|IMAGES IN CLINICAL MEDICINE
|Ahead of print publication
Yew Toong Liew, Andrew Charles Gomez Junior, Adzreil Bakri, Prepageran Narayanan
Department of Otorhinolaryngology, Faculty of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
|Date of Submission||01-Nov-2019|
|Date of Acceptance||30-Dec-2019|
|Date of Web Publication||01-Apr-2020|
Yew Toong Liew,
Department of Otorhinolaryngology, Faculty of Medicine, University Malaya Medical Centre, Kuala Lumpur 50603
Source of Support: None, Conflict of Interest: None
A 65-year-old female was referred to our otolaryngology clinic by anesthetic clinic for the assessment of her dysphagia for 3 months. She underwent anesthetic assessment as per hospital protocol before a planned surgery under general anesthesia for her posterior upper torso lipoma. She denied symptoms of weight and appetite loss. However, she felt a persistent globus sensation on her right side of the throat. Endoscopic examination showed a pulsatile mass at the right posterior pharyngeal wall with smooth surface and round contour [Video 1]. Computed tomography arteriogram noticed a bended tortuous right internal carotid artery indenting on the right posterolateral pharyngeal wall [Figure 1], [Figure 2], [Figure 3]. There have been reported cases of carotid artery anomalies such as aberrant and agenesis of the carotid artery, but tortuosity of the carotid artery has rarely been seen. It is believed that acquired causes such as atherosclerosis, hypertension, and other peripheral vascular diseases could contribute to the formation of tortuosity. The congenital reason may explain the incidence in the younger age group. Our patient was diagnosed to have Type II diabetes and hypertension recently but was not compliant on the treatment. This incidence was mostly on the right side and among females, in most of the cases reported. The most common clinical presentation was abnormal sensation in the throat. Atypical symptoms included temporal blindness, stroke, lingual spasm, and vertigo,. It was suggested that surgical reconstruction could help relieve the symptoms and may prevent future risk of ischemic stroke. However, most articles were underpowered. She was managed conservatively with speech and language input with advice regarding food textures and swallowing techniques. Simultaneously, expert consultation was acquired from the endocrinology team in managing her comorbidities with strict control. The tortuous internal carotid artery is a risk factor for any pharyngeal procedures. Endotracheal intubation or even insertion of laryngeal mask could lead to disastrous outcome. Her planned surgery under general anesthesia was, therefore, cancelled in view of the risks mentioned. In conclusion, most head-and-neck surgeons should recognize this rare anomaly as any pharyngeal procedure can lead to devastating complications.
|Figure 1: Coronal computed tomography angiogram shows a severe tortuous internal carotid artery impinging on the right pharyngeal wall (arrow)|
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|Figure 2: Axial computed tomography angiogram shows the anomaly at the right posterolateral of the pharyngeal wall|
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|Figure 3: Reconstructed computed tomography angiogram showing obvious asymmetry of both internal carotid arteries where the right has more tortuous course|
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Declaration of patient consent
The authors certify that an appropriate patient consent form has been obtained. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity.
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Conflicts of interest
There are no conflicts of interests.
| References|| |
Weibel J, Fields WS. Tortuosity, coiling, and kinking of the internal carotid artery. I. Etiology and radiographic anatomy. Neurology 1965;15:7-18.
Hosokawa S, Mineta H. Tortuous internal carotid artery presenting as a pharyngeal mass. J Laryngol Otol 2010;124:1033-6.
Wahba M. Lingual spasms associated with internal carotid artery tortuosity. Arch Neurol Neurosci 2019;2:1-3.
Yu J, Qu L, Xu B, Wang S, Li C, Xu X, et al.
Current understanding of dolichoarteriopathies of the internal carotid artery: A review. Int J Med Sci 2017;14:772-84.
Togay-Işikay C, Kim J, Betterman K, Andrews C, Meads D, Tesh P, et al.
Carotid artery tortuosity, kinking, coiling: Stroke risk factor, marker, or curiosity? Acta Neurol Belg 2005;105:68-72.
[Figure 1], [Figure 2], [Figure 3]