Aberrant internal carotid artery (ICA) is a rare congenital vascular anomaly where the artery takes an atypical course through the temporal bone and middle ear cavity. Its co-existence with chronic suppurative otitis media (CSOM), a persistent inflammatory disease of the middle ear and mastoid cavity, creates complex diagnostic and therapeutic challenges. This case report presents a 37-year-old female with a 14-year history of CSOM accompanied by pulsatile tinnitus and progressive conductive hearing loss. High-resolution CT and MRI confirmed the presence of an aberrant ICA traversing the tympanic cavity, closely related to the ossicular chain and tympanic membrane.The clinical examination included tuning fork tests which indicated right-sided conductive hearing loss, supported by audiometric findings revealing moderate conductive hearing loss in both ears. The right ear audiogram showed consistent thresholds around 60 dB HL, with absent responses at high frequencies, necessitating careful interpretation to rule out mixed hearing pathology. A multidisciplinary team including otolaryngologists, radiologists, and an audiologist collaborated to manage this case conservatively to avoid catastrophic intraoperative bleeding.This case underscores the critical role of comprehensive imaging, detailed audiological evaluation, and collaborative planning in managing such complex otologic conditions. Early identification of vascular anomalies like an aberrant ICA can dramatically alter surgical decisions and outcomes.

Dr. Deepanshu Mishra is a dedicated resident doctor in the Department of Otorhinolaryngology at R. D. Gardi Medical College and Ujjain Charitable Hospital, located in the historic city of Ujjain, Madhya Pradesh, India. He is currently honing his clinical and surgical expertise under the esteemed mentorship of Dr. Sudhakar Vaidhya, one of India’s most respected and skilled ENT surgeons, admired for both surgical finesse and academic excellence.Driven by a passion for precision- based ENT care, Dr. Mishra has been actively involved in the management of diverse cases ranging from advanced otology and rhinology to head & neck pathologies. His keen interest in research, patient-centered care, and evidence-based clinical practice reflects his commitment to shaping modern ENT practice.