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PERSISTENT STAPEDIAL ARTERY

Persistent Stapedial Artery (PSA): "The Persistent Stapedial Artery (PSA) is a rare congenital vascular anomaly that occurs when the embryologic stapedial artery fails to regress during fetal development. Normally, the stapedial artery, which originates from the second aortic arch, plays a crucial role in supplying blood to the structures of the first and second pharyngeal arches during early development. By the eighth week of gestation, this artery typically regresses, and its role is replaced by branches of the external carotid artery, primarily the middle meningeal artery. In cases where this regression does not happen, the PSA persists and takes an abnormal course through the middle ear, passing over the stapes bone. Anatomically, this can result in the PSA entering the middle ear cavity via the obturator foramen of the stapes and continuing anteriorly, where it may anastomose with the internal maxillary artery to supply the middle meningeal artery. Clinical Presentation Most cases of PSA are asymptomatic and discovered incidentally during imaging for other conditions. However, when symptomatic, patients may present with conductive hearing loss due to the presence of the pulsatile artery in the middle ear. Less commonly, tinnitus can occur because of the vascular anomaly. A key clinical implication is the increased risk of hemorrhage during middle ear surgeries, such as stapedectomy or cochlear implantation, if the PSA is not identified preoperatively. diagnosis, imaging plays a vital role: **CT Scan**: High-resolution CT imaging is the gold standard for detecting PSA, showing an aberrant vascular channel coursing through the middle ear and over the stapes. It may also reveal an absent foramen spinosum and a double-sized facial canal, which are critical diagnostic clues. **MRI/MRA**: MRI helps to further delineate the vascular nature of the PSA and its anatomical course. **Angiography**: Digital subtraction angiography provides a detailed view of the PSA and its vascular connections, which is particularly useful in surgical planning. *Differential Diagnosis:* When evaluating a suspected PSA, it’s important to differentiate it from other vascular anomalies such as: **Aberrant Internal Carotid Artery**: Which may take an abnormal course through the middle ear. **Dehiscent Jugular Bulb**: An enlarged jugular bulb that can protrude into the middle ear. **Glomus Tympanicum Tumors**: Vascular tumors in the middle ear that can mimic PSA. **Facial Nerve Anomalies**: Variations in the course of the facial nerve that can present similarly. *Management:* Management of PSA is generally conservative if the patient is asymptomatic. The primary concern is avoiding complications during otologic surgery. Preoperative imaging is crucial to identify the PSA and plan surgeries accordingly. If surgical intervention is necessary, meticulous dissection and vascular control are essential to prevent hemorrhage. For patients with conductive hearing loss, hearing aids or other non-invasive interventions may be considered. *Surgical Implications:* Surgeons must be vigilant about the presence of PSA during middle ear procedures to avoid inadvertent damage to this artery. Detailed preoperative imaging should guide the surgical approach to minimize risks and ensure patient safety. In summary, Persistent Stapedial Artery is an important vascular anomaly to recognize in otologic practice. Awareness, appropriate imaging, and careful surgical planning are key to managing this condition effectively, ensuring the best outcomes for patients.