Silent obstruction: The hidden role of aberrant internal carotid artery in middle ear pathology

PURPOSE: Aberrant Internal carotid artery (ICA) within the middle ear is a rare congenital vascular anomaly, occurring in approximately 1% of the population [1]. It often remains clinically silent or presents with nonspecific otological symptoms, making preoperative diagnosis challenging. This study aims to highlight the importance of early identification and safe management of aberrant ICA through a clinical case and literature review. METHODS: We report a case of 36 year old female presenting with bilateral chronic ear discharge and tympanic membrane retraction. Detailed otoscopic examination and radiological imaging were performed. A focused literature review was conducted to contextualize clinical presentation, diagnostic strategies and management. RESULTS: Imaging revealed an aberrant ICA coursing through the middle ear. The patients presentation was non specific, and the diagnosis was established only after radiological evaluation. Recognition of this anomaly preoperatively prevented inadvertent vascular injury. Literature suggests that such cases are frequently diagnosed incidentally, with intraoperative hemorrhage being the most severe complication when missed. CONCLUSION: Preoperative identification of aberrant ICA is critical in patients with atypical middle ear findings. Routine consideration of vascular anomalies and appropriate imaging can avert life threatening complications and guide safe surgical planning.