Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-017-4747-9
OTOLOGY
Prevention and management of vascular complications in middle
ear and cochlear implant surgery
Filippo Di Lella1   · Maurizio Falcioni1 · Silvia Piccinini2 · Ilaria Iaccarino1 ·
Andrea Bacciu1 · Enrico Pasanisi1 · Davide Cerasti2 · Vincenzo Vincenti1
Received: 7 June 2017 / Accepted: 18 September 2017
© Springer-Verlag GmbH Germany 2017
Abstract  The objective of this study is to illustrate pre-
vention strategies and management of vascular complica-
tions from the jugular bulb (JB) and internal carotid artery
(ICA) during middle ear surgery or cochlear implantation.
The study design is retrospective case series. The setting is
tertiary referral university hospital. Patients were included
if presented pre- or intraoperative evidence of high-risk
anatomical anomalies of ICA or JB during middle ear or
cochlear implant surgery, intraoperative vascular injury,
or revision surgery after the previous iatrogenic vascular
lesions. The main outcome measures are surgical outcomes
and complications rate. Ten subjects were identified: three
underwent cochlear implant surgery and seven underwent
middle ear surgery. Among the cochlear implant patients,
two presented with anomalies of the JB impeding access
to the cochlear lumen and one underwent revision surgery
for incorrect positioning of the array in the carotid canal.
Subtotal petrosectomy was performed in all cases. Anoma-
lies of the JB were preoperatively identified in two patients
with attic and external auditory canal cholesteatoma, respec-
tively. In a patient, a high and dehiscent JB was found during
myringoplasty, while another underwent revision surgery
after iatrogenic injury of the JB. A dehiscent ICA compli-
cated middle ear effusion in one case, while in another case,
a carotid aneurysm determined a cholesterol granuloma.
Rupture of a pseudoaneurysm of the ICA occurred in a child
* Filippo Di Lella
filippo.dilella@gmail.com
1 ing revision surgery in patients with the previous iatrogenic
Otolaryngology and Otoneurosurgery Department, Azienda
Ospedaliero-Universitaria di Parma, Via Gramsci 14,
43126 Parma, Italy
2
The Neuroradiology Department, Azienda
Ospedaliero-Universitaria di Parma, Parma, Italy
 
during second-stage surgery and required permanent balloon
occlusion without neurological complications. Knowledge of
normal anatomy and its variants and preoperative imaging
are the basis for prevention of vascular complications during
middle ear or cochlear implant surgery.
Keywords  Cochlear implant · Middle ear surgery ·
Complications · Vascular · Jugular bulb · Internal carotid
artery
Introduction
Vascular complications during middle ear surgery are rare
but may give rise to devastating consequences. Lying within
millimeters in the operating field, the jugular bulb (JB), and
the petrous portion of internal carotid artery (ICA) may
accidentally be injured while performing surgical maneu-
vers in the tympanic cavity. Although uncommon, various
anatomical anomalies of both the JB and the petrous ICA
have been described. They may involve position and course
of the vessels (high riding jugular bulb; lateralized or aber-
rant ICA) or absence of the compact bone that divides these
structures from the middle ear cavity (dehiscent JB and ICA)
[1]. The ICA or the JB may be inadvertently damaged also
in the absence of anatomical anomalies, mainly in the pres-
ence of massive inflammation; in the latter case, landmarks
may be altered and the hypotympanic bone may be eroded.
Furthermore, potential vascular complications may result
from unexpected intraoperative findings or when perform-
injuries [2–4].
In the present study, the authors describe their experience
in the management of patients at risk for or who experienced
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vascular complications from JB and ICA during middle ear
surgery and cochlear implantation.
Materials and methods
All clinical investigations were conducted according to the
principles expressed in the Declaration of Helsinki. The oto-
logical surgical database of the authors’ tertiary referral uni-
versity hospital was reviewed. Medical charts, imaging, and
surgical reports of all patients who underwent middle ear or
cochlear implant surgery since January 2000 to June 2016
were analyzed. Details regarding patient demographics, type
and site of disease, site of anatomical anomalies, previous
surgical charts (when available), as well as anatomical and
functional results at last available follow-up were collected
in a retrospective manner. Subjects with preoperative evi-
dence or intraoperative evidence of high-risk anatomical
abnormalities of the JB and/or ICA, patients who experi-
enced intraoperative bleeding from ICA or JB, and patients
who underwent revision surgery because of previous iatro-
genic vascular lesions were included in the study. Anoma-
lies were defined as high risk, in case bone dehiscence was
noted at the level of the JB or ICA wall into the middle ear;
anatomical anomalies requiring modification of a standard
surgical procedure and revision cases were addressed as high
risk too.
Only patients with a minimum follow-up period of
12 months were included. Informed consent was obtained
from all patients before any treatment.
Anatomical abnormalities have been defined using tem-
poral bone high-resolution CT scan (HRCT); magnetic reso-
nance imaging (MRI) with angiographic sequences was per-
formed if required. A high riding jugular bulb was defined
as a protrusion of the JB into the tympanic cavity above the
level of the bony tympanic annulus; dehiscent jugular bulb
was defined as the absence of the bone covering the dome
Table 1  Demographics and clinical data of patients with cochlear implants
Pt Age (years) Disease Vascular findings/
Sex side
1 12 males Bilateral profound HJB/R
SNHL
2 31 females Bilateral profound JB diverticulum/L
SNHL
3 73 females Previous CI Array in horizontal TBCT
petrous ICA/L
Mean 38.6
CI cochlear implant, HJB high riding jugular bulb, ICA internal carotid artery, JB jugular bulb, L left, MRI magnetic resonance imaging, R right,
SNHL sensorineural hearing loss, TBCT temporal bone computed tomography
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Eur Arch Otorhinolaryngol
of the JB (i.e., hypotympanic-jugular plate) as evident from
coronal temporal bone CT images. A focal outpouching of
the JB wall with superior, medial, or posterior extension was
considered as a diverticulum [5–8]. The lack of high-density
CT signal of the thin bony wall that separates the tympanic
cavity from the carotid canal was interpreted as dehiscent
carotid artery [9].
Results
Ten patients fulfilled inclusion criteria: one male and nine
females. Age ranged from 7 to 73 years, with two patients
in the pediatric age. Three subjects underwent primary or
revision cochlear implant surgery and seven underwent pri-
mary or revision middle ear surgery for chronic otitis media
(COM), with or without cholesteatoma. Clinical details are
reported in Tables 1 and 2.
All patients underwent preoperative HRCT scan of the
temporal bones, except patients 6, 9, and 11, which were
scheduled for myringoplasty, exploratory tympanotomy for
cholesterol granuloma, and second-stage surgery for COM,
respectively. Patient 10 underwent MRI with venous angio-
graphic sequences to assess the patency of the contralateral
JB before revision surgery.
Among the three implanted patients, two underwent pri-
mary surgery. In both cases, preoperative CT scans docu-
mented anomalies of the JB: a high riding JB covering the
round window and proximal basal turn (patient 1) and a
dehiscent JB diverticulum (patient 2). These anomalies were
judged as unsafe for properly access the cochlea through
a posterior tympanotomy. After adequate counseling, both
patients underwent cochlear implantation along with sub-
total petrosectomy with complete insertion of active elec-
trodes into the scala tympani. In patient 1, the JB completely
covered the round window; access to the scala tympani was
obtained through a cochleostomy (Fig. 1). The remaining
Preoperative imag- Surgical technique Complications Follow-up (months);
ing Results
TBCT/MRI SP and CI No 12 open sets
TBCT/MRI SP and CI No 12 open sets
SP and CI; previ- No 24 open sets
ous electrode in
place; basal drill-
out; complete
insertion
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Eur Arch Otorhinolaryngol

Table 2  Demographics and clinical data of patients with COM

Pt Age (years) Disease Vascular findings/ Preoperative Surgical technique Complications Follow-up
Sex side imaging (months);
Results

4 36 females Attic cholestea- HDJB/R TBCT Modified radical no 60 regular cavity

toma mastoidectomy
5 47 females CSOM HDJB/L No; anomaly was Myringoplasty; no 48 intact TM
an intraoperative
finding
6 64 females EAC cholestea- Exposed lateral TBCT Canaloplasty and no 24 regular enlarged
toma wall/R meatoplasty; EAC
7 40 females Middle ear effu- Dehiscent genu CT Ventilation tube no 36 resolution of the
sion petrous ICA/L Angio-MRI in posterior effusion
quadrant
8 71 females Cholesterol granu- Petrous ICA No; anomaly was Exploratory tym- no 36 no modification
loma aneurysm/L an intraoperative panotomy at last Angio-MRI
finding
9 10 females Middle ear HDJB/R TBCT/MRI Canal wall down no 12 regular cavity,
cholesteatoma; MRI venography mastoidectomy planned second
previous surgery (revision) stage
with JB injury
10 7 females COM; previous Pseudoaneurysm No; TBCT before CWU—second Intraoperative 120 SNHL, no neu-
CWU mastoid- petrous ICA/R first-stage CWU stage ICA blow rological deficits
ectomy out requiring
packing and per-
manent balloon
occlusion
Mean 39 48

CSOM chronic suppurative otitis media., CWU canal wall up mastoidectomy, CWD canal wall down mastoidectomy, HDJB high riding and
dehiscent jugular bulb, ICA internal carotid artery, JB jugular bulb, L left, MRI magnetic resonance imaging, R right, SNHL sensorineural hear-
ing loss, TBCT temporal bone computed tomography

positioned into the petrous carotid canal (Fig. 2a, b). She

Fig. 1  Intraoperative view after blind sac closure of the external
auditory canal and removal of the posterior canal wall. The high rid-
ing JB covers the round window region and an anterior cochleostomy
was performed. The scala tympani and the scala vestibule are both
visible (patient 1)
patient (patient 3), previously operated on elsewhere, under-
went revision surgery, because the electrode array had been
was asymptomatic and no other preoperative radiological
investigation was deemed necessary apart from temporal
bone CT scan. A subtotal petrosectomy was performed and
the original array was left in place; due to partial cochlear
ossification, drill out of the basal turn was needed to identify
the cochlear lumen. All implanted patients had an uneventful
postoperative course and use their implant with success in
the everyday life.
Among the seven patients in the COM group, patient
4 had epitympanic cholesteatoma associated with a high
and dehiscent JB (Fig. 3); since the tympanic cavity was
disease-free, a modified radical mastoidectomy was per-
formed without opening the tympanic cleft. At last clini-
cal follow-up, the cavity was regular and dry. Patient 5
underwent myringoplasty for an anterior perforation by a
retroauricular approach: intraoperatively, a high and dehis-
cent JB was discovered. The inferior tympanic remnants
were in contact with the lateral JB wall and were carefully
dissected from it following a large canalplasty. At the last
follow-up, the tympanic membrane was intact. Patient 6
presented with a large external auditory canal cholestea-
toma determining an erosion of the lateral JB wall. The

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Fig.  2  a Presurgical CT scan (axial plane) demonstrates the previ-
ously placed array passing through the anterior wall of the partially
ossified cochlear basal turn into the horizontal carotid canal. b Post-
Fig. 3  Preoperative otoscopy showing attic cholesteatoma with ero-
sion of the long process of the incus. The inferior annulus is draped
over a high and dehiscent JB (patient 4)
external meatus was enlarged and regularized well below
the inferior annulus with identification of the facial nerve;
the matrix on the JB wall was removed as last surgical
step and the cavity was filled with bone paste and covered
with temporalis fascia and full thickness skin graft. At last
follow-up, the cavity was regular and dry.
Patient 7 had been scheduled for treatment of a per-
sistent middle ear effusion. Preoperative HRCT indicated
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Eur Arch Otorhinolaryngol
operative skull X-ray (Stenvers view) showing the correct positioning
of the electrode in the cochlea just aside the remnant of the previous
one horizontally located (patient 3)
dehiscence of the genu of the petrous ICA; a ventilation
tube was inserted in the postero-inferior quadrant.
Patient 8 underwent exploratory tympanotomy because of
persistent conductive hearing loss; otomicroscopy showed
tympanic retraction and a browny retrotympanic middle
ear effusion. After elevation of the tympanic membrane
and aspiration of dense mucosal secretions and choles-
terol granuloma, a pulsating mass was seen in the inferior
protympanum, obstructing the Eustachian tube. Surgery
was terminated without further procedures. Postoperative
imaging evaluation of the intracranial circulation revealed
a 2.5 cm aneurysm of the petrous ICA (Fig. 4). Due to the
lack of contralateral compensatory circulation, the patient
was scheduled for follow-up. After 4 years, there were no
modifications of the aneurysm and the middle ear effusion
was still present.
In two patients of the COM group, an intraoperative
bleeding occurred. A 10-year-old girl (patient 9) with a high
and dehiscent JB had been operated on elsewhere for chole-
steatomatous COM. Massive bleeding from the JB occurred
after elevation of inferior tympanic remnants. Bleeding had
been controlled with oxidized cellulose packing and the
patient was subsequently sent for revision surgery. MRI with
venous angiographic sequences showed functional collat-
eral venous circulation; a canal wall down mastoidectomy
was scheduled. Residual cholesteatoma was removed from
mastoid and posterior mesotympanum; the hypotympanum
was explored as last surgical step; hypertrophic mucosal tis-
sue was found covering the dehiscent lateral wall of the JB
without evidence of residual cholesteatoma. Diseased tissue
Eur Arch Otorhinolaryngol

Fig.  4  a Axial skull base CT scan shows a mass scalloping left tem- struction) reveals an abnormal aneurysmal dilatation of the left inter-
poral bone and protruding in the tympanic cavity; linear calcification nal carotid artery at the external opening of the carotid canal (patient
of the lesion margin has to be noted. b MR angiography (VR recon- 8)

was left in place after low intensity bipolar coagulation. At

last follow-up, the cavity was regular and dry.
The other patient (patient 10) who experienced intraoper-
ative bleeding was a 7-year-old girl. She underwent second-
stage surgery 8 months after canal wall up tympanoplasty
for chronic otitis media with hyperplastic mucosal reac-
tion. During second-stage surgery, granulation tissue was
still present in the protympanum and a massive bleeding
occurred when attempting its removal. The middle ear was
immediately packed with oxidized cellulose and the patient
was sent to the Neuroradiology Department for an emergent
angiographic procedure. A pseudoaneurysm of the genu of
the right petrous ICA was identified and a permanent bal-
loon occlusion (PBO) was performed (Fig. 5). Postoperative
course was uneventful with no neurological deficits in the
short term or long term. One year later, the patient under-
went surgical revision and a radical mastoidectomy was per-
formed. Follow-up visit after 8 years showed intact tympanic
membrane with a moderate sensorineural hearing loss.

Discussion Fig. 5  Digital subtraction angiography (DSA): the right petrous

The tympanic cavity has a close anatomical relationship with
the two main head and neck vascular structures, namely the
ICA and the JB. These structures are normally covered by
a thin bony plate and surrounded by a variable amount of
pneumatized bone. Variations in temporal bone pneumatiza-
tion as well as thickness of covering compact bone or ana-
tomical abnormalities may expose ICA and JB to surgical
internal carotid artery has developed a pseudoaneurysm at the level of
the genu (patient 10)
injury. Exposure and subsequent endanger of vascular struc-
tures may occur also in chronic otitis with or without chole-
steatoma and in previously operated ears [2–4].
The JB connects the sigmoid sinus with the internal jug-
ular vein through the jugular foramen; volume asymmetry

13

between the two sides is a common finding [1, 10]. Various
anomalies have been described, including both position
and configuration of the JB. In the tympanic cavity, the JB
may have an anomalous superior course (high riding JB),
be partially or totally uncovered from bone (dehiscent JB),
or present a focal outpouching (JB diverticulum). These
anomalies may combine each other or present as isolated
findings. High riding JB is a common anomaly with a
reported incidence up to 7% of cases, while JB dehiscence
and JB diverticula are rare findings [5, 6].
The petrous ICA presents a short vertical portion at
the entrance of the petrous canal followed by a genu, and
then, by a horizontal portion with anteromedial direction.
The genu is in close proximity with the basal turn of the
cochlea and the posteromedial wall of the bony Eustachian
tube. In the tympanic cavity, the ICA may be uncovered
from bone (dehiscent carotid canal), may protrude laterally
and superiorly (lateralized ICA), or may have an anoma-
lous course through the inferior tympanic canaliculus in
the middle ear (aberrant ICA). The latter case represents
an enlarged inferior tympanic artery anastomosing with an
enlarged caroticotympanic artery due to underdevelopment
or regression of the cervical portion of the ICA during
embryogenesis [11]. Reduction of the cochlear–carotid
interval with bony dehiscence between the ICA and the
cochlear lumen has also been described [12]. Abnormali-
ties of ICA and JB may coexist in the same patient [5, 13].
Even in the absence of congenital anomalies, ICA or JB
may be inadvertently exposed and damaged, especially in
case of massive inflammatory reaction with bone resorp-
tion or in previously operated ears where anatomical bony
landmarks may be altered or absent [4].
Fig.  6  a Otoscopy showing a reddish pulsatile mass in the inferior quadrants behind an intact left tympanic membrane. b CT scan (axial view)
showing an aberrant course of the ICA in the right middle ear
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Eur Arch Otorhinolaryngol
In chronic otitis media, with or without cholesteatoma,
otomicroscopy and temporal bones HRCT usually allow pre-
operative identification of patients at risk for vascular com-
plications (Fig. 6a, b). However, surgeons should be aware
that vascular anomalies could be an unanticipated intraop-
erative finding; for this reason, maneuvers in the hypotym-
panic and protympanic regions should be performed with
utmost care (Table 3). The ICA or JB may be endangered
during myringocentesis, inferior tympanomeatal flap eleva-
tion, and removal of disease (mucosal granulation/hypertro-
phy or cholesteatoma) at the level of the hypotympanum and
protympanum [14, 15].
When vascular anomalies are preoperatively identified,
conservative techniques should be adopted and surgical
maneuvers in the tympanic cleft avoided; in Case 4 of this
series, an epitympanic cholesteatoma associated with a high
and dehiscent JB was treated by a modified radical mastoid-
ectomy without entering the disease-free tympanic cavity.
Should the surgeon intraoperatively identify unantici-
pated vascular anomalies that prevent from performing safe
surgical maneuvers or in case of any doubt regarding disease
extension or vascular integrity, surgery should be stopped to
inform the patient and perform appropriate imaging study.
Staging the surgery may also be considered as a treatment
strategy. Staged surgery allows working in a partially healed
middle ear with reduced inflammatory mucosal reaction.
Staging the surgery does not preserve from accidental vascu-
lar injury if predisposing factors do exist; in Case 10 of this
series, second-stage surgery for COM was performed, but a
pseudoaneurysm of the ICA ruptured intraoperatively during
removal of protympanic granulation tissue. A pseudoaneu-
rysm or “false aneurysm” is a dilatation of the artery where
at least part of its wall is composed only of the adventitial
 Eur Arch Otorhinolaryngol

Table 3  Schematic representation of prevention and management of vascular complications in chronic otitis media surgery
High-risk situations for vascu- Clinical and radiological evaluation Prevention and surgical hints Illustrative cases
lar injury in COM

Preoperative identification
Intraoperative finding
Revision after iatrogenic injury
Intraoperative injury
Otomicroscopy Modify technique as needed; consider staging. Case 4 (HDJB in epitympanic cholesteatoma: modified radi-
 Radiology Large and regular surgical field cal mastoidectomy)
  TBCT scan Address disease in high-risk regions as last surgical step. Case 6 (EAC cholesteatoma with exposure of JB: enlarged
  Bony surfaces of ICA and JB; canalplasty; matrix removal as last step)
height of the JB; position of ICA.
 Radiology Modify technique as needed; consider staging; proceed Case 5 (HDJB in contact with tympanic remnants: large
  Review TBCT scan if available without imaging only if deemed safe canalplasty with careful dissection of the inferior annulus
Careful and limited dissection maneuvers in hypotympa- from JB wall)
num even in supposed normal cases. Case 8 (middle ear effusion and ICA aneurysm: surgery
interrupted and radiological evaluation)
 Radiology Adopt open techniques; consider SP Case 9 (revision surgery after iatrogenic injury of HDJB:
  TBCT scan Hypotympanic region to be explored only after landmarks canal wall down mastoidectomy; hypotympanic region
  MRI angiography (vessel patency identification and disease clearing addressed after cavity regularization and removal of
and contralateral circulation) residual disease)
JB injuries: ladder approach—minor injuries: bone wax; larger lesions: haemostatic agents and compression; severe
hemorrhage: SS and IJV ligation (only if contralateral circulation patent)
ICA injuries: middle ear and nasal packing; cervical compression; endovascular treatment

COM chronic otitis media, CWU canal wall up mastoidectomy, CWD canal wall down mastoidectomy, EAC external auditory canal, HDJB high riding and dehiscent jugular bulb, ICA internal
carotid artery, IJV internal jugular vein, JB jugular bulb, MRI magnetic resonance imaging, SP subtotal petrosectomy, SS sigmoid sinus, TBCT temporal bone computed tomography

13

layer or even by the hematoma; pseudoaneurysms usually
follow traumatic injuries. In the temporal bone, they may
form in association with an aberrant course of the artery, as
complication of surgical maneuvers or as consequence of
chronic middle ear inflammation [13, 16].
When the disease (cholesteatoma, cholesterol granuloma
or massive mucosal hypertrophy) encroaches an exposed
ICA or JB, or if revision surgery has to be performed after
the previous iatrogenic vascular injury, surgery should be
conducted after appropriate imaging study. Surgical maneu-
vers in the regions at risk for vessel injury should be per-
formed as last steps, after disease clearing, cavity regulari-
zation, and haemostasis. Dissection should be performed
bluntly, using cottonoids soaked with epinephrine and in a
medial to lateral way, avoiding to pull mucosal tissue and
reducing brisk maneuvers to a minimum [17].
In these cases, the authors favor an open mastoidectomy
technique and advocate to be ready to perform a subtotal
petrosectomy if deemed necessary. The major advantage of
the latter technique is represented by the large surgical field
facilitating the identification of surgical landmarks, while
the main drawback is represented by permanent conductive
hearing loss [18–22].
Intraoperative treatment of bleeding from the JB may usu-
ally be controlled with bone wax in case of limited injury
when there is residual bone covering the dome. Bone wax
may then be used on the surface of the JB taking care not to
insert the wax into the bulb to avoid embolism. Haemostatic
agents (oxidized cellulose polymer or gelatin matrix-throm-
bin sealant) should be used in larger lesions [23]; packing
should be placed on the site of the lesion and pressure
Table 4  Schematic representation of prevention and management of vascular complications in cochlear implant surgery
High-risk situations for vascu- Clinical and radiological evaluation Prevention and surgical hints
lar injury during CI surgery
Preoperative identification Otomicroscopy
 Radiology
  TBCT scan
  JB: surgical corridors for com-
plete RW and basal turn exposure
  ICA: hypotympanic pneumatiza-
tion; cochleo-carotid dehiscences
Intraoperative finding  Radiology
  Review TBCT scan if available
Revision after iatrogenic injury  Radiology
  TBCT scan
  MRI angiography
Intraoperative injury
COM chronic otitis media, HDJB high riding and dehiscent jugular bulb, ICA internal carotid artery, JB jugular bulb, MRI magnetic resonance
imaging, SP subtotal petrosectomy, RW round window, TBCT temporal bone computed tomography
13
Eur Arch Otorhinolaryngol
applied on a cottonoid. Severe hemorrhage may require
a combination of middle ear packing and internal jugular
vein and sigmoid sinus closure. The last maneuver should
be performed if adequate collateral circulation through the
contralateral JB has been confirmed [24].
Rupture of the carotid artery in the middle ear represents
an emergency requiring immediate middle ear packing irre-
spective of hearing preservation; nasal packing may also be
needed together with neck compression. The patient should
be immediately sent for an emergency endovascular proce-
dure to control the bleeding. Severe neurological sequelae
represent a possible consequence of permanent ICA occlu-
sion [25].
ICA and JB may be also endangered during coch-
lear implantation (Table 4). As the main goal of cochlear
implant surgery is the complete insertion of the electrode
array into the scala tympani, the access routes to the coch-
lear lumen should be assessed before surgery [26]. A high
riding JB may cover the round window or the basal coch-
lear turn, hindering access to the cochlear lumen through
a standard transmastoid approach. Lowering of the JB has
been described during skull base procedures. In authors’
opinion, such maneuvers should not be adopted in cochlear
implantation because of their serious potential complications
(thrombosis and bleeding) [27]. Incorrect identification of
anatomical landmarks may mislead the surgeon during array
positioning; pneumatized hypotympanic air cells and poly-
poid mucosa have been reported in association with posi-
tioning of the array into the carotid canal [28]. Inadvertent
exposure or even penetration of the carotid canal may also
occur in case of cochlear–carotid dehiscence or if extensive
Illustrative cases
Standard transmastoid technique Case 1 (HDJB covering RW and
only if access to cochlear lumen basal cochlear turn: subtotal pet-
is deemed adequate. rosectomy with anterior cochle-
Consider subtotal petrosectomy ostomy)
Switch to subtotal petrosectomy if
landmarks identification is not
clear or if cochleostomy in the
anterior one-half of basal turn or
drill-out procedures are required.
Subtotal petrosectomy; array in Case 3 (revision surgery for array in
carotid canal to be left in place carotid canal: subtotal petrosec-
if asymptomatic and no signs of tomy with partial cochlear drill-out
infection/foreign body reaction and previous array left in place)
Same as COM
Eur Arch Otorhinolaryngol
drill-out procedures on the basal turn are required as in case
of cochlear ossification [12, 29]. In patient 3, the electrode
array positioned in the carotid canal during primary surgery
was cut and left in place to reduce risk of adjunctive injury
to the carotid wall, as there were no signs of infection or
inflammatory mucosal reaction. In other published cases,
the electrode array had been removed from the carotid canal
during revision surgery [28, 29]; this decision should be
taken on a case-by-case basis after careful radiologic evalu-
ation of vessel wall integrity.
Knowledge of anatomical landmarks and their possible
variations may help in correctly identifying the cochlear
lumen in the vast majority of the cases using a standard
transmastoid approach with posterior tympanotomy. Oth-
erwise, when dealing with JB or ICA anomalies, as well as
in other complex cases such as inner ear malformations at
risk of cerebrospinal fluid leak and anomalous facial nerve
course, the authors prefer performing subtotal petrosectomy.
This surgical technique permits clear and safe identifica-
tion of surgical landmarks and allows to gain access to the
cochlea in almost all situations. Its complication rate is low
as well as morbidity, that is mainly related to abdominal fat
graft harvesting and iatrogenic cholesteatoma [18, 19].
Conclusions
Vascular complications during middle ear and cochlear
implant surgery are rare, but potentially life threatening. In
chronic otitis media, surgical maneuvers in the hypotym-
panic/protympanic region should be performed with utmost
care, especially in massively inflamed ears or during revision
surgery. In cochlear implantation; in case of uncertainty, sur-
gery should be interrupted and appropriate imaging studies
planned. In complex CI cases, including vascular anomalies
or revision surgery, the accessibility to the cochlear lumen
should be assessed; subtotal petrosectomy may give signifi-
cant advantages in terms of landmarks identification and
surgical exposure. Knowledge of anatomy and its variants,
preoperative evaluation of imaging, and the ability of the
surgeon to adapt the surgical technique to the specific case
are the basis for prevention of vascular complications.
Compliance with ethical standards  20(1):46–50
Funding  No funding sources were used for this study.
Conflict of interest  The authors (F. Di Lella, M. Falcioni, I. Iacca-
rino, S. Piccinini, A. Bacciu, E. Pasanisi, D. Cerasti, and V. Vincenti)
declare no conflict of interest.
Ethical statement  All procedures performed in this study involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent  Informed consent was obtained from all indi-
vidual participants included in the study.
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