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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 19  |  Issue : 1  |  Page : 27-29

Pseudoaneurysm of petrous internal carotid artery presenting as aural polyp


Department of ENT, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Web Publication6-Mar-2013

Correspondence Address:
A V Sandeep
Puthiyottumkandy (HO), Ponnaram Street, Balussery (PO), Kozhikode, Kerala - 673 612
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.108163

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  Abstract 

A 62-year-old male presented with a rare case of pseudoaneurysm of petrous internal carotid artery (ICA) caused by chronic otitis media manifesting as right aural polyp. There was massive bleeding following aural polypectomy and histopathology came as inflammatory polyp. HRCT temporal bone showed defect in petrous part of right ICA canal and features suggestive of cholesteatoma. CT angiogram showed a laterally directed aneurysm from the junction of horizontal and vertical segment of petrous ICA. Right ICA trapping done using coil embolization. Postcoiling angiogram showed nonopacification of aneurysm and good cross circulation from opposite side. After two months right modified radical mastoidectomy was done and intraoperative findings showed automastoidectomy with cholesteatoma filling mastoid and middle ear and erosion of ossicles. There was no postoperative complications and patient is now on regular follow-up and is asymptomatic. Psedoaneurysm of petrous ICA is rare and psedoaneurysm as a complication of chronic otitis media is extremely rare.

Keywords: Aural polyp, Chronic otitis media, Coil trapping, Modified radical mastoidectomy, Petrous internal carotid artery, Pseudoaneurysm


How to cite this article:
Johnson M, Madhavakurup V, Sandeep A V. Pseudoaneurysm of petrous internal carotid artery presenting as aural polyp. Indian J Otol 2013;19:27-9

How to cite this URL:
Johnson M, Madhavakurup V, Sandeep A V. Pseudoaneurysm of petrous internal carotid artery presenting as aural polyp. Indian J Otol [serial online] 2013 [cited 2020 Feb 26];19:27-9. Available from: http://www.indianjotol.org/text.asp?2013/19/1/27/108163


  Introduction Top


Pseudoaneurysm of petrous internal carotid artery is rare and may occur as a result of gunshot penetrating trauma, arterial dissection, invasive tumor, radiation therapy, fibromuscular disease, or as a complication of surgery. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] Such pseudoaneurysms may grow and become a potential source of thromboembolic complications or rupture. [1],[2],[3],[4],[5] Pseudoaneurysm caused by infectious disease such as chronic otitis media is extremely rare, with only seven reported cases. [1],[3],[5],[8],[9],[10],[16] We treated a rare case of ruptured psedoaneurysm in the petrous ICA caused by chronic otits media.


  Case Report Top


A 62-year-old man presented with a history of sudden torrential right ear bleed following an ear pick procedure for which he was taken into a local hospital. From the local hospital as per records they noticed an aural polyp on right side for which polypectomy was done. Following the procedure there was again torrential bleeding (approximately one litre) and referred to our institution with a compressed ear pack. Histopathology later came as inflammatory polyp.

There was history of right ear discharge for last 15 years which was scanty, purulent, foul smelling and occasionally blood stained. Associated gradually progressive hard of hearing of right ear for last eight years. No history of tinnitus or bleeding diathesis. All the routine blood examinations and coagulation profiles were within normal limits except for a low Hb level of 6.5 gm%. We started two pint packed red cell transfusion and pack removed from theater. There was again massive bleeding and repacked. As the patient was not free of ear pack during the course in the hospital we could not do a proper ear examination or pure tone audiogram.

We took a high-resolution CT of temporal bone, which showed automastoidectomy with canal wall erosion, erosion of ossicles and features suggestive of cholesteatoma. There was defect in the petrous segment of right carotid canal with intact facial canal, dural and sinus plate [Figure 1]. CT angiogram showed a laterally directed aneurysm from the junction of vertical and horizontal segment of right petrous part of internal carotid artery [Figure 2]. With the help of intervention from radiologist, a right internal carotid artery (ICA) trapping was done using coil embolization under guidance of intraoperative angiography [Figure 3]a and b. Before the procedure, a balloon embolization was done for ensuring the adequacy of cross circulation. Post coiling angiogram showed non-opacification of aneurysm and good cross circulation from opposite side [Figure 3]c and d. There were no complications following the procedure except for a transient dimness of vision, which recovered fully within two days. Ear pack was removed and there was absolutely no bleed.
Figure 1: High-resolution CT temporal bone axial view showing defect in the petrous internal carotid artery canal (arrow) and massive hematoma in the middle ear

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Figure 2: Right carotid angiogram three dimensional oblique view showing a pseudoaneurysm (arrow) arising from right petrous internal carotid artery

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Figure 3: (a) Right internal carotid artery trapping using coil embolization; (b) Post coiling angiogram showing non-opacification of aneurysm

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After two months, when the patient's general condition was stable, right modified radical mastoidectomy and type four tympanoplasty were done as a definitive treatment. Intraoperative findings were automastoidectomy with cholesteatoma sac filling mastoid and middle ear with erosion of ossicles [Figure 4]. There was no postoperative complications, patient is on regular follow-up and is asymptomatic.
Figure 4: Right modified radical mastoidectomy showing automastiodectomy with cholesteatoma in the mastoid cavity

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  Discussion Top


Ear bleeding may be due to rupture of eardrum, trauma, tumors, infections, aural polyp, granulations or bleeding disorders. Aural polyp may be due to chronic suppurative otitis media, cholesteatoma, glomus tumor, malignancy or granulomatous diseases. Pseudoaneurysm of petrous ICA may be due to gunshot penetrating trauma, arterial dissection, invasive tumors, radiation therapy, fibromuscular diseases or very rarely chronic otitis media.

The previous cases of pseudoaneurysm in the petrous ICA were caused by chronic otitis media manifested as facial numbness, diplopia, seventh cranial nerve dysfunction and auditory dysfunction, [6],[8],[11],[12] whereas dysfunction of the ninth, tenth and twelfth cranial nerves was less common. Direct pressure of the pseudoaneurysm on these nerves caused disturbance in nerve functions. Pseudoaneurysms can also cause pulsatile tinnitus or bruit and are sometimes discovered as a retrotympanic vascular mass during otological examinations. Pseudoaneurysms can also manifest as massive otorrhagia or epistaxis following acute rupture, so these rare aneurysms require care. [1],[2],[3],[5],[11]

Our patient gives history of hearing loss which may be due to chronic otitis media. Aural polyp that occurred as a complication of long-standing chronic otitis media may be attached to the pseudoaneurysm. Ear bleeding occurred during earpick procedure may be from aural polyp and torrential bleeding occurred during aural polypectomy may be due to rupture of pseudoaneurysm. Therefore avulsion of aural polyp may be very risky in a patient with chronic otitis media.

Our patient presented with only otorrhagia. However, rupture of pseudoaneurysm could have caused epistaxis through the  Eustachian tube More Details. Direct compression may not be able to stop epistaxis, and aspiration of the blood may cause apnea, respiratory failure or hemorrhagic shock.

The appropriate management strategy for these rare lesions is unclear. [7],[15] Revascularization of the carotid artery using a cervical to middle cerebral artery vein bypass graft may be necessary to provide immediate restoration of high blood flow and to reduce the risk of morbidity and mortality caused by acute ischemic complications. [1],[11]

Searching through the literature, there are seven reported cases of ruptured pseudoaneurysm caused by chronic otitis media. Three cases were treated without revascularization and two cases with revascularization. [1],[3],[5],[9],[11] One case was treated with coil embolization of the aneurysm dome as done in our patient. [8] We have also done a modified radical mastoidectomy as a definitive procedure.


  Conclusion Top


Pseudoaneurysm of petrous internal carotid artery is rare and pseudoaneurysm as a complication of chronic otitis media is extremely rare. It should be in mind while taking a biopsy from aural polyp that it can cause torrential bleeding due to hidden vascular incidents. So aural polyp should never be avulsed.

 
  References Top

1.Oyama H, Hattori K, Tanahashi S, Kito A, Maki H, Tanahashi K. Ruptured Pseudoaneurysm of the Petrous Internal Carotid Artery Caused by Chronic Otitis Media: Neurol Med Chir (Tokyo) 2010;50:578-80.  Back to cited text no. 1
    
2.Auyeung KM, Lui WM, Chow LC, Chan FL. Massive epistaxis related to petrous carotid artery pseudoaneurysm after radiation therapy: Emergency treatment with covered tent in two cases. AJNR Am J Neuroradiol 2003;24:1449-52.  Back to cited text no. 2
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3.Chiapetta F, Vangelista S, Pirrone R. Recurrent massive otorrhagia caused by petrous carotid aneurysm. J Neurosurg Sci 1982;26:205-7.  Back to cited text no. 3
    
4.Cohen JE, Grigoriadis S, Gomori JM. Petrous carotid artery pseudoaneurysm in bilateral ccarotid fibromuscular dysplasia: Treatment by means of self expanding covered stent. Surg Neurol 2007;68:216-20.  Back to cited text no. 4
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5.Costantino PD, Russell E, Rreisch D, Breit RA, Hart C. Ruptured petrous carotid aneurysm presenting with otorrhagia and epistaxis. Am J Otol 1991;12:378-83.  Back to cited text no. 5
    
6.Halbach VV, Higashida RT, Hieshima GB, Dowd CF, Barnwell SL, Edwards MS, et al. Aneurysms of the petrous portion of the internal carotid artery: Results of treatment with endovascular or surgical occlusion. AJNR Am J Neuroradiol 1990;11:253-7.  Back to cited text no. 6
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7.Henriksen SD, Kindt MW, Pedersen CB, Nepper-Rasmussen HJ. Pseudoaneurysm of a lateral inernal carotid artery in the middle ear. Int J Pediatr Otorhinolaaryngol 2000;52:163-7.  Back to cited text no. 7
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8.Kawakami K, Kayama T, Kondo R, Kureyama H, Maruya J, Nakia O, et al. A case of mycotic ICA petrous portion aneurysm treated with endovascular surgery. No Shinkei Geka 1996;24:253-7.  Back to cited text no. 8
    
9.Kimmelman CP, Grossman R. Intratemporal carotid aneurysm as a complication of chronic otitis media: Treatment with balloon catheter obliteration. Otolaryngol Head Neck Surg 1983;91:306-8.  Back to cited text no. 9
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10.Kudo S, Colley DP. Multiple intrapetrous aneurysms of the internal carotid artery. AJNR Am J Neuroradiol 1983;4:1119-21.  Back to cited text no. 10
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11.McGrail KM, Heros RC, Debrun G, Beyerl BD. Aneurysm of the ICA petrous segment treated by balloon entrapment after EC-IC bypass. Case report. J Neurosurg 1986;65:249-52.  Back to cited text no. 11
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12.Morantz RA, Kirchner FR, Kishore P. Aneurysms of the petrous portion of the internal carotid artery. Surg Neurol 1976;6:313-8.  Back to cited text no. 12
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13.Oates JW, McAuliffe W, Coates HL. Management of pseudoaneurysm of a lateral aberrant internal carotid artery. Int J Pediatr Otorhinolaryngol 1997;42:73-9.  Back to cited text no. 13
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14.Rawlinson J, Colquhoun IR. Aneurysms involving the intrapetrous internal carotid artery: A rare cause of Horner's syndrome. Br J Radiol 1990;63:69-72.  Back to cited text no. 14
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15.Rostomily RC, Newell DW, Grady MS, Wallace S, Nicholls S, Winn HR. Gunshot wounds of the internal carotid artery at the skull base: Management with vein bypass grafts and a review of the literature. J Trauma 1997;42:123-32.  Back to cited text no. 15
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16.Samuel J, Fernandes CM. Mycotic aneurysm of the petrous portion of the internal carotid artery. J Laryngol Otol 1989;103:111-4.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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