Bilateral Aberrant Internal Carotid Artery

A 75-year-old woman with Parkinson disease presented with complaints of a weak voice that had been worsening as her Parkinson disease progressed. She had been working with speech pathology with only minimal improvement in her vocal quality and volume.

On examination under fiberoptic laryngoscopy through the right nares, an incidental note was made of bilateral pulsating masses from the level of her larynx extending up into her nasopharynx (figure 1). Particularly on the right, which was the more prominent side, the mass was nearly in the midline. The pulsations were noted to be synchronous with the patient's heartbeat. High-resolution computed tomography (CT) confirmed the impression that these pulsating masses were in fact aberrantly positioned internal carotid arteries (figure 2).

Figure 1.

A: The fiberoptic camera is positioned at the level of the oropharynx looking down toward the larynx, which can be seen distally. Note the large masses on each side of the pharynx. B: In this view, the camera is positioned at the level of the nasopharynx looking down into the oropharynx. Note the large mass extending up into the nasopharynx ceiling and how the body of the mass extends medially.

Figure 2.

A: This CT scan corresponds with the view shown in figure 1, A. Note the medially displaced internal carotid artery bilaterally. B: This CT scan corresponds with the view shown in figure 1, B. Note the medially displaced right internal carotid artery almost to the midline.

No further intervention was required, but this incidental finding did stress the due diligence required whenever one is performing procedures in the nasopharynx down to the hypopharynx (e.g., adenoidectomy, tonsillectomy). Failure to recognize midline pharyngeal pulsations indicating a medially displaced internal carotid artery could result in disastrous bleeding.

Regarding the patient's original complaint of a weak voice, further sessions with speech pathology were recommended. However, she did not pursue speech therapy.