ARTERIOVENOUS MALFORMATION OF THE EXTERNAL EAR

Radian Nasution,

Lina Lasminingrum

DepDepartementartement of Otorhinolaryngology of Otorhinolaryngology Head and Neck Surgery Head and Neck Surgery

FacultyFaculty of Medicine Padjadjaran University of Medicine Padjadjaran University / / Hasan Sadikin General HospitaHasan Sadikin General Hospitall

BandungBandung

Arteriovenous malformations (AVMs)

• congenital vascular lesions • associated with a variable degree of arteriovenous shunting. • some of these lesions are thought to originate from arteriovenous

channels that have failed to regress during development.• usually first noted several years after birth, after trauma, the

hormonal changes of puberty, pregnancy, inadequate surgical intervention .

• including the type of high flow vascular malformations and potentially give cardiac failure and even cause death risk.

AVM at external ear second most common site for extracranial arteriovenous malformation in the head and neck.

INTRODUCTION

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INCIDENCE

• The incidence of arteriovenous malformation intra and extracranial in the head and neck between 2-6%.

• The incidence of Arteriovenous malformation in ORL-HNS Dept Dr. Hasan Sadikin Hospital Bandung from January 2009-December 2013 only one case.

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GROUPS OF AVMS

• There are 3 major groups of AVMs:o Truncal: common in the head, neck, upper limb and

lower limb and pelvis (trunk area).

o Diffuse: common in the lower limbs

o Localized: common in any organ

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SCHOBINGER’S STAGES OF AVMS

•There are Schobinger’s stages of AVMs:o Stage I, lesion has a pinkish-bluish stain and warmth.

o Stage II, the lesion has pulsations, thrill, and bruit.

o Stage III, the patient has dystrophic skin changes,

ulceration, bleeding, and pain.

o Stage IV, the patient has high-output cardiac failure.

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IMAGING

• CT angiography is the best modality for examination of venous and arterial malformations and most commonly used in the classification of vascular malformations, because it able to describe the anatomical relationship of the vascular lesion.

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MANAGEMENT

• Treatment of these lesions poses a challenge to the clinician due to their extreme vascularity and high incidence of recurrence.

• Gold standard for this case is percutaneous puncture embolization which costs quite expensive.

• We made another attempt to manage AVMs

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CASE

Male, 25 years old– since 2 years old has complaining about marble sized lumps on the

back of his ear,– at the age of 12 the lumps became larger and pulsating. – ear ache(+), hearing disorder (-), chronic otorrhoea (-), headache (-),

dizziness (-), fever (-), cough (-).

•Consciousness : Full alert, Blood Pressure : 110/80 mmHg, Heart rate : 82 bpm,

•Respiratory rate : 20 x/minute, body temperature : 36,8 C

•Local Examination Findings :– Right Ear : External Acoustic Canal not hyperemic, discharge (-), ear wax

(-), ear drum intact (+), light con reflex (+), retroauricular not hyperemic

– Left Ear : Hyperemic Mass (+), multiple size pulsating nodule (+), thrill (+), bruit (+), External Acoustic Canal not hyperemic, discharges (-), ear wax (-), ear drum intact (+), light con reflex (+)

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Clinical Picture (2-25-2014)

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Clinical Picture (2-25-2014)

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Examinations

• The Tuning Fork Test

Rinne Test : Positive

Weber Test : No lateralization

• 12-lead ECG Normal

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CT Angiography (2-25-2014)

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JOINT CONFERENCE

• On July 22, 2014 conducted a joint conference between ORL-HNS Dept; Vascular Surgery and Radiology Dept. and decided management for this patient is arterial ligation and sclerotherapy.

Surgical Operation (4-1-2014) 13

CT Angiography (6-26-2014)

CT Angiography (6-26-2014)

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Clinical Picture (6-26-2014)

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Discussion

• Presented a man, 25 years old, suffer with swelling and pulsatile mass of the posterior auricular region of the left ear, since 23 years ago. From CT scan angiography the nidus was found with the main arteries feeding of left branches of the external carotid artery.

• In this patient undergone the combination therapy of ethanol sclerotherapy and ligation of the artery, with good results, in which the 3 months after therapy, the lesions shrank up to 40%.

• Complete eradication may require several treatment sessions during which complications should be minimized with careful techniques.

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Thank You 18