea was 830 nm. A 2.7-mm-diameter endoscope was used, as appropriate for the size of the mouse cochlea. Our endoscopic LSCI system was used to illuminate the right cochlea after dissection of the mouse. We observed changes in the speckle signals when we applied the endoscopic LSCI system to the ischemia-reperfusion mouse model. The anatomical structure of the mouse cochlea and surrounding structures were clearly visible using the xenon light. The speckle signal of the cochlea was scattered, with an intensity that varied between that of the stapes (with the lowest signal), the negative control, and the stapedial artery (with the highest signal), the positive control. In the cochlear ischemia–reperfusion mouse model, the speckle signal of the cochlea decreased during the ischemic phase, and increased during the reperfusion phase, clearly reflecting cochlear blood-flow. The endoscopic LSCI system generates high-resolution images in real-time, allowing visualization of blood-flow and its changes in the mouse cochlea. Anatomical structures were clearly matched using LSCI along with visible light.

Segmental agenesis of the cervical internal carotid artery with collateral blood supply from the ascending pharyngeal artery and intercavernous anastomosis: a clinical case and literature review

The article presents a clinical case of segmental agenesis of the cervical ICA with collateral blood supply to the ICA territory through the intercavernous anastomosis and ascending pharyngeal artery with the branching primitive stapedial artery - the aberrant ICA variant. A feature of the case is a unique combination of the intercavernous anastomosis and the aberrant ICA, which provide collateral blood flow in cervical ICA agenesis. In the world literature, there are no reports of similar combinations. The discussion provides information on the stages of circle of Willis formation and presents a literature review of cases of intercavernous anastomoses associated with ICA agenesis.

UCHYŁEK ZATOKI ESOWATEJ Z OKOŁO ZATOKOWĄ PNEUMATYZACJĄ POWODUJĄCA PULSUJĄCE SZUMY USZNE

Tinnitus is a bothersome symptom with various etiologies. Pulsatile tinnitus constitutes only a small percentage of tinnitus types and is due to a vascular pathology close to the inner ear which causes a sensation of noise. Many vascular lesions are associated with pulsatile tinnitus: paraganglionoma, persistent stapedial artery, a vascular loop in the internal auditory meatus or cerebello-pontine angle, carotid-vertebral stenosis, and arterio-venous malformation. We report one case of pulsatile tinnitus that originated in a venous diverticulum of the sigmoid sinus and which was transmitted to the inner ear through perisinus pneumatisation. Treatment options for this condition are discussed, with insights from the literature.

Surgical Management of a Persistent Stapedial Artery: A Review.

Objective:To evaluate the outcome and per- and postoperative complications of the surgical management of patients with a persistent stapedial artery (PSA).Methods:A systemic literature search for reports on patients treated for pulsatile tinnitus and/or conductive hearing loss caused by a PSA was conducted of the PubMed and Embase databases using the terms “stapedial” and “artery.” Inclusion criteria were adequate description of the intervention and pre- and postoperative signs and symptoms. In addition, one case of a PSA, treated at VU University Medical Center Amsterdam, The Netherlands, was included in this series.Intervention:Middle ear surgery consisting of stapedotomy or stapedectomy, and/or transection of the PSA.Main Outcome Measures:Pre- and postoperative hearing levels, pre- and postoperative pulsatile tinnitus, and per- and postoperative complications.Results:Seventeen patients and 18 operated ears were evaluated (16 patients described in 14 articles and our case). Twelve out of 14 ears in which a stapedotomy or stapedectomy was initiated experienced improvement in hearing. In four cases pulsatile tinnitus was described pre- and postoperatively. In all four, pulsatile tinnitus subsided after transection of the PSA. Peroperative bleeding from the PSA was described in four patients, which could be controlled during the procedure. No significant postoperative sequelae were reported.Conclusions:In case of a PSA, improvement of conductive hearing loss is best achieved by stapes surgery, while pulsatile tinnitus is effectively treated with transection of the PSA. To date no long-term postoperative complications have been reported.

Retroauricular Approach for Targeted Cochlear Therapy Experiments in Wistar Albino Rats.

Background:As the idea of stem cell technology in the treatment of sensorial hearing loss has emerged over the past decades, the need for in vivo models for related experiments has become explicit. One of the most common experimental models for inner ear stem cell delivery experiments is the Wistar albino rat.Aims:To investigate the surgical anatomy of the temporal bone of the Wistar albino rat with respect to the dissection steps, operative techniques and potential pitfalls of surgery.Study Design:Animal experimentation.Methods:Adult Wistar albino rats were operated on via the retroauricular approach under an operation microscope. The anatomy of the temporal bone, the surgical route to the temporal bulla and the inner ear were investigated. Technical details of surgical steps, complications and potential pitfalls during the surgery were noted.Results:The study group consisted of 40 adult Wistar albino rats. The mean times to reach the bulla and to achieve cochleostomy were 4.3 (2-13 min) and 7.5 min (3.5-22 min), respectively. The mean width of the facial nerve was 0.84 mm (0.42-1.25 mm). The stapedial artery lay nearly perpendicular to the course of the facial nerve (88-93 °C). There were three major complications: two large cochleostomies and one massive bleed from the stapedial artery.Conclusion:The facial nerve was the key anatomical landmark in locating the bulla. By retrograde tracing of the facial nerve, it was possible to find the bulla ventral (inferior) to the main trunk. The facial nerve trunk was the upper limit when drilling the bulla. By dissecting the main trunk of the facial nerve and retracting cranially, a large drilling space could be achieved. Our results suggest that the retroauricular approach is an effective, feasible route for inner ear drug delivery experiments in Wistar albino rats.

Ectopic Mineralization and Conductive Hearing Loss in Enpp1asj Mutant Mice, a New Model for Otitis Media and Tympanosclerosis.

Otitis media (OM), inflammation of the middle ear, is a common cause of hearing loss in children and in patients with many different syndromic diseases. Studies of the human population and mouse models have revealed that OM is a multifactorial disease with many environmental and genetic contributing factors. Here, we report on otitis media-related hearing loss in asj (ages with stiffened joints) mutant mice, which bear a point mutation in the Enpp1 gene. Auditory-evoked brainstem response (ABR) measurements revealed that around 90% of the mutant mice (Enpp1asj/asj) tested had moderate to severe hearing impairment in at least one ear. The ABR thresholds were variable and generally elevated with age. We found otitis media with effusion (OME) in all of the hearing-impaired Enpp1asj/asj mice by anatomic and histological examinations. The volume and inflammatory cell content of the effusion varied among the asj mutant mice, but all mutants exhibited a thickened middle ear epithelium with fibrous polyps and more mucin-secreting goblet cells than controls. Other abnormalities observed in the Enpp1 mutant mice include over-ossification at the round window ridge, thickened and over-calcified stapedial artery, fusion of malleus and incus, and white patches on the inside of tympanic membrane, some of which are typical symptoms of tympanosclerosis. An excessive yellow discharge was detected in the outer ear canal of older asj mutant mice, with 100% penetrance by 5 months of age, and contributes to the progressive nature of the hearing loss. This is the first report of hearing loss and ear pathology associated with an Enpp1 mutation in mice. The Enpp1asj mutant mouse provides a new animal model for studying tympanosclerotic otitis and otitis media with effusion, and also provides a specific model for the hearing loss recently reported to be associated with human ENPP1 mutations causing generalized arterial calcification of infancy and hypophosphatemic rickets.