Endovascular techniques can be utilized in many common otolaryngologic conditions. Advancements in in these techniques including but not limited to better distal access catheters, new embolization materials and stents allows this to be a relatively safe and successful procedure. Here we highlighted a few related procedures.
Key learning points
At the end of this article, the reader will:
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Understand the role of endovascular treatments in common otolaryngologic conditions.
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Be familiar with endovascular techniques used for these diseases.
Venous stenting (pseudotumor cerebri, tinnitus)
Embolization (tumors, epistaxis, dural arteriovenous fistula)
Balloon test occlusion (vessel sacrifice, tinnitus)
Arterial stenting (carotid stenosis postradiation, carotid blow out)
Coiling (traumatic pseudoaneurysm)
Pulsatile tinnitus
The differential diagnosis of pulsatile tinnitus includes the following ( Fig. 1 ):
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Middle ear conductive hearing loss
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Middle ear effusion
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Chronic otitis: Tympanic Membrane or ossicular abnormalities
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Otosclerosis
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Neoplasm
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Glomus tympanicum or jugulare
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Middle ear adenoma
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Geniculate ganglion hemangioma
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Arterial
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Atherosclerotic disease
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Carotid (ipsilateral or contralateral)
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Subclavian
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Dural arteriovenous fistulas
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Carotid-cavernous fistula
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Fibromuscular dysplasia of carotid artery
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Carotid artery dissection
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Aberrant internal carotid artery
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Hyperdynamic states (anemia, thyrotoxicosis, pregnancy)
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Hypertension
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Internal auditory canal vascular loops
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Venous
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Benign intracranial hypertension
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Sigmoid or jugular diverticulum
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High jugular bulb
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Transverse or sigmoid stenosis
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Condylar vein abnormalities
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Sinus Venous Stenosis
Case example
A 23-year-old previously healthy woman presents with 3 months of pulsatile tinnitus in the right ear with normal examination ( Figs. 2–5 ). The patient had immediate resolution of her pulsatile tinnitus after stent placement. She was started on aspirin and clopidogrel. At 3-month follow-up, the patient remained symptom-free.
Paragangliomas
These are highly vascular neuroendocrine tumors arising from chemoreceptors of paraganglia.
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Types
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Carotid body
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Temporal bone: glomus tympanicum, glomus jugulare, jugular fossa
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Glomus vagale
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Associated with familial paraganglioma, neurofibromatosis type 1, von Hippel-Lindau disease, Carney triad, and multiple endocrine neoplasia type 2 ( Table 1 )
Table 1
Classification of glomus jugularis tumors of the temporal bone as proposed by Fishch
Type
Description
A
Tumors restricted to middle ear (glomus tympanicum tumors)
B
Tumors restricted to tympanomastoid site
C
Tumors involving the infralabyrinth portion toward the petrous apex
D1
Tumor with intracranial invasion (<2 cm)
D2
Tumor with intracranial invasion (>2 cm)
From Fisch U. Infratemporal fossa approach for glomus tumors of the temporal bone. Ann Otol Rhinol Laryngol 1982;92:474–9; with permission.
Symptoms of paraganglioma include the following :
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Temporal bone paragangliomas: hearing loss, pulsatile tinnitus, cranial neuropathy
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Carotid body tumor: slow growing, painless neck mass
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5% of cases have signs/symptoms of catecholamine hypersecretion
Case example
A 63-year-old woman developed pulsatile tinnitus for the last 2 months with a normal examination ( Figs. 6 and 7 ).
Dural Arteriovenous Fistula
Dural arteriovenous fistula refers to direct shunting of arterial blood into the wall of a dural venous sinus or a cortical vein. Clinical presentation is as follows :
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Pulsatile tinnitus
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Cranial nerve deficits
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Visual symptoms and headache
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Focal neurologic deficit caused by venous hypertension, which leads to edema in the surrounding parenchyma
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Intraparenchymal hemorrhage
The prognosis for dural arteriovenous fistula depends on venous outflow. Symptomatic dural arteriovenous fistulas have hemorrhage or nonhemorrhagic complications of at least 15% to 19% per year. Asymptomatic dural arteriovenous fistulas with cortical reflux have a much lower rate of complications (<2% per year).
Case example
A 67-year-old woman presents with pulsatile tinnitus for the last 3 months. She is initially diagnosed with mastoiditis, but continued to be symptomatic despite antibiotic therapy. She had normal examination. Cerebral angiogram showed a direct left vertebral artery to internal jugular vein fistula located at C1 level with retrograde filling of the left sigmoid and transverse sinus but no cortical venous reflux (cognard type IIa) ( Figs. 8 and 9 ).
