Aberrant Course of the Internal Carotid Artery in Surgery of Adenoids and Tonsils

Abstract

Tonsillectomy and adenoidectomy are among the most common operations performed woldwide. Improvements in anesthesia and surgical techniques over the years have made these operations relatively safe, yet the potential exists for serious complications and even death if the surgeon fails to recognize arterial abnormalities and variations such as the aberrant course of the internal carotid artery. We present a case of an aberrant course of the internal carotid artery which was discovered during adenotonsillectomy in a seven-year-old boy. The significance of the condition and its recognition are discussed. Otolaryngologists should be cognisant of such abnormalities and the serious complications they may cause. Case ReportA seven-year-old boy with a history of recurrent adenotonsillitis was admitted for adenotonsillectomy under general anesthesia. There was no history of systemic disease, previous surgery or bleeding tendency. Clinical examination was unremarkable except the tonsils which were enlarged. Pre-operative investigations including coagulation profile were within normal limits.The operation was performed under general anesthesia with endotracheal tube. The adenoid was removed by currette, but excessive bleeding was encountered after the operation. Temporary application of nasopharyngeal pack for about 10 minutes was necessary to control the bleeding. During re-examination of the post-nasal space, a pulsating mass was seen extending from the upper pole of the left tonsil to the base of the skull. Tonsillectomy was not performed and the procedure was terminated in order to avoid injury. The patient had an uneventful postoperative course and the relatives were informed about the intraoperative findings. Angiography and magnetic resonance (MR) imaging revealed an aberrant course of the internal carotid artery (Figure 1).

Magnetic Resonance Imaging Evaluation of Distance Between Adenoid Tissue and Internal Carotid Artery in Children With Adenoid Hypertrophy

“…For posttonsillectomy bleeding, massive bleeding was detected from mainly arterial origin (lingual or facial artery). Massive venous bleeding was also reported to be related to large venous varicosity 15 . Devastating bleeding due to an injury to aberrant ICA during routine nasopharyngeal surgery such as adenoidectomy has been reported in the literature 12,16–18 .…”

“…Where the artery is very curvy or redundant in the cervical course, ICA may be in close contact with the superior pharyngeal constrictor muscle 26 . The proximity of the artery and tonsil bed will put the artery at risk during adenotonsillectomy 15 …”

“…Massive venous bleeding was also reported to be related to large venous varicosity. 15 Devastating bleeding due to an injury to aberrant ICA during routine nasopharyngeal surgery such as adenoidectomy has been reported in the literature. 12,[16][17][18] Serious complications during eustachian tuboplasty (ET) occurred by not appreciating the proximity of the ICA to the ET.…”

“…Arterial variations of the cervical part of the ICA include the following: (1) occipital lingual or ascending pharyngeal arteries can arise from it, (2) ICA may arise directly from the aortic arch or innominate artery, (3) complete absence of artery, and (4) can be arterial and may be redundant or tortuous. 15 Life-threatening bleeding may occur because of nasopharyngeal ICA aberrancy during routine nasopharyngeal surgery. 22 Under normal conditions, the ICA is located 2 to 3 cm posterolateral of the pharyngeal mucosa and the superior constrictor muscle separating the artery from the palatine tonsil.…”

“…Group 2 (10-15 years of age): 50 boys and 50 girls (n = 100). The mean age was 12.25 ± 1.70 years (range, [10][11][12][13][14][15].…”