What is the appropriate evaluation and management for an incidentally discovered jugular bulb lateral diverticulum in an asymptomatic adult?

Jugular Bulb Lateral Diverticulum: Evaluation and Management

Asymptomatic Incidental Finding

For an incidentally discovered jugular bulb lateral diverticulum in an asymptomatic adult, no intervention is required—observation alone is appropriate. 1, 2

Understanding the Anatomy

A jugular bulb diverticulum represents an extraluminal outpouching from the jugular bulb, which is the venous structure connecting the sigmoid sinus to the internal jugular vein. 3 These diverticula can extend in two directions:

• Lateral extension: Into the tympanic cavity or external auditory canal 2
• Medial extension: Toward the petrous pyramid near the inner ear 2

Clinical Significance

When Asymptomatic

Most jugular bulb diverticula are benign anatomic variants that require no treatment when discovered incidentally. 1, 4 The key is confirming the patient truly has no symptoms.

When Symptomatic

Symptoms depend on the direction of extension:

Lateral diverticula may cause: 2

• Conductive hearing loss
• Pulsatile tinnitus
• Visible retrotympanic mass on otoscopy

Medial diverticula may cause: 2

• Sensorineural hearing loss
• Pulsatile tinnitus
• Vertigo

Diagnostic Imaging

Initial Evaluation

High-resolution temporal bone CT without contrast is the imaging modality of choice for characterizing jugular bulb abnormalities, including diverticula and bony dehiscence. 5, 1

Additional Imaging Considerations

• CT angiography (CTA) can assess for dehiscence of the sigmoid plate or jugular bulb using bone algorithms 5
• MRI/MRA may be useful if soft tissue characterization is needed or to exclude other causes of symptoms 5

Management Algorithm

For Asymptomatic Patients (Incidental Finding)

1. Confirm absence of symptoms: Specifically assess for pulsatile tinnitus, hearing loss, or vertigo 1, 2
2. Document the finding on imaging
3. Counsel the patient: Advise against inserting sharp objects into the ear due to risk of vascular injury 4
4. No routine follow-up imaging is required

For Symptomatic Patients

1. Perform otoscopic examination to identify any retrotympanic mass 1
2. Obtain audiometry if hearing loss is present 2
3. Consider vestibular testing if vertigo is present 6
4. Refer to otolaryngology for management decisions

Intervention Indications

Intervention is only warranted when: 7, 4

• Active hemorrhage occurs (rare, typically during middle ear surgery)
• Severe symptomatic compression of adjacent structures
• Planned middle ear surgery where the diverticulum poses surgical risk

Endovascular embolization has been successfully used for hemorrhagic complications. 7

Critical Pitfalls to Avoid

Surgical Risk

The most important complication risk is inadvertent injury during middle ear procedures (myringotomy, tympanoplasty), which can cause massive bleeding. 7, 4 Always review preoperative imaging before any middle ear surgery.

Misdiagnosis

A jugular bulb diverticulum with bony dehiscence can mimic:

• Paraganglioma (glomus tumor) 1
• Vascular middle ear tumor 1
• Other causes of pulsatile tinnitus 1

High-resolution CT reliably distinguishes these entities by demonstrating the venous origin and connection to the jugular bulb. 5

Inappropriate Intervention

Do not perform biopsy or instrumentation of a suspected vascular retrotympanic mass without imaging confirmation of its nature. 4

Differential Diagnosis Context

When evaluating pulsatile tinnitus or retrotympanic masses, consider the broader differential including: 1

• Sigmoid sinus diverticulum
• High jugular bulb (without diverticulum)
• Paragangliomas
• Dural arteriovenous fistulas
• Superior semicircular canal dehiscence

Temporal bone CT effectively differentiates these vascular and bony abnormalities. 5, 1