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We present a case of a patient with a jugular diverticulum causing persistent pulsatile tinnitus which was successfully treated with a CO2 laser endoscopic procedure. To our knowledge this is the first instance of a dehiscent jugular diverticulum being successfully treated in this manner. We believe this procedure is advantageous when compared to other treatment modalities because it is 1) minimally invasive 2) there is decreased pain and recovery time compared to other surgical approaches and 3) the risk of serious post-op infection such as meningitis is theoretically much lower when compared to posterior auricular approaches that must expose the dura of the brain to reach the jugular diverticulum.
Endoscopic Repair of a Jugular Diverticulum with a CO2 laser
pulsatile tinnitus that is severe enough to interfere with a patient's quality of life
pulsatile tinnitus that cannot be adequately treated with masking techniques
serious bleeding disorder such as hemophilia, or severe comorbidities that preclude general anesthesia except for life-saving procedures
OmniGuide CO2 laser
round knife
Standard middle ear instrument tray
straight suction
patient is prepped with sterile solution, draped to create sterile field, and an ear endoscope is used in addition to instruments standard for endoscopic ear surgery such as suction tips, curved and straight picks, round knife, etc. We used an Omniguide CO2 laser.
CT scan to plan for surgical approach and rule out any other pathologies
TM, hypotympanum
bleeding, iatrogenic damage to middle ear structures with laser
there are no conflicts, financial or otherwise, to disclose
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Manjila S, Bazil T, Kay M, Udayasankar UK, Semaan M. Jugular bulb and skull base pathologies: proposal for a novel classification system for jugular bulb positions and microsurgical implications. Neurosurgical focus. 2018;45(1):E5. doi:10.3171/2018.5.FOCUS18106
Hu J, Peng A, Deng K, et al. Value of CT and three-dimensional reconstruction revealing specific radiological signs for screening causative high jugular bulb in patients with Meniere’s disease. BMC medical imaging. 2020;20(1):103. doi:10.1186/s12880-020-00504-0
Fox R, Nash R, Tatla T. Encountering a high jugular bulb during ear surgery. Annals of the Royal College of Surgeons of England. 2017;99(1):36-37. doi:10.1308/rcsann.2016.0290
Reardon MA, Raghavan P. Venous Abnormalities Leading to Tinnitus: Imaging Evaluation. Neuroimaging Clinics of North America. 2016;26(2):237-245. doi:10.1016/j.nic.2015.12.006
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