Dysphagia in a 73 year old African American Female Due to an Aberrant Course of Internal Carotid Artery: A Case Report

Abstract

Purpose: The prevalence of oropharyngeal dysphagia amongst individuals older than 50 years of age is 15- 22%, which predisposes them to multiple complications like aspiration, malnutrition and even death. Unlike esophageal dysphagia, oropharyngeal dysphagia is more commonly attributed to functional causes rather than mucosal and structural aberration. We are reporting a rare case of oropharyngeal dysphagia in a 73 year old African American Female (AAF) caused by aberrant right internal carotid artery. Methods: Our patient was a 73 y/o AAF who presented to the ED for evaluation of difficulty in swallowing solids and liquids for one week duration. This was a new onset that was gradually progressive with an intermittent and painless difficulty in swallowing of solids more than liquids with a subsequent sensation of choking and shortness of breath. She stated that despite a good appetite her oral intake has been poor over the past week. No loss of weight and appetite, no chest pain, fever, abdominal or other neurological complaints. Patient had history of hypertension, dyslipidemia and asthma. She had allergy to penicillin and shellfish. She was an ex smoker and did not abuse alcohol or illicit drugs. Her initial vital was stable. Results: Multiple specialties were involved in the care of the patient due to the unclear etiology of dysphagia. A CT scan of the soft tissue of the neck showed a protuberance in the region of the right piriform sinus. Later, an MRA of the neck showed deviation of the proximal right internal carotid artery medially. The proximal portion of the right internal carotid artery deviating medially which resulted in moderate bulging in the mucosa at the level of right pyriform sinus and aryepiglottic folds.The cause of dysphagia was further investigated by modified barium swallow which showed no abnormality in any phases of deglutition. The direct laryngoscopy performed by the ENT specialist showed no anatomical abnormality or foreign body of pharynx or larynx.Gastroenterology team performed an esophagogastroduodenoscopy which showed hiatal hernia and gastritis but no mechanical obstruction of the esophagus. Conclusion: There have been several reports on variation of extracranial portion of Internal Carotid Artery (ICA) that can be of surgical significance but only a few symptomatic cases have been reported. Investigators described the restricted classification for cervical ICAs anomalies which may help radiologist to differentiate actual cervical ICA aberrancy from variations in shape and trajectory. According to their classification our patient had Grade B 1 aberrancy of internal carotid artery which was possibly the cause of dysphagia.