Extremely High-Riding Jugular Bulb With Conductive Hearing Loss Presenting as a Mass Posterior to the Tympanic...

A high-riding jugular bulb is defined by the superior aspect of the jugular bulb being present above the level of the inferior aspect of the internal auditory canal. Though typically asymptomatic, patients with high-riding jugular bulb may report several otologic and vestibular symptoms, most often conductive hearing loss, pulsatile tinnitus, and vertigo. The presentation of each symptom is highly variable and related to the anatomy abutted. The abnormal positioning of the jugular bulb, depending on its location, may have implications related to the viability of certain clinical procedures (like myringotomy) and in the treatment of presenting symptoms. It may also affect surgical planning, especially if mastoidectomy or a translabyrinth approach is being considered. We present the case of a 12 year old male seen in clinic for worsening conductive hearing loss and having no family history of hearing loss or anatomical abnormality. Upon otoscopy, a dark mass was visible posterior to the tympanic membrane, prompting further examination of temporal structures via computed tomography. CT revealed a dehiscent sigmoid plate with the jugular bulb protruding into the middle ear past the round window and contacting the stapes, an uncommon extreme case of high-riding jugular bulb. This case exemplifies a situation in which high-riding jugular bulb must be considered while treating conductive hearing loss and underscores the importance of recognizing any abnormal venous structure in the middle ear before proceeding with myringotomy or surgical intervention.