I read with great interest an article by W oodhouse et al. about spontaneous superficial temporal artery pseudoaneurysm mimicking as a parotid mass. The case is very interesting but I have two observations on article.

First, in the case report there is no information whether patient experienced in the past parotid inflammation. This is important because it could explain the formation of pseudoaneurysm. Not only trauma but also infection or severe atherosclerosis could lead to pseudoaneurysm formation. Because of close relationship of the parotid gland with external carotid artery and its terminal branch superficial temporal artery, an infection in this area could be transferred to the vessel wall and thus weaken it. After the infection subsides what is left is vulnerable vessel wall. With this repetitive Valsalva maneuvers the pressure inside the lumen of the vessel increases and the vessel wall eventually partially ruptures.

Second, I do not agree with the treatment presented in this article. Obviously the formation of the pseudoaneurysm is related to Valsalva maneuvers or in other words to periodically increasing pressure inside the chest. With every Valsalva maneuver the systolic blood pressure rises above normal initially and at the end of the maneuver. This condition is practically present in various situations in everyday life like lifting heavy object or strenuous physical exercise , defecation while constipated, micturition in obstructive disorders, normalizing middle ear pressures when ambient conditions change (e.g. diving or aviation).

Leaving a patient with a pseudoaneurysm that responds to rise in blood pressure could potentially lead into pseudoaneurysm dilation or even worse, blow out and severe hemorrhage. It is similar to leaving a patient with cerebral aneurysm untreated. So I do not agree that observation in this case is enough, surgical or radiological intervention should be undertaken.