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This next case is an unusual case in that

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it has both congenital abnormalities,

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posttraumatic abnormalities,

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and postinflammatory abnormalities.

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So it's a little bit of a complicated case in a

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patient who actually had bilateral tinnitus and

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vertigo and a prior history of head trauma.

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So I'm going to start on the left ear and

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walk you through it. So, once again,

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we start with the external auditory canal,

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which looks nicely demonstrated. No issues there.

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And then we come to the tympanic membrane here,

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and we see that there is a soft tissue mass,

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which is in the middle ear cavity.

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It's overlying the cochlear promontory.

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Here's.

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The cochlear promontory here

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is the soft tissue mass.

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You're getting a little bit of the eustachian tube

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coming into the middle ear cavity right here.

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This is the internal carotid artery.

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So when we see this soft tissue mass overlying

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the cochlea and the promontory,

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we want to ask the clinician,

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or we want to go into the electronic medical record

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and say, is this a red mass or is this a white mass?

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If it's a red mass,

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we would be concerned about a glomus tympanicum

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tumor. If it's a white mass,

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we could be dealing with a congenital

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cholesteatoma or epidermoid,

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or we could be dealing with

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an acquired cholesteatoma.

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Or we can be dealing with flesh-colored lesions,

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which could be middle ear adenomas, for example,

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or minor salivary gland soft tissue rests.

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And these may be on a congenital basis.

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So looking at this case,

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we're going to take a little bit finer

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look at the middle ear ossicles.

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So here we have the malleus and the incus that looks

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like the ice cream and the ice

1:44

cream cone looking normal.

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And we have the two parallel lines of the neck of

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the malleus and the long process of the incus.

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And we have our communication here with the stapes,

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and that all looks good.

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And we have an incudostapedial joint.

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So so far, the ossicles look fine.

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And we are not seeing soft tissue in the middle ear

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cavity other than over the cochlear promontory to

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suggest that this was an acquired cholesteatoma.

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We don't even have thickening of the tympanic

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membrane back here to suggest that.

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So right now we're going to be asking the question,

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is this a white lesion?

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Is this a red lesion?

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Now let's look at some of the other structures.

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And in this case,

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what we see is evidence of a prior fracture.

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So here you see a fracture line going

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into the cochlear basal turn and into the vestibule.

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And this fracture line is seen coursing

2:46

here as well. And therefore,

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this is what we would call an otic

2:51

capsule-violating fracture.

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And you can also see the fractured line coming

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above here actually extends into

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the fundus of the internal auditory canal right

3:03

through here. And this is the fracture line of this,

3:07

what we would normally call

3:09

a vertical fracture and now is called

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an otic capsule-violating fracture.

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So those are some of the findings

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that we're seeing on this case.

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The other congenital abnormality that I wanted to

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point out for you is the positioning

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of the jugular bulb.

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So we say that the jugular bulb that ascends higher

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than the external auditory canal or the lower border

3:33

of the internal auditory canal is

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a high-riding jugular bulb.

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So here we have our internal auditory canal,

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here we have portions of the

3:42

top of the jugular bulb.

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It is above the lowermost border of the internal

3:49

auditory canal and it's certainly above

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the external auditory canal.

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We've lost the external auditory canal,

3:54

we still have the jugular bulb.

3:57

So this would be called a high-riding jugular bulb.

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It also shows another congenital finding,

4:02

which is communication of the jugular

4:05

bulb to the endolymphatic sac,

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which is the vestibular aqueduct right here.

4:10

And you can see that they are connecting with an

4:13

area of dehiscence and that also is another

4:16

congenital anomaly or variant and may be associated

4:20

with some dizziness on the right side.

4:25

We will follow the jugular up above and

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here's the jugular bulb. In this case,

4:33

you see that there is an area of dehiscence of

4:36

the anterior margin of this jugular bulb.

4:40

There's no bony margin here, and therefore this

4:43

patient, if they were doing otoscopy,

4:46

they might see a red retro-tympanic mass which could

4:50

be posteriorly the dehiscent jugular bulb.

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Not only is it dehiscent,

4:55

but if we follow it to its top,

4:58

going up and up and up, here's the jugular bulb,

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here's the jugular bulb,

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here's the internal auditory canal.

5:05

Again, if it resides above the inferior margin

5:08

of the internal auditory canal,

5:10

it's a high-riding jugular bulb, which you see here.

5:12

And this jugular bulb also, as you can see,

5:15

is above the level of the external auditory canal.

5:19

This one does not appear to communicate well,

5:23

maybe it does a little bit of communication

5:25

with the endolymphatic sac as well.

5:27

So multiple congenital anomalies in this case.

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We want to go back to deal with this cholesteatoma

5:34

or the white lesion that was seen

5:36

in the retro-tympanic space.

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Is this an acquired cholesteatoma

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from the previous trauma

5:44

with a fracture, or was it always there as a

5:47

congenital epidermoid lesion, a congenital cyst?

5:52

We will never know. So,

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a somewhat complicated case of a patient who has

5:56

congenital anomalies as well as changes from trauma

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with a consequential acquired or congenital

6:07

white lesion, epidermoid or cholesteatoma.