Surg Radiol Anat (2014) 36:369–374
DOI 10.1007/s00276-013-1196-z
ORIGINAL ARTICLE
High and dehiscent jugular bulb: clear and present danger
during middle ear surgery
Sinan Atmaca • Muzaffer Elmali • Harun Kucuk
Received: 9 February 2013 / Accepted: 22 August 2013 / Published online: 4 September 2013
Ó Springer-Verlag France 2013
Abstract
Purpose Internal jugular vein is anatomic continuation of
cranial dural sinuses in the neck region. During the course
of skull base the first enlarged segment of jugular vein is
described as jugular bulb. The aim of this study is to
evaluate the jugular bulb abnormalities and define the risk
of high and dehiscent jugular bulb injury during middle ear
surgery.
Methods This is a retrospective radiologic study of 1,010
patients (2,020 temporal bones) with various ear symptoms
who had high resolution temporal bone computed tomog-
raphy scans between 2007 and 2011.
Results High jugular bulb was seen in 308 (15.2 %)
temporal bones. Jugular bulb dehiscence was encountered
in 153 (7.5 %) temporal bones. High jugular bulb and
jugular bulb dehiscence were more common in the right
ears and females. Forty-one (2 %) temporal bones revealed
high and dehiscent jugular bulb which can be vulnerable
during middle ear surgery. High and dehiscent jugular bulb
was more common in the right ears and males. Male pre-
dominance becomes more significant in the left ears. Of the
308 temporal bones with high jugular bulb, 87 (28.2 %)
also had coexisting carotid canal dehiscence.
S. Atmaca (&)
H. Kucuk
Department of Otolaryngology Head and Neck Surgery,
Ondokuz Mayis University School of Medicine,
Samsun 55200, Turkey
e-mail: sinanatmaca@yahoo.com
H. Kucuk
e-mail: drharunk@gmail.com
M. Elmali
Department of Radiology, Ondokuz Mayis University School
of Medicine, Samsun 55200, Turkey
e-mail: muzafel@yahoo.com.tr
Conclusion High and dehiscent jugular bulb is an
important anatomic variation that can result in catastrophic
outcomes during middle ear surgery. Our series show that
2 % of patients can be considered in the ‘‘high-risk’’ group.
Precise assessment of the preoperative computed tomog-
raphy scans by both the radiologist and the ENT surgeon is
of utmost importance. Preoperative awareness will mini-
mize morbidity and mortality.
Keywords High jugular bulb
Dehiscence
Ear
surgery
Injury
Bleeding
Temporal bone ct
Introduction
Internal jugular vein is anatomic continuation of cranial
dural sinuses in the neck region [1, 12, 14]. During the
course of skull base the first enlarged segment of jugular
vein is described as jugular bulb (JB) and the jugular bulb
is the junction between the internal jugular vein and the
sigmoid sinus [4, 11, 14, 16]. JB which is surrounded by
bony jugular fossa lies inferior and posterior to the internal
auditory canal (IAC). Anatomically, it lies below the
hypotympanum of the middle ear space [8, 13]. It is sep-
arated from the IAC and middle ear cavity by a compact
bone. The most common anatomic variation of JB in
temporal bone is called ‘‘High Jugular Bulb’’ (HJB)
(Fig. 1). Temporal computed tomography (CT) scan stud-
ies report the incidence of HJB ranging from 6 to 20 % [6].
Other reports including cadaveric and clinical studies
suggest a HJB incidence between 3 and 65 % [9, 10, 13,
14]. HJB is commonly asymptomatic. When symptomatic,
HJB may cause tinnitus, vestibular and hearing disorders.
Sometimes the bony septum of JB may be absent and may
show indentation to the middle ear (Figs. 2, 3). Some
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Fig. 1 White arrow right-sided high jugular bulb reaching above the
floor of internal auditory canal, right IAC exists below the axial cut
Fig. 2 Axial cut. White star left-sided high and dehiscent jugular
bulb reaching the external ear canal lateral to the eardrum. White
arrow points the junction of eardrum, external ear canal and the
jugular bulb
Fig. 3 Intraoperative picture the same patient in Fig. 2 (left ear,
tympanomeatal flap elevated) White arrow jugular bulb, black thick
arrow promontory
authors describe this situation as high jugular bulb or lat-
erally high jugular bulb [3, 8, 12, 14]. This described pattern of
jugular vein makes it easily vulnerable during myringotomy
and tympanomeatal flap elevation and may cause significant
morbidity and mortality [3, 8, 13, 14]. The purpose of this
study is to investigate the jugular bulb abnormalities on tem-
poral bone CT scans and define the risk of injury to high and
dehiscent JB during middle ear surgery.
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Methods
This study was approved by the Local Institutional Ethics
Committee (2011/347). High resolution CT scans of 1,010
patients (2,020 temporal bones) with various ear symptoms
including hearing loss, otitis media, tinnitus, vertigo and
trauma performed between 2007 and 2011 were reevalu-
ated. Of the 1,010 patients aged 1–94 years (mean:
34.8 ± 19.8 years), 494 (48.9 %) were males and 516
(51.1 %) were females. The high resolution temporal bone
CT scans were all performed on a single Toshiba multi
detector scanner (Aquilion 16 system, Toshiba Medical
Systems Corporation, Tokyo, Japan) with 1-mm thick
sections and 0.5-mm reconstruction thickness in bone
algorithm. All axial and coronal images were evaluated by
the same head and neck radiologist. HJB was defined as a
JB position above the lower level of IAC. Absence of
hyperdense bony septa between tympanic cavity and jug-
ular bulb was accepted as jugular bulb dehiscence (JBD).
We defined another dehiscent JB position to determine the
risk of injury during middle ear surgery. Patients having a
dehiscent JB protrusion into mesotympanum or a JB dome
to posterior and inferior tympanic annulus distance of
1 mm or less were defined as high-risk group. Carotid
canal dehiscence (CCD) was defined as lack of bony septa
in the carotid canal facing the tympanic cavity.
Results
In 2,020 temporal bones 308 (15.2 %) HJBs were present
with 113 (43.1 %) males and 149 (56.9 %) females. Forty-
six (4.6 %) patients had bilateral HJB. Right-sided HJB
was seen in 174 (17.2 %) temporal bones with 71 (40.8 %)
males and 103 (59.2 %) females. Left-sided HJB was seen
in 134 (13.3 %) temporal bones with 59 (44 %) males and
75 (56 %) females. HJB was more common in the right
ears and females (Table 1). One hundred and fifty-three
temporal bones (7.5 %) revealed dehiscent JB with 55
(41 %) males and 79 (59 %) females. Nineteen patients
had bilateral JBD. Right-sided JBD was seen in 94 (9.3 %)
temporal bones with 35 (37.2 %) males and 59 (62.8 %)
females. Left-sided JBD was seen in 59 (5.8 %) temporal
Table 1 High jugular bulb incidence
Male Female Total
RHJB 71 103 174/1,010 (17.2 %)
LHJB 59 75 134/1,010 (13.3 %)
Total 130 178 308/2,020 (15.2 %)
Three hundred and eight temporal bones in 262 patients, 17 males and
29 females had bilateral HJB
RHJB right-sided high jugular bulb, LHJB left-sided high jugular bulb
Surg Radiol Anat (2014) 36:369–374
bones with 30 (50.8 %) males and 29 (49.2 %) females.
JBD was also more common in the right ears and females
(Table 2). Forty-one (2 %) temporal bones were found to be
in the high-risk group with 21 (53.8 %) males and 18 (46.2 %)
females. Two patients had bilateral high and dehiscent JB.
Right-sided high and dehiscent JB was seen in 25 (2.5 %)
temporal bones with 12 (48 %) males and 13 (52 %) females.
Left-sided high and dehiscent JB was seen in 16 (1.6 %)
temporal bones with 11 (68.8 %) males and 5 (31.2 %)
females. High and dehiscent JB was more common in the right
ears and males. Male predominance becomes more significant
in the left ears (Fig. 4). Of the 308 temporal bones with HJB,
87 (28.2 %) also had coexisting CCD. Right-sided CCD
coexistence was seen in 49 of 174 (28.1 %) temporal bones
with HJB. Left-sided CCD coexistence was present in 28.3 %
(38/134) of temporal bones with HJB.
Discussion
Internal jugular vein is anatomic continuation of cranial
dural sinuses [2, 4–6, 14]. The first enlarged segment of
Table 2 Dehiscent jugular bulb incidence
Male Female Total
RJBD 35 59 94/1,010 (9.3 %)
LJBD 30 29 59/1,010 (5.8 %)
Total 65 88 153/2,020 (7.5 %)
One hundred and fifty-three temporal bones in 134 patients, 10 males
and 9 females had bilateral JBD
RJBD right-sided jugular bulb dehiscence, LJBD left-sided jugular
bulb dehiscence
Fig. 4 High and dehiscent jugular bulb (high-risk group) incidence.
Every single bar represents a patient of corresponding age, side and
gender. 39 patients with 41 (2 bilateral) high and dehiscent jugular
bulbs
371
internal jugular vein during the course of skull base is
described as jugular bulb [14]. Jugular vein shows varia-
tions on temporal bone as well as other vascular structures.
These vascular variations are high jugular bulb, dehiscent
jugular bulb, anterior location of sigmoid sinus and
dehiscent internal carotid artery [2, 6, 12, 14, 15]. After
birth, hemodynamic changes and mastoid pneumatization
play an important role in JB development [3, 6, 9].
Friedmann et al. [5] stated that jugular bulb formation is
not present at birth and develops after 2 years. In our ser-
ies, contrary to their opinion, we have a 1-year-old male
boy who has a right-sided high and dehiscent jugular bulb
(Fig. 5). Temporal CT scan studies report a HJB incidence
between 6 and 20 % which is also consistent with our
15.2 % incidence rate [7]. There is a lack of consensus in
description of high jugular bulb and definition varies
between authors. It is considered high when (1) JB apex is
above the superior tympanic annulus or the level of basal
turn of cochlea and round window (Fig. 6), (2) it is above
the floor of external auditory canal (Fig. 7), (3) the vertical
distance between inferior wall of IAC and JB dome is
2 mm or less (Fig. 8), (4) JB is above the cochlear aque-
duct (Fig. 9), (5) close relationship between IAC and
endolympathic duct (medial) or protrusion to the meso-
tympanum or hypotympanum (lateral) exists (Fig. 10) [4,
6, 9, 12–14]. In this study, the JB position above the lower
level of IAC was considered to be high. The bony lamella
which covers the JB apex is sometimes absent and shows
dehiscence [12]. In this situation, JB may protrude to the
middle ear cavity. It may even rise up to external ear canal
and tympanic annulus level. In this study, our overall JBD
incidence was 7 % (153/2,020). We defined the ‘‘high-
risk’’ patients as those having a dehiscent JB rising up to
the level of mesotympanum or having a JB dome to the
posterior and inferior tympanic annulus distance of 1 mm
or less. These are the patients in whom an ENT surgeon
can encounter unexpected diffuse bleedings during myr-
ingotomy, tympanomeatal flap elevation and middle ear
Fig. 5 Axial cut. Right-sided high and dehiscent jugular bulb in
1-year-old infant. White arrow points the dehiscent jugular bulb
protruding into the external ear canal
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Fig. 6 Axial cut. Both white arrows bilateral high jugular bulb above
the superior tympanic annulus. The axial cut is above the external ear
canals on both sides
Fig. 7 Axial cut. Both white arrows bilateral high jugular bulb above
the floor of external ear canal. Both white stars right and left external
ear canals
procedures. In our series, 2 % (41/2020) of all temporal
bones were in the high-risk group. The first jugular bulb
injury during myringotomy was reported by Page in 1914
[4, 12–14]. He presented a 10-month infant with acute
otitis media who had massive bleeding after myringotomy
of a dark blue ear drum. Bleeding was controlled by
packing external auditory canal with gauze; nevertheless,
the infant was died due to sigmoid sinus thrombosis [4, 12–
14]. One of the authors (S.A.) of this paper also witnessed
profuse bleeding after myringotomy in another clinic
6 years ago. Eight-year-old boy lost 700 cc blood before
the bleeding was controlled with SurgicelÒ and gauze
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Fig. 8 Axial cut. White arrow left-sided high jugular bulb above the
internal auditory canal inferior wall. White star internal auditory canal
Fig. 9 Axial cut. Left-sided high jugular bulb above the cochlear
aqueduct. Thin-long white arrow cochlear aqueduct. Thick-short
white arrow high jugular bulb
packing. There was no sign of a bluish discoloration behind
the eardrum. The patient recovered uneventfully but nee-
ded packed red blood cell transfusion. Myringotomy and
ventilation tube (VT) insertion are among the most com-
mon childhood procedures. Most of the patients who are
scheduled for VT insertion, if not all, do not have a pre-
operative temporal CT scan. There is no warning sign other
than the presence of a blue mass behind the eardrum. We
strongly recommend a careful tympanic membrane exam-
ination before starting the incision for myringotomy. In
Surg Radiol Anat (2014) 36:369–374
Fig. 10 Axial cut. Right-sided high jugular bulb protruding into
mesotympanum. Thick-long white arrow high jugular bulb. Thin-
short white arrow right eardrum
Fig. 11 White star left-sided high and dehiscent jugular bulb
reaching the external ear canal lateral to the eardrum. White arrow
points the junction of eardrum, external ear canal and the jugular bulb
case of an unexpected diffuse bleeding during myringot-
omy, the patient must be placed in a head-down position to
avoid air embolism and the ear must be packed. In the
literature, Smyth, Black and Belfost, in 1964, reported a
case in which they found a jugular bulb occupying half of
the middle ear space [13]. Overton et al. [13] in 1965,
encountered massive bleeding during biopsy of a middle
ear mass which he later recognized as the jugular bulb.
Moore reported three cases of significant bleeding due to
dehiscent JB laceration during middle ear surgery [12]. In
one case, bleeding occurred during the elevation of the
tympanomeatal flap through an endaural incision. In two of
his cases, he encountered bleeding during the separation of
fibrous annulus from the bony margin following endaural
incisions. He confirmed the presence of high and dehiscent
JB with CT scans after the surgeries [12]. Ball et al. [2] also
373
reported a case of bleeding due to high and dehiscent JB
injury during mastoid exploration. They encountered brisk
bleeding during tympanomeatal flap elevation while still
lateral to the annulus. Later, they realized that they missed
the presence of a dehiscent JB extending into the external
ear canal in the preoperative CT scan because they focused
on the areas of cholesteatoma [2]. In our clinic, we oper-
ated on a 17-year-old male patient with adhesive otitis
media and cholesteatoma. At surgery, left ear was
approached by a postauricular incision. During tympa-
nomeatal flap elevation, before the fibrous annulus was
reached, brisk venous bleeding occurred. EAC was packed
with SurgicelÒ and gelfoam immediately and the patient
was brought to head-down position. Bleeding was con-
trolled with no significant blood loss. Intraoperative
assessment of the CT scan showed that we missed an
evident JBD rising up to the external ear canal level similar
to the case described by Ball et al. (Fig. 11) [2]. Further
exploration was canceled and the patient recovered
uneventfully with no need of blood transfusion. ENT sur-
geons mostly focus on the area of cholesteatoma, facial
nerve, position of the sigmoid sinus and the tegmen tym-
pani, ossicular chain and the semicircular canals. Jugular
bulb, in most cases, is not the area of interest. These
experiences illustrate the importance of preoperative CT
scan evaluation both by the radiologist and the ENT sur-
geon [3, 17]. Either the radiologists’ or the ENT surgeons’
preoperative awareness could have avoided these bleed-
ings. In this study, we also investigated that 28.2 % of
patients with HJB have a coexisting CCD which is slightly
higher than the series (21.8 %) defined by Wang et al. [15].
This finding is another warning sign during middle ear
surgery that will force the surgeons to be watchful for the
coexistence of these two great vessel anomalies. Wang
et al. [15] also noted that dehiscence site in most of the ears
with CCD was near the Eustachian tube orifice and warned
the ENT surgeons to be very cautious during surgical
procedures around the orifice. It is imperative that preop-
erative CT scans should be thoroughly evaluated including
all anatomical sites not only the area in question. Our series
clearly demonstrated that 2 % of all temporal bones have
high and dehiscent JB which can be vulnerable during
myringotomy, tympanomeatal flap elevation, fibrous
annulus separation from the bony margin and removal of
granulation tissue during middle ear surgery.
Conclusion
High and dehiscent JB is an important anatomic variation
that can result in catastrophic outcomes during middle ear
surgery. Our series show that 2 % of patients can be con-
sidered in the ‘‘high-risk’’ group. Precise assessment of the
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preoperative CT scans by both the radiologist and the ENT
surgeon is of utmost importance. Preoperative awareness
will minimize morbidity and mortality.
Conflict of interest The authors declare that they have no conflict
of interest.
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