Preventing the Catastrophe: Aberrant Carotid in Adenoid and Tonsil Surgery:
Two Case Reports

Irshad   M.   Mohiuddin; Sajid      Burud; Mayank      Vats; Deepa      Vats

doi:10.2174/03666211230093409

Abstract

Background: Adenoid and tonsil surgeries are the most commonly done surgical procedures, with haemorrhage being an important complication. Fatalities due to haemorrhage almost never occur, but the occasional devastating outcomes that are life-threatening become a frequent source of litigations and audits. Catastrophic bleeds are usually due to an aberrant vessel or carotid protruding in the pharyngeal airway. The aberrant carotid poses a risk during routine pharyngeal surgeries like adenoidectomy, tonsillectomy, Quincy and Para-pharyngeal abscess drainage, UPPP, pharyngeal biopsies, etc. and injuries during routine pharyngeal surgical procedures can be catastrophic due to massive bleeding.

Case report: We report two cases of routine Adeno-tonsillectomy surgeries where aberrant carotid vessels protruding in the adeno-tonsil surgical area were identified by endoscopic transoral evaluation intraoperatively. The surgery in these cases was postponed for further investigation due to the risk of injury and catastrophic bleeding.

Conclusion: Aberrant carotids are usually clinically silent, and adenoid removal in most cases is a blind procedure done by curettage. There are no guidelines to identify aberrant vessels pre or intraoperatively, and preventing injury and catastrophic bleeding depends on surgeon’s experience and caution.

These cases underline the importance of due vigilance and taking steps before starting the procedures, particularly pre-and intraoperative transoral endoscopic assessment for identifying aberrant vessels in the upper airway area, thus preventing injury and avoiding devastating complications. We report these cases and underline the steps to identify aberrant vessels in the upper airway surgical field before starting surgery to prevent a potentially catastrophic complication.

Keywords: Carotid, Aberrant, Tonsil, Adenoid, Tonsillectomy, Adenoidectomy, Adenotonsillectomy, Surgery.

[1] 
Windfuhr JP, Schloendorff G, Sesterhenn AM, Prescher A, Kremer B. A devastating outcome after adenoidectomy and tonsillectomy: Ideas for improved prevention and management. Otolaryngol Head Neck Surg  2009; 140(2): 191-6.
[http://dx.doi.org/10.1016/j.otohns.2008.11.012] [PMID: 19201287] 
[2] 
Schmiegelow E. A case of primary death after removal of adenoid tissue. MschrOhrenheilk  1897; 31: 115.
[http://dx.doi.org/10.1016/S0140-6736(00)52698-1] 
[3] 
Windfuhr JP. Aberrant internal carotid artery in the middle ear. Ann Otol Rhinol Laryngol Suppl  2004; 192(3)(Suppl.): 1-16.
[http://dx.doi.org/10.1177/00034894041130S301] [PMID: 15053213] 
[4] 
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; 197(Pt 3): 373-81.
[http://dx.doi.org/10.1046/j.1469-7580.2000.19730373.x] [PMID: 11117624] 
[5] 
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; 3(1): 29.
[http://dx.doi.org/10.1186/1746-160X-3-29] [PMID: 17650347] 
[6] 
Tillmann B, Christofides C. The “dangerous loop” of the internal carotid artery. An anatomic study. HNO  1995; 43(10): 601-4.
[PMID: 7499165] 
[7] 
Gossner J, Manka R, Larsen J. Aberrations of the cervical carotid artery which may be dangerous in pharyngeal surgery—a computed tomographic study. ACT  2013; 02(01): 29-33.
[http://dx.doi.org/10.4236/act.2013.21006] 
[8] 
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; 264(12): 1483-9.
[http://dx.doi.org/10.1007/s00405-007-0398-6] [PMID: 17638001] 
[9] 
Jun BC, Jeon EJ, Kim DH, et al. Risk factors for decreased distance between internal carotid artery and pharyngeal wall. Auris Nasus Larynx  2012; 39(6): 615-9.
[http://dx.doi.org/10.1016/j.anl.2011.10.018] [PMID: 22341333] 
[10] 
Muñoz A, De Vergas J, Crespo J. Imaging and clinical findings in patients with aberrant course of the cervical internal carotid arteries. Open Neuroimaging J  2010; 4: 174-81.
[http://dx.doi.org/10.2174/1874440001004010174] [PMID: 21283647] 
[11] 
Kelly AB. Tortuosity of the internal carotid in relation to the pharynx. J Laryngol Otol  1925; 40(1): 15-23.
[http://dx.doi.org/10.1017/S0022215100026955] 
[12] 
Ramsden. National Prospective Tonsillectomy Audit - final report of an audit carried out in England and Northern Ireland between July 2003 and September. RCS Eng 2004. Available from: https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/tonsillectomy-audit/
[13] 
Bashaer A, Imtiaz MQ, Jamal M AH, Milind G, Zakir H, Abdullah AS. Post-tonsillectomy hemorrhage: An analysis of incidence and risk factors in Kuwait. Kuwait Med J  2015; 47(3): 210-4. https:// applications.emro.who.int/imemrf/Kuwait_Med_J/Kuwait_Med_J_2015_47_3_210_214.pdf
[14] 
Pratt LW. Tonsillectomy and adenoidectomy: Mortality and morbidity. Trans Am Acad Ophthalmol Otolaryngol  1970; 74(6): 1146-54.
[PMID: 5493402] 
[15] 
Ricciardelli E, Hillel AD, Schwartz AN. Aberrant carotid artery. Presentation in the near midline pharynx. Arch Otolaryngol Head Neck Surg  1989; 115(4): 519-22.
[http://dx.doi.org/10.1001/archotol.1989.01860280117029] [PMID: 2923696] 
[16] 
Pratt LW, Gallagher RA. Tonsillectomy and adenoidectomy: Incidence and mortality, 1968--1972. Otolaryngol Head Neck Surg  1979; 87(2): 159-66.
[http://dx.doi.org/10.1177/019459987908700201] [PMID: 503482] 
[17] 
Gupta A, Shah AD, Zhang Z, Phillips CD, Young RJ. Variability in the position of the retropharyngeal internal carotid artery. Laryngoscope  2013; 123(2): 401-3.
[http://dx.doi.org/10.1002/lary.23393] [PMID: 22614949] 
[18] 
Windfuhr JP. An aberrant artery as a cause of massive bleeding following adenoidectomy. J Laryngol Otol  2002; 116(4): 299-300.
[http://dx.doi.org/10.1258/0022215021910591] [PMID: 11945195] 
[19] 
Banjar AA, Hussain SA, Haoumi A, Shamani MR. Aberrant course of the internal carotid artery in surgery of adenoids and tonsils. Ann Saudi Med  2002; 22(5-6): 344-5.
[http://dx.doi.org/10.5144/0256-4947.2002.344] [PMID: 17146259] 
[20] 
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; 4(1): 20.
[http://dx.doi.org/10.1186/1746-160X-4-20] [PMID: 18727830] 
[21] 
La Barbera G, La Marca G, Martino A, Lo Verde R, Valentino F, Lipari D, et al. Kinking, coiling, and tortuosity of extracranial internal carotid artery: Is it the effect of a metaplasia?. Surg Radiol Anat  2006; 28(6): 573-80.
[http://dx.doi.org/10.1007/s00276-006-0149-1] 
[22] 
Becker C, Ridder GJ, Pfeiffer J. The clinical impact of aberrant internal carotid arteries in children. Int J Pediatr Otorhinolaryngol  2014; 78(7): 1123-7.
[http://dx.doi.org/10.1016/j.ijporl.2014.04.028] [PMID: 24791679] 