BrazJOtorhinolaryngol.2014;80(5):453---454
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
CASE
REPORT
One
case,
two
lessons:
an
aberrant
internal
carotid
artery
causing
acquired
cholesteatoma
夽
Um
caso,
duas
lic
¸ões:
artéria
carótida
interna
aberrante
causando
colesteatoma
adquirido
Sady
Selaimen
da
Costa
a,
Maurício
Noschang
Lopes
da
Silva
b,∗,
Letícia
Petersen
Schmitt
Rosito
c,
Fábio
André
Selaimen
caFaculdadedeMedicinadaUniversidadeFederaldoRioGrandedoSul(FAMED-UFRGS),PortoAlegre,RS,Brazil bClínicadoOuvidodoSistemadeSaúdeMãedeDeus,PortoAlegre,RS,Brazil
cHospitaldeClínicasdePortoAlegre,PortoAlegre,RS,Brazil
Received18November2012;accepted4May2013 Availableonline4July2014
Introduction
The sequenceof eustachiantube (ET)dysfunctionleading tonegativepressure and progressivetympanicmembrane (TM) retraction has long been implicated as one of the mostplausiblehypothesesinthepathogenesisofacquired cholesteatoma.1,2 The objective of this case report is to notifyonapatientwithaparstensacholesteatoma,whose developmentwascloselyrelatedtoan aberrantcourseof theinternalcarotidartery.
Case
report
Thecaseofa31-year-oldwomanwiththechiefcomplaint oflong-standing,left-ear,purulent,foul-smellingotorrhea, ipsilateralpulsatiletinnitus,andhearinglossisdescribed. Shehadnohistoryofprevioussurgery.
夽 Pleasecitethisarticleas:daCostaSS,daSilvaMN,RositoLP,
SelaimenFA.Onecase,twolessons:anaberrant internalcarotid arterycausing acquired cholesteatoma.Braz J Otorhinolaryngol. 2014;80:453---4.
∗Correspondingauthor.
E-mail:[email protected](M.N.L.daSilva).
Otomicroscopyrevealedanextremelyinfectedleftear, a posterior mesotympanic cholesteatoma, and erosion of the long process of the incus and the suprastructure of thestapes.The TMwasintactanteriortomanubrium,but apulsatilebrownishbulge wasnoticedfillingthe anterior mesotympanum.Theappearanceofthisfindingresembled a cholesterol granuloma or a superiorly displaced jugular bulb.Thecontralateralearwascompletelynormal. Audio-gramconfirmedapureconductivehearinglossintheleftear andnormalityintheright side.High-resolutionaxial com-putedtomography scanshowedanabnormalcourseofthe petrousportionoftheleftinternalcarotidartery,protruding intothetympaniccavitythroughacompletedehiscencein thecarotidplate(Fig.1).Thedisplacedarterycompletely filled the bony lumen of the eustachian tube, expanding and filling the protympanum. The mastoid was sclerotic, theTMseverelyretracted,andthemucosamarkedly thick-ened in the posterior recesses (Fig. 1). The patient was submittedtoinside-outwall-downmastoidectomy,without complications.
Discussion
The authors decided to present this case for two main reasons: to illustrate the development of a middle ear
http://dx.doi.org/10.1016/j.bjorl.2014.05.021
454 daCostaSSetal.
Figure1 Leftearaxialcomputedtomographyscan---petrous internalcarotidarteryfillingprotympanumandveiledposterior recesses.
cholesteatoma through a retraction of the TM triggered by an unusual anatomical obstruction, an ectopiccarotid artery and to emphasize the importance of obtaining a comprehensivepre-operative imagingworkup inCOMwith cholesteatoma.
ET obstruction may beeither anatomic or, more com-monly, physiological. As indicated by Paparella et al.,3 obstructivesites (OS) canbe caused by genetic anatomic variationsorcongenitalmalformations.Inthepresentcase, therewas a clear relationship between the displacement ofthecarotidartery,theobstructionoftheET,middleear gasdeprivation,andthefurtherretractionoftheTM lead-ingtocholesteatomaformation.Itappearsunequivocalthat the sealing of the protympanum by the artery led to TM invagination,keratinaccumulation,andinfection.
The authors firmly believe that, at the present time, thereisnoreasontoperformcholesteatomasurgerywithout orderingaCTscan. Themorbidityandthecostofsuchan examcannotbecomparedwiththebenefitsthatitprovides forthesurgicalplanning.Manystructuresarereadily iden-tifiableduringtheinvestigation.4Moreover,itismandatory tofollowaprotocolwhileanalyzingtemporalboneCT sec-tions.Itmayvaryaccordingtothesituation,buttheminimal
routineadoptedinthiscenterincasesofCOMissummarized bythesepoints:5
1. Degreeofpneumatization 2. Ossicularchain
3. Courseofthefacialnerve
4. Tegmentympaniandduraldehiscence 5. Integrityoflabyrinth
6. Relationwiththegreatvessels(carotidarteryandjugular bulb)
7. Aerationoftheprotympanum 8. Positionofthelateralsinus 9. Anatomicalvariations
Inconclusion,throughtheanalysisofonesinglecase,two importantconceptsemerge:(1)ETdysfunctionmayplaya decisive role in the pathogenesis of COM, at least in the earlierphasesoftheprocess;(2)temporalboneCTscanis affirmed asan extremely important stepin surgical plan-ning.Ithastheabilitytoshowtheextentofthedisease,to influencethesurgicaltechniqueemployed,anditcanhelp an informedsurgeonanticipateintraoperative difficulties. Aswasseenhere,onesimplecasedemonstratedtwogood lessons!
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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2.SadéJ,ArA.Middleearandauditorytube:middleearclearance, gasexchange and pressureregulation. OtolaryngolHead Neck Surg.1997;116:499---524.
3.JunhSK,PaparellaMM,KimLS,GoycooleaMV.Pathogenesisof otitismedia.AnnOtolRhinolLaryngol.1977;86:481---93.
4.DesaiSB,MehtaPS.Imagingofthetemporalbone.In:SouzaSD, ClaussenC,editors.Modernconceptsofneurotology.Mumbai: Prajakta;1997.p.13---66.
