head JofIMAB
Journal of IMAB - Annual Proceeding (Scientific Papers)
Publisher: Peytchinski Publishing
ISSN: 1312-773X (Online)
Issue: 2017, vol. 23, issue 3
Subject Area: Medicine
DOI: 10.5272/jimab.2017233.1657
Published online: 31 August 2017

Case report

J of IMAB 2017 Jul-Sep;23(3):1657-1666
BILATERAL TORTUOUS INTERNAL CAROTID ARTERIES – a case report, otorhinolaryngologic and general clinical implications
Klaudia Ziółkowska1ORCID logo Corresponding Autoremail, Chavdar Bachvarov2ORCID logo, Nicolay Sapundzhiev3ORCID logo, Petia Genova3ORCID logo,
1) Collegium Medicum in Bydgoszcz, Faculty of Medicine, Nicolaus Copernicus University in Torun, Poland
2) Department of Radiology, Saint Marina Varna Hospital, Bulgaria
3) Department of ENT, Medical University in Varna, Saint Marina Varna Hospital, Bulgaria.

Variations in the anatomical course of the cervical portion of the internal carotid arteries appear to be more common than expected and recognised, reaching a prevalence of 10-43%. A case of atypical course of both internal carotid arteries with medial transposition is described. The general clinical implications are presented in the base of review the literature.
In an otherwise healthy adult female pulsating masses on the posterior oropharyngeal wall were observed on transnasal endoscopy for other indications. Contrast enhanced computer tomography revealed bilateral symmetrical tortuous internal carotids, angulated medially at the level of C2 and almost contacting in the midline. However, no significant stenosis was ascertained within any of the evaluated arteries. The patient was informed about potential risk during the prospective surgical procedures around the pharyngeal area. Carotid tortuosity may present a potential threat in otolaryngological surgery. Whereas no symptoms occur in the most of the patients and the condition can be an accidental finding during physical examination as well as endoscopic or radiological evaluation, the frequency in the general population is higher than assumed.  The treatment is not indispensable, however, setting down in the patient’s medical history is important. Medical specialists should keep in mind that aberrant internal carotid arteries pose a risk of severe haemorrhage when even routine surgical or diagnostic procedures within the head and neck region are performed.

Keywords: internal carotid arteries, tortuosity, oropharynx, retropharyngeal pulsation,

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Please cite this article in PubMed Style or AMA (American Medical Association) Style:
Ziółkowska K, Bachvarov Ch, Sapundzhiev N, Genova P. Bilateral tortuous internal carotid arteries – a case report, otorhinolaryngologic and general clinical implications. J of IMAB. 2017 Jul-Sep;23(3):1657-1666. DOI: 10.5272/jimab.2017233.1657

Corresponding AutorCorrespondence to: Klaudia Ziółkowska, Department of ENT, University Hospital Saint Marina Varna; 1, Hristo Smirnenski Blvd, 9010 Varna, Bulgaria; E-mail: klaudia.ziolko92@gmail.com

1. Gupta A, Shah AD, Zhang Z, Phillips CD, Young RJ. Variability in the position of the retropharyngeal internal carotid artery. Laryngoscope. 2013 Feb;123(2):401-3. [PubMed] [CrossRef]
2. Togay-Isikay C, Kim J, Betterman K, Andrews C, Meads D, Tesh P, et al. Carotid artery tortuosity, kinking, coiling: stroke risk factor, marker, or curiosity? Acta Neurol Belg. 2005 Jun;105(2):68-72. [PubMed]
3. Zenteno M, Vinuela F, Moscote-Salazar LR, Alvis-Miranda H, Zavaleta R, Flores A, et al. Clinical implications of internal carotid artery tortuosity, kinking and coiling: a systematic review. Romanian J Neurosurgery. 2014; 21(1):50-59.
4. Bissacco D, Domanin M, Schinco G, Gabrielli L. Bovine Aortic Arch and Bilateral Retroesophageal Course of Common Carotid Arteries in a Symptomatic Patient. Vasc Specialist Int. 2016 Sep;32(3):133-136. [PubMed] [CrossRef]
5. Clarуs P, Bandos R, Gilea I, Clarуs A Jr, Capdevila A, Garcнa Rodrнguez J, et al. Major congenital anomalies of the internal carotid artery: agenesis, aplasia and hypoplasia. Int J Pediatr Otorhinolaryngol. 1999 Jun 15;49(1):69-76. [PubMed] [CrossRef]
6. Fix TJ, Daffner RH, Deeb ZL. Carotid transposition: another cause of wide retropharyngeal soft tissues. AJR Am J Roentgenol. 1996 Nov;167(5):1305-7. [PubMed] [CrossRef]
7.Gossner J, Manka R, Larsen J. Aberrations of the Cervical Carotid Artery Which May Be Dangerous in Pharyngeal Surgery--A Computed Tomographic Study. Advances in Computed Tomography. 2013;  2:29-33. [CrossRef]
8. Munoz A, De Vergas J, Crespo J. Imaging and clinical findings in patients with aberrant course of the cervical internal carotid arteries. Open Neuroimag J. 2010 Nov 5;4:174-81. [PubMed] [CrossRef]
9. Paulsen F, Tillmann B, Christofides C, Richter W, Koebke J. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications.  J Anat. 2000 Oct;197 Pt 3:373-81. [PubMed] [CrossRef]
10. Prokopakis EP, Bourolias CA, Bizaki AJ, Karampekios SK, Velegrakis GA, Bizakis JG. Ectopic internal carotid artery presenting as an oropharyngeal mass. Head Face Med. 2008 Aug 26;4:20. [PubMed] [CrossRef]
11. Bochenek A, Reicher M. Anatomia człowieka. Podręcznik dla studentów i lekarzy. Tom 5. Red. Warszawa: Wydawnictwo Lekarskie PZWL, 1960. Wydanie IV (I): 230-235, 248-250, 255-268.
12. Drake R, A. Vogl W, Mitchell AWM. Gray’s Anatomy for Students: With Student Consult Online Access, 3e. 3 edition. Philadelphia, PA: Churchill Livingstone. 2014: 1000-1011.
13. Xenos ES, Orr N, Valentino J. Internal Carotid Pseudoaneurysm Associated with Tortuosity after Tonsillectomy: A Case Report. Int J Angiol. 2012 Sep;21(3):159-62. [PubMed] [CrossRef]
14. Wong YS, Ong CT, Sung SF, Wu CS, Hsu YC, Su YH, et al. Association Between Abnormal Course of Carotid Artery and Cerebrovascular Disease. Acta Neurol Taiwan. 2014 Sep;23(3):90-94. [PubMed]
15. Sacco S, Totaro R, Baldassarre M, Carolei A. Morphological variations of the internal carotid artery: Prevalence, characteristics and association with cerebrovascular disease. Int J Angiol. 2007 Summer;16(2):59-61. [PubMed]
16. Ovchinnikov NA, Rao RT, Rao SR. Unilateral congenital elongation of the cervical part of the internal carotid artery with kinking and looping: two case reports and review of the literature. Head Face Med. 2007 Jul 25;3:29. [PubMed] [CrossRef]
17. Radak D, Babić S, Tanasković S, Matić P, Sotirović V, Stevanović P, et al. Are the Carotid Kinking and Coiling Underestimated Entities? Vojnosanit Pregl. 2012 Jul; 69(7): 616-19. [CrossRef]
18. Cairney J. Tortuosity of the cervical segment of the internal carotid artery. J Anat. 1924 Oct;59:87-96. [PubMed]
20. Iwanaga J, Watanabe K, Tsuyoshi S, Tabira Y, Yamaki K. Tortuous Common Carotid Artery: A Report of Four Cases Observed in Cadaveric Dissections. Case Rep Otolaryngol. 2016 (2016), Article ID 2028402, 4 pages. [CrossRef]
21. Bektas D, Caylan R, Korkmaz O, Savaş FS. Acquired and congenital internal carotid artery anomalies in two cases: an important threat for the otolaryngologist. Kulak Burun Bogaz Ihtis Derg. 2004; 13(1-2):35-37
22. Singhal M, Prabhakar N, Rohit MK, Khandelwal N. Retropharyngeal Course of Right Internal Carotid Artery. J Postgrad Med.Edu Res. 2014;48(4):201-202. [CrossRef]
23. Ozgur Z, Celik S, Govsa F, Aktug H, Ozgur T. A Study of the Course of the Internal Carotid Artery in the Parapharyngeal Space and Its Clinical Importance. Eur Arch Otorhinolaryngol. 2007 Dec 1;264(12):1483–89. [PubMed] [CrossRef]
24. Oliviero U, Cocozza M, Picano T, Policino S, Russo N, Fazio S, Coto V, Saccá L. Prevalence of Carotid Kinking and Coiling in a Population at Risk. Vasc Endovasc Surg. 1997 Jan 1;31(1):43-49. [CrossRef]
25. Dungan DH, Heisermann JE. The carotid artery. Embryology, normal anatomy, and physiology. Neuroimag Clin N Am. 1996 Nov;4:789-99.
26. Sadler TW. Langman’s Medical Embryology. 13 edition. Philadelphia: LWW, 2014: 202-207.
27. Matussek VK, Sapundzhiev N, Werner JA, Kaschke O. OrtnerSyndrom - gefährlicheRaritat. HNO-Nachrichten. 2005; 6:36-38.
28. Bhandarkar AM, Nayak R, Chidambaranathan N, Gopinath D. Beware of a Pulsating Oropharynx. BMJ Case Rep. 2014; Nov 25, 2014  [PubMed] [CrossRef]
29. Deshpande SH, Nuchhi AB, Bannur BM, Patil BG. Bilateral Multiple Variations in Carotid Arteries-A Case Report. J Clin Diagn Res. 2015 Dec;9(12):AD01–AD03. [CrossRef]
30. Uchino A, Saito N, Okada Y, Kozawa E, Nishi N, Mizukoshi W, et al. Variation of the Origin of the Left Common Carotid Artery Diagnosed by CT Angiography. Surg Radiol Anat. 2013 May;35(4):339-42. [PubMed] [CrossRef]
31. Jain R, Marotta TR, Redekop G, Anderson DW. Management of aberrant internal carotid artery injury: A real emergency. Otolaryngol Head Neck Surg. 2002 Nov;127(5):470-473.
32. Muderris T, Bercin S, Sevil E, Cetin H, Kiris M. A Potentially Catastrophic Anatomical Variation: Aberrant Internal Carotid Artery in the Middle Ear Cavity. Case Rep Otolaryngol. 2013; 2013:743021. [PubMed] [CrossRef]
33. Cvetko E. Concurrence of bilateral kinking of the extracranial part of the internal carotid artery with coiling and tortuosity of the external carotid artery – a case report. Rom J Morphol Embryol. 2014;55(2):433–435.
34. Vinnakota S, Nandagiri B, Neelee J. A rare association of curving and looping of internal carotid artery and variation in the branching pattern of the external carotid artery – a case report. Int J Biol Med Res. 2011; 2(3): 822-823.
35. Virvilis D, Koullias G, Labropoulos N. Bilateral retroesophageal course of the carotid arteries. J Vasc Surg. 2013 May 1;57(5):1395-97. [PubMed]
36. Tsamis A, Krawiec JT, Vorp DA. Elastin and collagen fibre microstructure of the human aorta in ageing and disease: a review. J R Soc Interface. 2013 Mar 27;10(83):20121004 [PubMed] [CrossRef]
37. La Barbera G, La Marca G, Martino A, Lo Verde R, Valentino F, Lipari D, Peri G, Cappello F, Valentino B. Kinking, coiling, and tortuosity of extracranial internal carotid artery: is it the effect of a metaplasia? Surg Radiol Anat. 2006 Dec;28(6):573–580.
38. Han HC. Twisted blood vessels: symptoms, etiology and biomechanical mechanisms. J Vasc Res. 2012;49(3):185–197.
39. Wang L, Zhao F, Wang D, Hu S, Liu J, Zhou Z, et al. Pressure Drop in Tortuosity/Kinking of the Internal Carotid Artery: Simulation and Clinical Investigation. Biomed Res Int. 2016; 2016:2428970 [PubMed]
40. Hao JH, Zhang LY, Lin K, Liu WD, Zhang SG, Wang JY, Li G, Wang LX. Surgical Revascularization of Symptomatic Kinking of the Internal Carotid Artery. Vasc Endovasc Sur. 2016 Oct;50(7):470-474.
41. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Ferranti S, et al. Heart Disease and Stroke Statistics-2015 Update: A Report from the American Heart Association. Circulation 2015 Jan 27;131(4): e114,e119.
42. Tse GG, Masuda EM, McMurtray AM, Nakamoto BK. Coiled internal carotid arteries associated with bilateral sequential strokes. Case Rep Vasc Med. 2013; 2013:929530. [PubMed] [CrossRef]
43. Shihada R, Goldsher M, Braun J, Luntz M. Aberrant Carotid Artery as an Incidental Finding before Tonsillectomy. Ear Nose Throat J. 2010 May;89(5):E17-18. [PubMed]
44. Marcucci C, Thomas P, Sewell DA.  Retropharyngeal Carotid Artery: An Important Anatomic Variation for the Anesthesiologist. Anesthesiology. 2009 Aug 1;111(2):454-455. [CrossRef]
45. Picel AC, Davidson TM. An Aberrant Internal Carotid Artery Discovered during Evaluation of Obstructive Sleep Apnea: A Report of 2 Cases with Consideration of a Possible Association. Ear Nose Throat J. 2011 Jan;90(1):29-31. [PubMed]
46. Beriat GK, Ezerarslan H, Kocatürk S, Mıhmanoğlu AF, Kuralay E. Pulsatile oropharyngeal and neck mass caused by bilateral tortuous internal carotid artery: a case report. Kulak Burun Bogaz Ihtis Derg. 2010 Sep-Oct;20(5):260-3 [PubMed]
47. Galletti B, Bucolo S, Abbate G, Calabrese G, Romano G, Quattrocchi C, et al. Internal carotid artery transposition as risk factor in pharyngeal surgery. Laryngoscope. 2002 Oct;112(10):1845-8. [PubMed] [CrossRef]
48. Uzun L, Eğilmez OK, Kalcioglu MT, Tekin M. Tortuous Carotid Artery Extended to Neck Level IIb Mimicking the Metastatic Mass. Case Rep Otolaryngol. 2016;2016:1376926. [PubMed] [CrossRef]
49. Tanaka H, Patel U, Shrier DA, Coniglio JU. Pseudoaneurysm of the Petrous Internal Carotid Artery after Skull Base Infection and Prevertebral Abscess Drainage. AJNR Am J Neuroradiol. 1998 Mar;19(3):502-4. [PubMed]
50. Zenteno MA, Santos-Franco JA, Moscote-Salazar LR, Lee A. Endovascular remodeling of tortuous cervical segments of the internal carotid artery that hinder the management of complex intracranial aneurysms. Rom Neuro. 2013 Sep;20(3):249-259. [CrossRef]
51. Nayak SB. Unusual Looping of the Internal Carotid Artery in Relation to an Enlarged Lymph Node. Int J Anat Var. 2010 Jan 1;3:84-85.
52. Windfuhr JP. An Aberrant Artery as a Cause of Massive Bleeding Following Adenoidectomy. J Laryngol Otol. 2002 Apr;116(4):299-300. [PubMed]
53. Agrawal R, Agrawal SK. Dangerous anatomic variation of internal carotid artery – a rare case report. Int J Anat Var. 2011; 4:174–76.
54. Wakao N, Takeuchi M, Nishimura M, Riew KD, Kamiya M, Hirasawa A, et al. Risks for Vascular Injury During Anterior Cervical Spine Surgery: Prevalence of a Medial Loop of Vertebral Artery and Internal Carotid Artery. Spine (Phila Pa 1976). 2016 Feb;41(4):293-8. [PubMed].

Received: 14 May 2017
Published online: 31 August 2017

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