aneurysms of the internal carotid artery ( ica ) in the middle ear are uncommon vascular anomalies   and are difficult to detect and treat the causes of aneurysms are multiple and include atherosclerosis and dysplastic , traumatic , and infectious lesions . differential diagnosis should include a glomus tumor ( tympanic , jugular or both ) , or other vascular temporal bone lesions such as a dehiscent jugular bulb , cholesterol granuloma , petrous carotid aneurysm , pseudoaneurysm , arteriovenous malformations or hemangioma . otoscopy may reveal a normal tympanic membrane with a mass in the middle ear that , in some cases , is pulsating . imaging studies are fundamental for diagnosis and can define the nature and origin of these lesions . high resolution computed tomography angiography ( cta ) is the technique of choice and , in some cases , can be complemented with a magnetic resonance angiography ( mra ) . in this article we describe an asymptomatic case of aneurysm of ica treated successfully by middle ear surgery . a 50-year - old female was referred to the emergency room of ent department of cluj- napoca for massive left otorrhagia started a few hours before presentation . there was no medical history of tinnitus , vertigo , otalgia , or otorrhea , or any history of trauma or surgery of the head and neck . recent psychological trauma ( death of her father ) with high blood pressure of 210/100 mm\hg was revealed at presentation . fresh blood flowed out from the left ear during a short period and hemostasis was accomplished with difficulty using compressive cotton balls . release of the compress resulted in relapse of the bleeding . a micro - otoscopic examination of the left ear showed a perforation at the level of the antero - inferior quadrant of the tympanic membrane with a red pulsatile mass . an audiogram revealed a left - sided conductive hearing loss of up to 30 db , whereas tympanometry showed a type c tympanogram with a low amplitude . computed tomography angiography ( cta ) showed an aneurysm of the internal carotid artery protruding into the middle ear and a massive hematoma of the mastoid cells . after the patient had been given a thorough explanation about the risks of ica injury during surgery , she provided an informed consent , and middle ear surgery was performed . a partial mastoidectomy canal wall down with evacuation of the left middle ear hematoma was performed ( figure 1 ) . a complete package of the middle ear and the mastoid cavity with merocel , surgicel , gelfoam and temporalis muscle fascia and a left anterior and posterior nasal package was also performed during surgery . after three days the patient underwent another computed tomography angiography . a complete obstruction by a massive thrombus of the left internal carotid artery at 1.2 cm from the bifurcation to clinoid area was revealed without any focal neurological deficits or stroke ( figure 2 ) . the anterior and posterior nasal package was suppressed two days after surgery . the follow - up magnetic resonance angiography ( mra ) 6 months later revealed the thrombosis of the left ica with new collateral vascularization in the left cerebral territory of ica by circle of willis ( figures 3 and 4 ) . the preponderance of men is clear in the literature , with a male / female ratio of 2:1.3 . the different causes and especially the traumatic lesions explain the relatively young age of this population , 56 years old . aneurysms of the extracranial carotid artery can be partially or completely thrombosed , can cause distal embolization , or compression of adjacent structures , and can be ruptured . before the introduction of antibiotics , dysplastic lesions appeared to be the main cause of aneurysms of the ica . in the experience of lotina et al . depending on the size and location of the aneurysm , the direction of its growth , and the specific adjacent structures involved , patients may or may not present signs and symptoms . our patient direct compression or anterior and posterior nasal package may not be able to stop the bleeding . in that situation a patient may enter a critical condition following hemorrhagic shock or respiratory failure . in our case , the appropriate management strategy for these rare lesions is unclear . in the cases reported until now most patients were treated with revascularization of the carotid artery using vein bypass grafts to reduce the risk of acute ischemic complications , but there are also cases treated without vascularization . successful treatment usually involves selective aneurysm embolization or carotid closure with detachable balloons . in our case middle ear surgery was effective in resolving bleeding and did not cause any permanent neurological deficit . because of the high blood pressure and the thrombosis of the left ica after surgery an antihypertensive ( enalapril 10 mg ) and antithrombotic ( aspirin cardio 100 mg ) chronic medication was mandatory in this case . aneurysms of the ica in the middle ear are rare and difficult to treat because the anatomy of the region and life threatening complications after surgery . otologists should be aware that symptoms and signs such as pulsatile tinnitus , conductive hearing loss , and a pulsatile retrotympanic mass in the anteroinferior part may be related to an ica aneurysm . thus , ica aneurysm , which is asymptomatic most of the time , will be diagnosed during middle ear surgery or a routine otoscopy or complications like otorrhagia . misdiagnosis of the ica aneurysm may lead to serious morbidity because of bleeding or vascular occlusion . long - term follow - up is necessary to look out for delayed post treatment complications .
middle ear aneurysms are rare and difficult to treat . the case of a 50-year - old female who presented with left otorrhagia caused by an internal carotid aneurysm 
 is reported . 
 she had no medical history of tinnitus , vertigo , otalgia or otorrhea . 
 middle ear surgery was effective in resolving bleeding and did not cause any permanent neurological deficit . 
 high resolution computed tomography angiography is the technique of choice and , in some cases , can be complemented with a magnetic resonance angiography . 
 misdiagnosis of the internal carotid artery aneurysm may lead to serious morbidity because of bleeding or vascular occlusion . 
 the use of modern imaging techniques explain the current relative increase in frequency .