Recurrent epistaxis as a red flag for petrous ICA pseudoaneurysm in malignant otitis externa: a case report

Abstract Background Malignant otitis externa (MOE) can extend to the skull base and rarely cause internal carotid artery (ICA) pseudoaneurysm, a potentially fatal complication. Recurrent epistaxis in this setting warrants urgent vascular evaluation. Case presentation A 63-year-old man with diabetes mellitus and chronic kidney disease presented with recurrent spontaneous epistaxis and lower cranial nerve palsies six months after treatment for MOE. MRI revealed a large pseudoaneurysm of the petrous ICA with distal thrombosis and small acute infarcts, while CT demonstrated extensive skull base erosion. Digital subtraction angiography confirmed the pseudoaneurysm, and endovascular coil trapping with parent artery occlusion was performed successfully. The patient remained stable without further bleeding on follow-up. Conclusion Recurrent epistaxis in MOE should raise suspicion for ICA pseudoaneurysm. Prompt imaging and early endovascular treatment are critical to prevent catastrophic hemorrhage.