Description 

Incorrect position of the vessels in the tympanic cavity is rare, yet they are sometimes seen in the otoscopic examination. Tumors in the tympanic cavity, colored reddish, bluish, sometimes pulsating, should be suspected to be vascular defects – most common enlarged jugular bulb, rarely paragangliomas, extremely rarely abnormal position of the internal carotid artery (but it happens!). It is of great importance to remember that biopsy, myringotomy and other surgical procedures are contraindicated in those situations without proper radiological examination and preparation to extensive bleeding during operation.


Case

The photo below shows enlarged jugular bulb, right ear, 16-year-old patient. In the inferior regions of the tympanic cavity is visible violet colored tumor. It extends from the hypotympanum. The posterior and superior part of the tympanic membrane creates deep retraction pocket. Tympanic membrane is atrophic, very thin and lies on the promontory, incudostapedial joint and directly on the jugular bulb which has no bone securing it. In some cases there can be effusion in the tympanic cavity when the tumor compresses the opening of the eustachian tube causing its obstruction. When the large amount of effusion is present, the image can be ambiguous and difficult to interpret (fig. 1 and 1a).

In this case the symptoms included moderate hearing loss which was connected to the presence of effusion in the middle ear and destruction of the tympanic membrane. There was also plugged ear and pulsating tinnitus. The diagnosis of this lesion should not be difficult in otoscopy.

Blood vessel abnormalities
Fig. 1 Blood vessel abnormalities
Blood vessel abnormalities - scheme
Fig. 1a Blood vessel abnormalities – scheme
  1. incus
  2. stapes
  3. blood vessel
  4. dotted line – retraction pocket in posterior quadrants
  • Becausse of the presence of deep retraction pocket, one should rather make a decision to refer to a specialist and perform surgery.
  • The surgical intervention is very risky in this case, but evident destruction of the tympanic membrane and deep retraction pocket being in fact the initial stage of cholesteatoma forced us to make a decision to operate.
  • Range of surgical intervention: removal of the retraction pocket, myringoplasty with tragal cartilage and perichondrium, adenoidectomy.
  • Ventilation tube insertion was contraindicated because of the presence of jugular bulb, which had no covering bone.
  • The effusion and destruction of the tympanic membrane was a consequence of chronic eustachian tube obstruction due to adenoid hypertrophy and patrially – presence of the mass in the tympanic cavity.
  • Non pharmacological methods to improve aeration of the tympanic cavity e.g. nasal balloons were ineffective.