Ruptured internal carotid artery aneurysm presenting with bloody otorrhoea and epistaxis as a result of ear syringing.
Article Type: Clinical report
Subject: Aneurysms (Risk factors)
Aneurysms (Diagnosis)
Aneurysms (Care and treatment)
CT imaging (Usage)
CT imaging (Health aspects)
Carotid artery diseases (Risk factors)
Carotid artery diseases (Diagnosis)
Carotid artery diseases (Care and treatment)
Carotid artery diseases (Research)
Authors: Tshifularo, M.
Masotja, M.S.L.
Pub Date: 11/01/2008
Publication: Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 South African Medical Association ISSN: 0038-2361
Issue: Date: Nov, 2008 Source Volume: 46 Source Issue: 4
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 204550638
Full Text: To the Editor: We would like to record an unusual presentation of rupture of an internal carotid artery (ICA) aneurysm with carotido-tympanic leak presenting as a middle ear mass, profuse bloody otorrhoea and anterior and posterior epistaxis, resulting from the minor trauma of ear syringing for impacted wax. This is a rare major complication from a very minor procedure.

A 32-year-old man with wax impaction was treated with routine syringing. A few hours later, he presented as an emergency with profuse bleeding from the right ear and massive epistaxis which was very difficult to control. The haemoglobin concentration dropped to <6 g/dl, requiring several blood transfusions. Radiological investigations (magnetic resonance angiography (MRA), computed tomography (CT) and angiogram) revealed a 6 cm x 4 cm right proximal petrous (carotido-tympanic) internal carotid pseudo-aneurysm eroding the right petrous-mastoid bone, carotid canal, middle ear cavity and mastoid air cells. It is of note that the patient was HIV-negative. The aneurysm was successfully treated with a coated coronary stent; 18 months later, the patient was well.

Aneurysms of the petrous part of the ICA are rare. (1) They are thought to arise because of developmental weaknesses in the arterial wall of the sites of origin of regressed embryonic arteries including the carotido-tympanic, pterygoid, vidian and stapedial arteries or the hyoid vessel. Histologically, there is degeneration of the internal elastic lamina and medial aplasia, as in intracranial berry aneurysms. (1,2) The carotidotympanic artery, a vestige of the embryonic hyoid artery, is a small branch that arises near the genu of the petrous ICA and passes superiorly through the stapes to supply the middle ear cavity. (1) The true incidence of carotido-tympanic petrous internal carotid aneurysm is not reflected in the literature but may account for 25% of extracranial ICA aneurysms. (2) Most are congenital, but trauma and infections have been implicated. 3 In addition, iatrogenic injury during myringotomy and temporal bone surgery has been reported. (1,2)

M. Tshifularo

ENT Department

Pretoria Academic Hospital

M. S. L. Masotja

University of Limpopo

Medunsa Campus

GaRankuwa

Pretoria

REFERENCES

(1.) Cohen JE, Grigoriadis S, Gomori JM. Petrous carotid artery pseudoaneurysm in bilateral carotid fibromuscular dysplasia: treatment by self-expanding covered stent. Surg Neurol 2007; 68: 216-220.

(2.) Liu JK, Gottfried ON, Amini A, et al. Aneurysms of the petrous internal carotid artery: Anatomy, origins, and treatment. Neurosurg Focus 2004; 17: E13.

(3.) Urso-Baiarda F, Saravanappa N, Courteney-Harris R. An unusual cause of massive fatal epistaxis. Emerg Med J 2004; 21: 266.
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