Aberrations of the Cervical Carotid Artery Which May Be Dangerous in Pharyngeal Surgery—A Computed Tomographic Study

Abstract

Background: There are recognised variations in the anatomical course of the cervical portion of the internal carotid artery. An aberrant vessel with direct contact to the pharyngeal wall could easily be injured during pharyngeal surgery or may appear as a pharyngeal pseudo mass. Previous anatomical studies predominantly involved older patients. The prevalence of such variations which are at risk of injury during pharyngeal surgery has thus not been established in a general patient population. Material and Methods: The course of the internal carotid artery in relation to the oro and hypopharyngeal walls was retrospectively evaluated bilaterally by simple visual inspection and measurement of the smallest distance between the respective vessels and the adjacent mucosal surface of the pharyngeal wall in 138 consecutive contrast-enhanced computed tomography scans of the neck. Results: 11/138 (7.9%) of patients demonstrated relevant cervical carotid artery aberrations, comprising medial kinking of a vessel with asymmetry of the adjacent pharyngeal lumen and/or an intimate submucous course in the pharyngeal wall with no identifiable separating fat plane. This prevalence increased with age. Simple visual inspection correlated well with the measurement of the smallest distance between an artery and the pharyngeal wall, which was statistically significant (p < 0.0001). Conclusions: The prevalence of about 8% in a general patient population is higher than previously recorded in anatomical studies. Prevalence increases with age. Otorhinolaryngologists should be aware of such variation as a risk factor for haemorrhagic complications during pharyngeal surgery and as a differential diagnosis of pharyngeal mass lesions, especially in older patients. Modern contrast-enhanced CT allows identification and characterisation of any surgically relevant variant vascular anatomy in the pre-operative work-up.

BILATERAL TORTUOUS INTERNAL CAROTID ARTERIES – a case report, otorhinolaryngologic and general clinical implications

“…However, there are a lot of discrepancies which arise from differences in the methods, analysed population, terminology, etc. [2, 3,7,8,9,15,17,23].…”

“…At last, an atypical course of the ICAs within the temporal bone can result in nonspecific signs (including hearing loss and tinnitus) or carry a threat of bleeding during the middle ear interventions [31,32]. Many authors have described the hypopharyngeal and oropharyngeal medialization [1,4,7,8,10,21,28,33,44,45,46]. Nonetheless, the reports concerning the epipharyngeal and intratemporal aberrations are noticeably rarer [19,22,31,32].…”

“…As was already remarked by investigators in the last century, the tortuous and atypical extracranial course of the ICAs carries a risk of severe haemorrhage when surgeries are performed, even if they are the common and frequent procedures like tonsillectomy or adenoidectomy [1,10,19,23,44]. To emphasise this problem, several authors have used the term "dangerous loop" with reference to an aberrant cervical part of the ICA that stays at risk during surgeries, maintains direct submucosal course and may cause an appearance of pulsative bulge on the retropharyngeal wall [6,7,8,9]. While the reported profuse bleeding as a result of iatrogenic injury of the tortuous ICAs is a rare complication of head and neck operations in the general population [43], this problem should not be underestimated by physicians.…”

“…The Doppler ultrasound is a useful and non-invasive technique but could make the evaluation more difficult and inadequate [2, 7,10].…”

“…dysphagia, dysphonia, snoring, foreign body sensation in the throat, difficulties in breathing. The term "dangerous loop" is used when this anomaly poses a risk for the surgical procedures performed within the area of the neck [6,7,8,9]. It is compelling for otolaryngologists, radiologists, surgeons, anaesthesiologists and other specialists to keep in mind that this kind of distinctness can be encountered, to distinguish it from other pathologies like aneurysms, neoplasms or abscesses.…”