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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