Abstract
Bleeding during mastoidectomy usually occurs because of injury to the dura mater and/or sigmoid sinus, which, in most cases, can be controlled easily. The other important cause is damage to the internal carotid artery during its course in the middle ear. Bleeding from the external carotid artery or a branch of it is very rare and unknown. We hereby report an extremely rare and first case of delayed torrential bleeding after modified radical mastoidectomy, which was because of infective necrosis and subsequent blowout of the anterior tympanic branch of superficial temporal artery and its management using microcoils via an endovascular approach.
1
Introduction
An important cause of bleeding during and immediately postmastoidectomy is damage to the internal carotid artery (ICA) during its course in the middle ear. Delayed bleeding, seen after days to weeks of a mastoidectomy, is usually because of infective necrosis and blow out of the internal carotid during its course in the tympanic cavity. This is a catastrophic situation with definite mortality and morbidity if management is delayed or imprecise. Fortunately, such presentations are very rare, but when you do encounter them, there is no definite treatment known.
2
Case report
A 24-year-old man who underwent a modified radical mastoidectomy of the left ear 3 weeks back presented to ear, nose, and throat emergency with complaints of torrential bleed from his operated ear for the past 1 hour. He also gave history of minor bleed on 2 previous occasions from the same ear during the past 3 days. These were not taken seriously by the patient, thinking it to be related to postoperative minor bleeds from the ear. The ear was immediately packed to control the bleeding.
The mastoidectomy was done for a posterosuperior retraction pocket filled with cholesteatoma flakes and scanty, foul-smelling, thick discharge. Intraoperatively, the cholesteatoma was seen to be involving the posterior epitympanum and mesotympanum extending to the antrum. A canal wall down procedure was done with adequate facial ridge lowering. The anterior attic, anterior mesotympanum, protympanum, and area of the glenoid fossa were clear and thus were not drilled. The suture line was healthy, and the patient was prescribed oral antibiotics and topical ear drops in postoperative period.
The patient was transfused 2 Units of whole blood in the emergency department because his hemoglobin level was 9 g/L and packed cell volume was 26%. He was later shifted to the operation theater for detailed examination under microscope.
During examination under microscope, the bleeding was identified to be coming from the anterior part of the middle ear, although no particular bleeding vessel could be identified. The ear was again packed to control the bleed.
At this point, the possibility of bleeding from the ICA was kept in mind, and it was assumed that the arterial wall might have undergone necrosis with pseudoaneurysm formation and later resulted in a blowout.
The patient was then subjected to magnetic resonance angiography, which surprisingly came out to be absolutely normal with no site of damaged ICA. The patient was then taken up for carotid angiography via transfemoral route.
The ICA was cannulated and radiopaque dye injected. The internal carotid system was found normal with no dye leak. Because the ear pack could possibly prevent an active bleeding and hence any dye leak on angiography, it was planned to remove the ear pack temporarily with the patient on catheterization table (the angiography catheter tip already parked in the ICA and ready to shoot dye) and repeat the angiography, which might reveal the source of bleeding. As soon as the mastoid pack was removed, there was a torrential rebleeding from the ear. Despite this continuing brisk arterial bleeding, the ICA angiography was quickly repeated during the bleeding in various different angulations within a minute or so, and the ear was quickly repacked to stop the active bleeding. Subsequently, a very careful review of this repeat ICA angiography was done, but there was no leak of dye from the ICA.
This led us to think that the offending vessel may be from the external carotid system.
The external carotid artery was then cannulated and the dye was injected. One of the terminal branches of the external carotid artery, probably the anterior tympanic branch of the superficial temporal artery, was leaking ( Fig. 1 ).
This artery was then selectively blocked using 2 microcoils under continuous angiographic monitoring ( Fig. 2 ). Repeat injection of dye in the external carotid artery indicated no active bleeding because there was no leakage of the dye. Encouraged by the above angiographic appearance, the mastoid pack was removed with the patient on catheterization table to check for a rebleed. There was no rebleeding from the ear even after removal of the mastoid pack.
The patient is under regular follow-up since then and is doing well. The mastoid cavity is well epithelised and healed at 5 months.
2
Case report
A 24-year-old man who underwent a modified radical mastoidectomy of the left ear 3 weeks back presented to ear, nose, and throat emergency with complaints of torrential bleed from his operated ear for the past 1 hour. He also gave history of minor bleed on 2 previous occasions from the same ear during the past 3 days. These were not taken seriously by the patient, thinking it to be related to postoperative minor bleeds from the ear. The ear was immediately packed to control the bleeding.
The mastoidectomy was done for a posterosuperior retraction pocket filled with cholesteatoma flakes and scanty, foul-smelling, thick discharge. Intraoperatively, the cholesteatoma was seen to be involving the posterior epitympanum and mesotympanum extending to the antrum. A canal wall down procedure was done with adequate facial ridge lowering. The anterior attic, anterior mesotympanum, protympanum, and area of the glenoid fossa were clear and thus were not drilled. The suture line was healthy, and the patient was prescribed oral antibiotics and topical ear drops in postoperative period.
The patient was transfused 2 Units of whole blood in the emergency department because his hemoglobin level was 9 g/L and packed cell volume was 26%. He was later shifted to the operation theater for detailed examination under microscope.
During examination under microscope, the bleeding was identified to be coming from the anterior part of the middle ear, although no particular bleeding vessel could be identified. The ear was again packed to control the bleed.
At this point, the possibility of bleeding from the ICA was kept in mind, and it was assumed that the arterial wall might have undergone necrosis with pseudoaneurysm formation and later resulted in a blowout.
The patient was then subjected to magnetic resonance angiography, which surprisingly came out to be absolutely normal with no site of damaged ICA. The patient was then taken up for carotid angiography via transfemoral route.
The ICA was cannulated and radiopaque dye injected. The internal carotid system was found normal with no dye leak. Because the ear pack could possibly prevent an active bleeding and hence any dye leak on angiography, it was planned to remove the ear pack temporarily with the patient on catheterization table (the angiography catheter tip already parked in the ICA and ready to shoot dye) and repeat the angiography, which might reveal the source of bleeding. As soon as the mastoid pack was removed, there was a torrential rebleeding from the ear. Despite this continuing brisk arterial bleeding, the ICA angiography was quickly repeated during the bleeding in various different angulations within a minute or so, and the ear was quickly repacked to stop the active bleeding. Subsequently, a very careful review of this repeat ICA angiography was done, but there was no leak of dye from the ICA.
This led us to think that the offending vessel may be from the external carotid system.
The external carotid artery was then cannulated and the dye was injected. One of the terminal branches of the external carotid artery, probably the anterior tympanic branch of the superficial temporal artery, was leaking ( Fig. 1 ).
