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Dehiscent high jugular bulb attached to the tympanic membrane.

A 67-year-old Japanese man was referred to our hospital because of cholesteatoma in his right ear. An otoscopic examination revealed a pars flaccida cholesteatoma and a blue pulsatile mass behind the pars tensa of the tympanic membrane (figure 1). The patient reported otorrhea in the right ear and bilateral hearing loss, but he denied tinnitus and ear bleeding. A pure tone audiogram showed moderate combined hearing loss bilaterally. High-resolution computed tomography (CT) revealed a dehiscent high jugular bulb attached to the tympanic membrane in the right ear (figure 2).

Taking care not to injure the jugular bulb, we performed tympanoplasty for the cholesteatoma. During elevation of the tympanomeatal flap, the pulsatile jugular bulb was found to be in direct contact with the tympanic membrane, but there was no adhesion between them. The jugular bulb was located apart from the cholesteatoma and the ossicular chain. The tympanoplasty was uneventful. At follow-up 2 years later, there was no recurrence of the cholesteatoma, and an audiogram showed acceptable audiometric results. The patient still denied pulsatile tinnitus.

High jugular bulb is a relatively common anatomic variation of the temporal bone. This condition can cause pulsatile tinnitus (1) and even conductive hearing loss. (2) The prevalence of high jugular bulb is 8.5 to 9.5%. (3,4) However, a jugular bulb attached to the tympanic membrane without bony covering is a rare occurrence, with only one report of a case similar to the present case. (5) The differential diagnosis includes cholesterol granuloma, aberrant carotid artery, and tumors such as paraganglioma or schwannoma. When an otoscopic examination reveals a dark-colored mass behind the tympanic membrane, further evaluation by CT or magnetic resonance imaging is needed before surgical intervention.

The significance of the present case lies in the potential risk of massive bleeding during middle ear surgery, and even during ear cleaning with a swab or an ear pick. The jugular bulb carries a large volume of blood returning to the heart. In a case of massive bleeding, subsequent air embolism can occur. We therefore advised the patient not to clean his ear canal by himself to prevent accidental bleeding.


(1.) El-Begermy MA, Rabie AN. A novel surgical technique for management of tinnitus due to high dehiscent jugular bulb. Otolaryngol Head Neck Surg 2010;142(4):576-81.

(2.) Haupert MS, Madgy DN, Belenky WM, Becker JW. Unilateral conductive hearing loss secondary to a high jugular bulb in a pediatric patient. Ear Nose Throat J 1997;76(7):468-9.

(3.) Woo CK, Wie CE, Park SH, et al. Radiologic analysis of high jugular bulb by computed tomography. Otol Neurotol 2012;33(7): 1283-7.

(4.) Friedmann DR, Eubig J, Winata LS, et al. Prevalence of jugular bulb abnormalities and resultant inner ear dehiscence: A histopathologic and radiologic study. Otolaryngol Head Neck Surg 2012;147(4):750-6.

(5.) Saito T, Lee K, Saito H. High jugular bulb adhering to the eardrum. Ann Otol Rhinol Laryngol 1999;108(6):620-2.

[Editor's note: A partial version of this article was published in the March 2015 issue o/ENT Journal as the result of a computer error.]

From the Department of Otorhinolaryngology-Flead and Neck Surgery, Mie University Graduate School of Medicine, Mie, Japan.

Hiroshi Sakaida, MD, PhD; Kazuhiko Takeuchi, MD, PhD
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Author:Sakaida, Hiroshi; Takeuchi, Kazuhiko
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Jun 1, 2015
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