Description

A 60-year-old female presented with dry cough since 6 months. There was no history of fever, weight loss, anorexia or gastroesophageal reflux disease. There was no history of dysphagia, hoarseness and lump in the throat or peroral bleed. On oropharyngeal examination, there was a pulsatile mass on right posterolateral pharyngeal wall, that is, behind posterior pillar with mild congestion of posterior pharyngeal wall. Doppler sonography revealed tortuous and medial course of right internal carotid artery (ICA). CT angiography disclosed the course of the right extracranial ICA which was seen to loop medially-reaching upto retropharyngeal space, indenting the right posterolateral wall of pharynx at level of palatine tonsils, that is, C2 vertebra (figure 1). Similarly on axial CT section view, this loop of right ICA is bulging into right pharyngeal wall (figure 2). No evidence of aneurysm was noted. Right common carotid and external carotid arteries were anatomically normal. Left ICA was also normal in course. The blood pressure and other general physical examination were normal.

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Figure 1

CT angiographic image depicting the aberrant course of extracranial right internal carotid artery (ICA). Right ICA is seen to loop medially, indenting the right posterolateral wall of pharynx at level of palatine tonsils.

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Figure 2

Axial CT section image showing looping of right ICA and its medial bulge into the right pharyngeal wall.

Common causes of ‘pseudo-tumour’ in retropharyngeal space are various anatomical variants of internal jugular vein, cervical vertebral osteophytes and muscular lesions besides tortuous and medially-deviated course of internal carotid arteries. Incomplete straightening of ICA during embryological development results in the tortuous or aberrant course, wherein it may indent posterolateral pharyngeal wall.1 Such carotid kinking is usually discovered incidentally, during routine head and neck examination. Due to its characteristic location, this anomaly may be confused with unilateral tonsillitis, peritonsillar abscess or parapharyngeal neoplasm. It is extremely important to recognise such an entity before any oropharyngeal surgery, as inadvertent incision may lead to massive haemorrhage and even death.2