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

Abstract

Case ReportsAberrant Course of the Internal Carotid Artery in Surgery of Adenoids and Tonsils Adel A. Banjar, FRCS Shaikh Altaf Hussain, MS Ammar Haoumi, and DIS Mansour R. ShamaniAB Adel A. Banjar Address reprint requests and correspondence to Dr. Banjar: ENT Department, Ohud Hospital, PO Box 779, Madina, Saudi Arabia. E-mail: E-mail Address: [email protected]. From the Departments of Otolaryngology and Radiology, Ohud Hospital, Madina, Saudi Arabia. Search for more papers by this author , Shaikh Altaf Hussain From the Departments of Otolaryngology and Radiology, Ohud Hospital, Madina, Saudi Arabia. Search for more papers by this author , Ammar Haoumi From the Departments of Otolaryngology and Radiology, Ohud Hospital, Madina, Saudi Arabia. Search for more papers by this author , and Mansour R. Shamani From the Departments of Otolaryngology and Radiology, Ohud Hospital, Madina, Saudi Arabia. Search for more papers by this author Published Online::1 Sep 2002https://doi.org/10.5144/0256-4947.2002.344SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTonsillectomy 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).Figure 1. MR angiography (2D-TOF sequence) showing tortuous course with medial convexity of the proximal segment of the left internal artery (arrow).Download FigureDISCUSSIONThe mortality rates of adenotonsillectomy range from about 1 in 16,000 to 1 in 35,000 cases. Excluding anesthetic related deaths, hemorrhage constitutes one of the major causes of deaths.1 The prevalence of hemorrhage with adenotonsillar surgery is reported as occurring in 0.1%-8.1% of the cases, the hemorrhage usually occurring in the postoperative period (primary or secondary) or during the surgery.1 Primary hemorrhage and reactionary hemorrhage occur during the procedure or within the first 24 hours, and secondary hemorrhage or late postoperative bleeding is that which usually occurs between the 1st to the 10th postoperative day.2 Most fatal hemorrhages occur within the first 24 hours postoperatively, but secondary hemorrhages are usually mild.1,2The tonsillar region is richly supplied by the ascending pharyngeal and palatal arteries, descending palatal artery and tonsillar branches of the facial and lingual arteries. Massive hemorrhage is uncommon and is usually attributed to arterial bleeding secondary to the lingual artery or facial artery, although massive venous bleeding due to large venous varicosity has been reported.3Arterial variations of the cervical portion of the internal carotid artery which has been reported include the following: 1) the occipital lingual or ascending pharyngeal arteries may arise from it; 2) the internal carotid artery may arise directly from the aortic arch or from the innominate artery; 3) total absence of the artery; and 4) the artery may be redundant or tortuous.Under normal circumstances, the internal carotid artery is located 2-3 cm posterolateral to the pharyngeal mucosa and the superior constrictor muscle, separating the artery from the palatine tonsil.3,4 Where the vessel is very tortuous or redundant in its cervical course, the internal carotid artery may lie in close contact with the superior pharyngeal constrictor muscle.4 The close proximity of the artery and the tonsillar bed will place the vessel at risk during adenotonsillectomy.Aberrant course of the internal carotid artery has been reported in 1% of patients.1,3 The diagnosis of such an abnormality is established by the identification and palpation of a pulsative tonsil mass or pulsation of the pharyngeal wall,1,5 though conditions such as dilated ascending pharyngeal artery and pulsation of tonsillar vessels in the presence of atrophic pharynx may confuse the diagnosis.4 Catastrophic hemorrhage and even death has been reported from injury to unrecognized aberrant course of the internal carotid artery during adenotonsillectomy or abscess drainage performed by both experienced and inexperienced surgeons.4Laceration of the internal carotid artery usually occurs medially and near the skull base, and transoral repair might be considerable while the management of pseudoaneurysm resulting from injury of the internal carotid artery may need embolization and proximal ligation.1 In our case, the clinical and intraoperative findings supported by the angiographic MR imaging was convenient in diagnosing the abnormality, therefore, conventional angiogram was not requested.Connolly described a similar case to ours, although we could not appreciate the presence of the lesion before the removal of the adenoids. Aberrant course of the internal carotid artery has no age or sex predilection. Shaeffer advocated that careful examination and palpation should be performed in order to judge the nearness of large or aberrant blood vessel. The risk appears when the superior constrictor muscle and the thin buccopharyngeal fascia are inadvertently torn in operative procedures.4 All necessary precautions should be taken to prevent complications arising from the aberrant course of the internal carotid artery, thereby avoiding the mortality associated with the condition.1ARTICLE REFERENCES:1. Randall DA, Hoffer ME. "Complications of tonsillectomy and adenoidectomy" . Otolaryngol Head Neck Surg. 1998; 118:16–8. Google Scholar2. Burstin PP, Hooper RE. "Massive primary hemorrhage during tonsillectomy from a large venous varicosity" . Otolaryngol Head Neck Surg. 1997; 117:287–90. Google Scholar3. Zalzal GH, Cotton RT. Pharyngitis and adenotonsillar disease. In: Cummings CW, Frednickson JM, Harker LA, Krause CJ, Schuller DE, editors. Otolaryngology Head and Neck Surgery, 2nd. edition. St.Louis: Mosby Year book Inc., 1993:1180–98. Google Scholar4. Shaeffer JP. "Aberrant vessels in surgery of palatine and pharyngeal tonsils" . JAMA;1921; 77:14–9. Google Scholar5. Connolly JH. "Large pulsating vessel in the right portion of the posterior pharyngeal wall partly concealed behind the right tonsil in a boy aged five" . Proc Royal Soc Med1914; 7:25–6. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 22, Issue 5-6September-November 2002 Metrics History Received16 February 2002Published online1 September 2002Accepted20 September 2002 InformationCopyright © 2002, Annals of Saudi MedicinePDF download