Learning Objectives: A high jugular bulb is a common vascular anomaly and the possibility of dehiscence should always be anticipated when pre-operative imaging is not available. If it is accidentally damaged and bleeding occurs, the ear should be packed and the procedure abandoned.

Introduction: Anatomic variations of the venous sinuses of the dura mater, however infrequent, may present puzzling diagnostic and operative problems. A high dehiscent jugular bulb is one of the most common and if not anticipated can present a hazard when performing middle ear surgery.

Method: We report the case a 10 year old girl with bilateral dry central tympanic membrane perforations who was admitted for right tympanoplasty. Through a post-aural approach temporalis fascia was harvested and the edges of the perforation freshened. A tympano-meatal flap was raised and as the annulus was lifted a sudden gush of blood ensued. A dehiscent jugular bulb was recognised. Instead of simply packing the ear and abandoning the procedure a decision was made to explore the mastoid in an attempt to control bleeding by compressing the sigmoid sinus so that the procedure could be completed. This greatly worsened the problem as the sigmoid sinus was huge, dehiscent and totally filling the mastoid. This started to bleed even more profusely. Telephone advice was sought from an eminent skull base surgeon who warned that an attempt to occlude the sigmoid sinus could compromise cerebral venous drainage if the contralateral sinus was vestigial. He advised the use of Floseal, Sugicel, crushed temporalis muscle and bone wax. Haemostasis was rapidly achieved and the tympanoplasty completed.

Result: Post-operative recovery was uneventful. Successful cloure of the perforation and improved hearing was achieved. Subsequent CT scanning showed good venous flow bilaterally (images).

Conclusion: A high jugular bulb is a common vascular anomaly and the possibility of dehiscence should always be considered when pre-operative imaging is not available. The decision to open the mastoid instead of simply packing the ear canal and abandoning the procedure was misguided and could easily have resulted in serious complications. It should not have been considered in the absence of pre-operative imaging.