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In the past, a persistent stapedial artery was frequently cited as a reason to discontinue stapes surgery, however, several authors have had success operating on the oval window despite the presence of a persistent artery. The stapedial artery is an important vessel in the developing embryo, supplying most of the nonneural structures of the head and neck; however, with maturation this vessel takes on much less importance and by ten weeks gestation the external carotid system becomes the primary arterial supply of the head and neck. Diagnostic considerations included otosclerosis with Schwartze's sign, a vascular tumor, persistent stapedial artery, or possibly granulation tissue. Exploratory tympanotomy was performed by one of the senior authors (MDS) under general anesthesia with continuous facial nerve monitoring (Silverstein Facial Nerve Monitor, Weigand; Minneapolis, MN). The stapedial artery is a second branchial arch derivative that develops from the dorsal end of the hyoid artery. The diagnosis of a persistent stapedial artery was usually made during surgery for otosclerosis and when it was encountered it was generally recommended to abort the procedure.5,6 The primary reasons cited, were concern of uncontrollable hemorrhage and the possibility of causing distal ischemia of neural or cochlear structures. Individual consideration for the patients problem including the degree of hearing loss and severity of the tinnitus must be carefully assessed prior to recommending surgical removal of a persistent stapedial artery. Our report represents a unique case of a persistent stapedial artery causing conductive hearing loss and pulsatile tinnitus. Normally, the superior canal is completely encased in bone so pulsations of the brain cannot move the fluid in the canal.
Since our eyes are tied to our inner ears, movement of the inner ear fluid will cause our eyes to oscillate creating nystagmus.
Each method has its own risks and benefits.A A The patient has two weigh out his or her own risks and benefits with the symptoms that are present. The idea is to prevent the leakage of fluid pressure energy, while maintaining continuity of the fluid flow internally by covering the window with a firm solid substance. The idea is to block the fluid flow through the semicircular canals, thereby shutting down the sensors so that the false sensation of motion is prevented.A A Abnormal fluid flow causes so much dizziness and distress that it is better to have no fluid flow than abnormal flow. We present a case of a patient with conductive hearing loss and tinnitus successfully treated with removal of a persistent stapedial artery that was filling the obturator foramen.
The diagnosis of a persistent stapedial artery is haphazard and usually only discovered by direct observation during tympanotomy which explains why it is commonly seen with otosclerosis. Laboratory testing was normal including tests for urine and serum norepinephrine and metanephrines.
A large persistent stapedial artery was identified and was seen to completely fill the obturator foramen (Fig.
Stapes mobility was only slightly reduced and it was felt to be due to the large size of the persistent vessel. In this area superior to the oval window and inferior to the facial nerve, cautery was set at 7 watts. The distal stapedial artery branches develop into the supraorbital, frontal, anterior ethmoid, lacrimal, inferior orbital and inferior alveolar arteries. The intracranial dural branch substitutes for the middle meningeal artery, and thus explains the absent foramen spinosum.
Glasscock,7 Jackson,7 Brackrnann,12 Silverstein,13 Graham14 and Kartushl5 raises doubts about the previously reported concerns regarding stapedial artery electrocauterization. The fact that this patient did not have complete resolution of her conductive hearing loss suggests that she may indeed have a component of otosclerosis. Fisch UP, Oldring DJ, Sennig A: Surgical Therapy of Internal Carotid Artery Lesions of the Skull Base and Temporal Bone.
Bergdahl B, Vallfors B: Studies on coagulation and the Development of an Automatic Computerized Bipolar Coagulator. Johnson JH, Jensen DM, Auth D: Experimental Comparison of Endoscopic Yttrium-Aluminum-Garnet Laser, Electrosurgery, and Heater Probe for Canine Gut Arterial Coagulation.
Harrison JD, Morris DL: Artery Weld Strength After Bipolar Electrocoagulation is Affected by Electrolyte Solutions Around the Artery. This lag is detected as a relative movement of the fluid to the canal by a motion detecting cupula (a nerve sensor) which signals the brain that there was motion. If one considers the eroded area as a window or hole in the inner ear, then sound energy can leak from the inner ear and dissipate. This experience, in conjunction with a review of the literature and a discussion with several neurotologic colleagues, leads us to suggest that a stapedial artery can be safely removed allowing unhindered access to the oval window.

In the patient, to be discussed, removal of a stapedial artery led to resolution of the pulsatile tinnitus and hearing improvement. Otoscopic examination demonstrated a small pulsatile red mass in the posterior-superior quadrant of the middle ear. Preoperative audiogram; note the 20 dB speech reception threshold with a 15-20 dB air-bone gap.
High resolution computed tomographic scan with 1.5 mm axial and coronal cuts with contrast was obtained, and initially was interpreted as normal. Axial CT scan of the temporal bone with the arrows indicating normal foramen ovale anteriorly on both sides, a normal foramen spinosum on the left with no foramen spinosum on the right. Although there was no evidence of otosclerotic plaque, mild otosclerosis could not be entirely ruled out.
The cauterized segment was excised and removed from the obturator foramen and middle ear exposing a 2 mm area of bone erosion in the promontory which extended inferiorly from the oval window (Fig.4). Demonstrates the appearance of the middle ear following removal of the persistent stapedial artery. The cartilage of the developing stapes, at ten weeks gestation, limits further growth of the artery while the external carotid artery anastomosis with the distal stapedial artery leads to eventual atrophy of the stapedial vessel. Cautious extension of these findings indicates that planned surgical ligation will not likely effect any distal neural or cochlear structures.
Additionally, in the presence of otosclerosis with a small persistent stapedial artery we would consider ablating the vessel and completing the stapedotomy.
We are also aware of the possibility that manipulation near the stapes during removal of the artery may have led to a partial mobilization, and caused some hearing improvement. SCD occurs when the bone overlying the inner ear erodes or thins out to the point where the top part of the balance system, the Superior Semicircular Canal protrudes and is in DIRECT contact with the pulsating brain above. The Weber lateralized to her right ear and Rinne was equivocal in the right and positive in the left with a 512 Hertz tuning fork, suggesting a right-sided conductive hearing loss. However, on repeat evaluation the classic findings of a widened tympanic segment of the facial nerve as well as an absent foramen spinosum were identified (Figs. Bone covered the facial nerve except for a small dehiscence on the inferior aspect of the nerve where the stapedial vessel turned medially.
The facial nerve was stimulated again at the lowest setting, and there was an excellent response, suggesting normal facial function. Preoperative angiogram or magnetic resonance angiography may better address this question, however no studies are available to prove this. In order to optimize coagulation lower heat with increased contact time and slow continuous motion along the vessel is recommended. Moving the vessel away from the stapedotomy site and then completing the procedure is also still an option. However, assessment of ossicular chain mobility prior to any middle ear manipulation showed normal malleus mobility and only slightly reduced stapes mobility. The balance function on the other hand is a closed system, set up like a race track.A A Movement of the fluid (or people- as in our analogy) within the racetrack is detected as head movement.
At surgery Glomus Jugulare tumor was removed.glomus tumor glomus tumor is very painful tumor usually found at finger tips.
Audiometric analysis revealed a 20 dB right conductive hearing loss with elevated stapedial reflexes (Fig. The facial nerve monitor was adjusted to its lowest setting, 0.05 mAmps, and stimulation of the inferior most portion of the facial nerve led to a response. A small amount of surgicel (Johnson and Johnson, Texas) was placed over the inferior stump of the vessel and after 15 minutes of observation, hemostasis was assured and the ear was closed (Fig. Uncontrolled hemorrhage is another reason surgeons in the past have recommended discontinuing stapes surgery in the presence of a persistent stapedial artery. Postoperatively, this patient's hearing improved and the pulsatile tinnitus resolved with removal of this artery. This suggested that cautery near this area could be dangerous, and that any use of the bipolar would have to be performed at a low setting and as far away from the facial nerve as possible. Additionally, it is routine during vestibular schwannoma surgery to use cautery at even closer distances without harmful effects on facial nerve function.

We were able to safely cauterize this vessel with bipolar cautery, excise it, and remove it from the obturator foramen with no bleeding or postoperative neural sequelae.
The inferior portion of the artery was cauterized using a standard bi-polar instrument set at 10-12 watts. Of the 48 reported cases of a persistent stapedial artery, nine underwent successful stapedotomy near the vessel with good audiologic results.4 Our case extends these findings and demonstrates that a large stapedial artery segment may be safely cauterized and removed giving unhindered access to the oval window.
The packing was removed one week postoperatively and the Rinne was positive to a 512 Hertz tuning fork.
Various lasers may be a suitable alternative to bipolar cautery when ablating small vessels. Additionally, an artery that completely fills the obturator foramen may also be a cause of conductive hearing loss and pulsatile tinnitus. We have found that defocusing either the potassium titanyl phosphate (KTP) or CO2 laser allows us to safely ablate smaller vessels less than 1.5 mm in diameter. It is clear from current thinking that complications such as faci al paralysis or hemiparesis secondary to vessel disruption are not likely. A postoperative audiogram at four weeks and six months showed improvement of the air-bone gap. Mohamed Sheeraye - Carotid body tumor- Hopital de Balbala- Djibouti 40 YRS OLD FEMALE WITH - UNCONTROLLED HYPERTENSION - MASS RT SIDE OF THE NECKGlomus Tympanicum Pulsation Glomus tympanicum is a slow growing benign vascular tumour involving the middle ear. It is derived form glomus bodies which are chemoreceptors found along certain blood vessels and nerves within the proximity of middle ear region. Its presenting symptoms include hearing loss (conductive type), pulsing tinnitus, ear pain or rarely bleeding from the ear. This video shows a pulsatile red vascular mass (synchronous with the patient heart beat) at its typical position (behind the lower quadrant of the middle ear). The Glomus-group is sent to investigate the case and in the end the butler is the murderer. Several authors have suggested that the carotid body tumor represents a proliferative response of the normal organ to some unknown disturbance within the nervous system, rather than a true neoplasm. Bungeler (1952) suggested that this was some form of adaptive hyperplasia, which was produced by traumatic destruction of the cortical projection fields of the X nerve.
In contrast to this hypothesis, is the realization that a significant number of these lesions undergo malignant transformation with metastasis, which establishes the carotid body tumor as a true neoplasm.
Study of the familial occurrence of chemodectomas has established a definite genetic influence in the development of these neoplasms. They proposed that hypoxia, acting from birth, served as a stimulus for chemoreceptor tissue hyperplasia, which eventually led to tumor formation. There is subjective tinnitus where the ringing or the wheezing is heard by the patient alone and objective tinnitus in which the doctor can also hear the noise by using acoustic instruments.
Some of these are unilateral (can be heard in one ear) or bilateral where it is heard in both the ears.
Persons suffering from Pulsatile Tinnitus can hear their own heartbeats while Somatic Tinnitus resonances lie outside the ear, probably beyond the cochlear nerves and is believed to arise from central crosstalk within the grey matters.
Atheroscl*** Carotid Artery Disease in which the arteries become narrowed due to heavy cholesterol buildup that result in uneven blood flow to the head and neck area.
Glomus tumor that consists of bunches of tissues and entangled blood vessels in the ear or the immediate surrounding area can become a cause of tinnitus.
Intracranial vascular lesion often causes tinnitus of aneurism and arteri-venous malformation or deformity that is usually typified by abnormal or irregular connection between the artery and the vein.. Prahlada NB, Senior consultant & Head, ENT-Head & Neck Surgery and Skull Base Surgery, BGS Global Hospital, Bengaluru.

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