Recurrent Facial Palsy Due to High Jugular Bulb Dehiscence

BACKGROUND: A high mega jugular Bulb is an enlarged and swollen upper portion of the internal jugular vein with a variation of its anatomical position among the population, mostly situated below the hypotympanum. Although most cases of jugular bulb diverticulum are asymptomatic, excessive pressure on the surrounding structures might cause various symptoms, most prominently vertigo, sensorineural hearing loss, or tinnitus. CASE REPORT: A middle-aged male who was referred to the Department of Neurology with a recurrent complaint of left-sided facial weakness associated with headache and vertigo for a period of 24 months. His symptoms were episodic, furthermore exacerbated by visiting high altitude sites. Non-resolving with conventional medical treatment. After thorough investigation, including preoperative and postoperative audiograms, neuroimaging, including computed tomography as well as magnetic resonance angiography, he was diagnosed to have right-sided superior mega jugular bulb as a causative factor. After surgical management, the patient improved significantly. At his regular follow-up in our clinic there were no exacerbations of his symptoms. CONCLUSION: Among patients who present with recurrent non-resolving facial palsy in which no apparent causative factor is identified, high jugular bulb should be suspected and investigated. Comprehensive and detailed medical history is essential for raising the suspicion for the diagnosis. Such as the case presented eliciting high altitudes as the main precipitating factor. The diagnosis is clinically elusive, commonly obscured by other common diagnoses. Surgery is recommended if antihypertensive drugs do not show improvement.