Prevention and management of vascular complications in middle ear and cochlear implant surgery

Abstract

The objective of this study is to illustrate prevention strategies and management of vascular complications from the jugular bulb (JB) and internal carotid artery (ICA) during middle ear surgery or cochlear implantation. The study design is retrospective case series. The setting is tertiary referral university hospital. Patients were included if presented pre- or intraoperative evidence of high-risk anatomical anomalies of ICA or JB during middle ear or cochlear implant surgery, intraoperative vascular injury, or revision surgery after the previous iatrogenic vascular lesions. The main outcome measures are surgical outcomes and complications rate. Ten subjects were identified: three underwent cochlear implant surgery and seven underwent middle ear surgery. Among the cochlear implant patients, two presented with anomalies of the JB impeding access to the cochlear lumen and one underwent revision surgery for incorrect positioning of the array in the carotid canal. Subtotal petrosectomy was performed in all cases. Anomalies of the JB were preoperatively identified in two patients with attic and external auditory canal cholesteatoma, respectively. In a patient, a high and dehiscent JB was found during myringoplasty, while another underwent revision surgery after iatrogenic injury of the JB. A dehiscent ICA complicated middle ear effusion in one case, while in another case, a carotid aneurysm determined a cholesterol granuloma. Rupture of a pseudoaneurysm of the ICA occurred in a child during second-stage surgery and required permanent balloon occlusion without neurological complications. Knowledge of normal anatomy and its variants and preoperative imaging are the basis for prevention of vascular complications during middle ear or cochlear implant surgery.

Revision cochlear implant surgery for clinical reasons

“…Violation of the carotid canal may be managed with or without removal of the malpositioned array 19-21 . In patient 15, the tip of the array was cut and left in place in order to reduce the risk of a vascular complication 21 . Possible array misplacement strongly support the necessity of a postoperative radiological control, at least in the unusual CI cases 22 .…”

Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience

“…The JB may be damaged during myringocentesis, tympanomeatal flap elevation, and removal of disease in hypotympanic and protympanic areas. 5 Surgical maneuvers in the regions at risk for vessel injury should be performed as last steps, after disease clearing, cavity regularization, and hemostasis. Dissection should be performed bluntly, using cottonoids soaked with epinephrine and in a medial to lateral way, avoiding pulling mucosal tissue.…”

“…Moreover, in case of a vascular anomalies, some authors advocate for open mastoidectomy techniques to obtain a large surgical field to easily identify all the surgical landmarks. 5 TEES is gaining popularity almost in every field of otologic surgery, including pediatrics and lateral skull base. [6][7][8] The main advantage is the enhanced visibility of the anatomy and pathology due to wide-angled view and the capability to look around the corner which permits to explore hidden recesses, such as the retro-and hypotympanum.…”

“…11 However, in case of trouble, intraoperative bleeding from the JB can be stopped by packing the middle ear cavity and closing the sigmoid sinus and the jugular vein, if an adequate contralateral circulation is present. 5 Indeed, an adequate knowledge of traditional microscopic procedures is mandatory for every otologic surgeon. Limitations of the present study are its retrospective design and the small size of the group of patients.…”

Surgical considerations during cochlear implantation: the utility of temporal bone computed tomography

“…13 A highriding jugular bulb may cover the round window or basal cochlear turn, thereby hindering access to the cochlear lumen via the standard transmastoid approach. 14 Hara et al found that reconstructed 3D-CT images were useful when surgically planning cochlear implantation in a patient exhibiting an abnormal facial nerve course; 15 3D images are optimal for assessing temporal bone anatomy, and they show the skull base and any middle-or inner-ear anomalies. 16,17 Breinbauer and Praetorius 12 described the optimal spatial orientation of insertion vectors for cochleostomy and the round window approach through 3D reconstruction of the temporal bones of 50 cochlear implant candidates (100 ears).…”