ARTERIOVENOUS MALFORMATION

OF THE EXTERNAL EAR

Radian Nasution,
Lina Lasminingrum

Departement
Departement of Otorhinolaryngology Head and Neck Surgery
Faculty of Medicine Padjadjaran University / Hasan Sadikin General Hospital
Hospital
Bandung

INTRODUCTION
Arteriovenous malformations (AVMs)

congenital vascular lesions

associated with a variable degree of arteriovenous shunting.
some of these lesions are thought to originate from arteriovenous
channels that have failed to regress during development.
usually first noted several years after birth, after trauma, the
hormonal changes of puberty, pregnancy, inadequate surgical
intervention .
including the type of high flow vascular malformations and potentially
give cardiac failure and even cause death risk.

AVM at external ear second most common site for

extracranial arteriovenous malformation in the head
and neck.

INCIDENCE
The incidence of arteriovenous malformation intra and
extracranial in the head and neck between 2-6%.
The incidence of Arteriovenous malformation in ORL-HNS
Dept Dr. Hasan Sadikin Hospital Bandung from January
2009-December 2013 only one case.

GROUPS OF AVMS
There are 3 major groups of AVMs:
o Truncal: common in the head, neck, upper limb and
lower limb and pelvis (trunk area).
o Diffuse: common in the lower limbs
o Localized: common in any organ

SCHOBINGERS STAGES OF
AVMS
There are Schobingers stages of AVMs:
o Stage I, lesion has a pinkish-bluish stain and warmth.
o Stage II, the lesion has pulsations, thrill, and bruit.
o Stage III, the patient has dystrophic skin changes,
ulceration, bleeding, and pain.
o Stage IV, the patient has high-output cardiac failure.

IMAGING
CT angiography is the best modality for examination of
venous and arterial malformations and most commonly
used in the classification of vascular malformations,
because it able to describe the anatomical relationship
of the vascular lesion.

MANAGEMENT
Treatment of these lesions poses a challenge to the clinician
due to their extreme vascularity and high incidence of
recurrence.
Gold standard for this case is percutaneous puncture
embolization which costs quite expensive.
We made another attempt to manage AVMs

CASE
Male, 25 years old
since 2 years old has complaining about marble sized lumps on the
back of his ear,
at the age of 12 the lumps became larger and pulsating.
ear ache(+), hearing disorder (-), chronic otorrhoea (-), headache (-),
dizziness (-), fever (-), cough (-).

Consciousness : Full alert, Blood Pressure : 110/80 mmHg, Heart

rate : 82 bpm,
Respiratory rate : 20 x/minute, body temperature : 36,8 C
Local Examination Findings :
Right Ear : External Acoustic Canal not hyperemic, discharge (-), ear wax
(-), ear drum intact (+), light con reflex (+), retroauricular not hyperemic
Left Ear : Hyperemic Mass (+), multiple size pulsating nodule (+), thrill (+),
bruit (+), External Acoustic Canal not hyperemic, discharges (-), ear wax
(-), ear drum intact (+), light con reflex (+)

Clinical Picture (2-25-2014)

Clinical Picture (2-25-2014)

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Examinations
The Tuning Fork Test
Rinne Test : Positive
Weber Test : No lateralization

12-lead ECG
Normal

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CT Angiography (2-25-2014)

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JOINT CONFERENCE
On July 22, 2014 conducted a joint conference between
ORL-HNS Dept; Vascular Surgery and Radiology Dept. and
decided management for this patient is arterial ligation and
sclerotherapy.

Surgical Operation (4-1-2014)

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CT Angiography (6-26-2014)

CT Angiography (6-26-2014)

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Clinical Picture (6-26-2014)

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Discussion
Presented a man, 25 years old, suffer with swelling and
pulsatile mass of the posterior auricular region of the left ear,
since 23 years ago. From CT scan angiography the nidus was
found with the main arteries feeding of left branches of the
external carotid artery.
In this patient undergone the combination therapy of ethanol
sclerotherapy and ligation of the artery, with good results, in
which the 3 months after therapy, the lesions shrank up to
40%.
Complete eradication may require several treatment sessions
during which complications should be minimized with careful
techniques.
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Thank You

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