Main Article Content
Internal Carotid Aneurysm, Internal Carotid Kinking, Peritonsillar Abscess, Endovascular Treatment
Background and aim: Extracranial Internal Carotid Artery Aneurysms are very rare. They can manifest with variable and unspecific clinical instances including neurologic symptoms associated with pulsatile cervical mass as the most frequent ones. This way, in presence of a mass in the oropharynx or neck, an aneurysm of the Internal Carotid Artery is not often considered as a prior diagnosis, therefore some of them are only discovered during surgical procedures. Here we describe a case of Extracranial Internal Carotid Artery Aneurysm misdiagnosed as a Peritonsillar Abscess which underwent surgical drainage. The purpose of this article is to emphasize factors which should be considered in differential diagnosis before doing inappropriate operative procedures. We will also focus on the effectiveness of Angiography, angio-CT and angio-MR in diagnosing the aneurysm and which factors to consider when choosing the best surgical or endovascular treatment.
Method: Retrospective case report. Results: An Extracranial Internal Carotid Artery Aneurysm was misdiagnosed as a Peritonsillar Abscess which underwent surgical drainage with consequent profuse haemorrhage. An emergency tracheostomy was immediately performed. The patient was moved to the Interventional Neuroradiology Department where angiography revealed a double kinking and a giant aneurism of the Internal Carotid Artery. Endovascular permanent occlusion of the Internal carotid Artery was performed with detachable coils. The patient reported neither neurologic sequelae nor haemorrhage recurrence during the 2–year follow-up. Conclusions: Aneurysmatic dilation of Extracranial Internal Carotid Artery in the parapharyngeal space may determine, especially in presence of kinking, a medialization of the lateral oropharyngeal wall, mimicking a PTA. A high index of suspicion is mandatory for diagnosis.
2. Miksic K, Flis V, Kosir G, Pavlovic M, Tetickovic E. Surgical aspects of fusiform and saccular extracranial carotid artery aneurysms. Cardiovasc Surg. 1997 Apr;5(2):190-195.
3. Attigah N, Külkens S, Zausig N, et al. Surgical therapy of extracranial carotid asrtery aneurysms: long-term results over a 24-year period. Eur J Vasc Endovasc Surg. 2009 Feb;37(2):127-133.
4. Chen Z, Chen L, Zhang J, et al. Management of Extracranial Carotid Artery Aneurysms: A 6-Year Case Series. Med Sci Monit. 2019 Jul;3(25):4933-4940.
5. Radak D, Davidovic L, Tanaskovic S, et al. A tailored approach to operative repair of extracranial carotid aneurysms based on anatomic types and kinks. Am J Surg. 2014 Aug;208(2):235-242.
6. Chen Z, Hu LN, Zhu H, Xiao EH. Validity of venous phase delay assessment in balloon occlusion test of internal carotid artery. Exp Ther Med. 2019 Jan;17(1):948-952.
7. Szopinski P, Ciostek P, Kielar M, Myrcha P, Pleban E, Noszczyk W. A series of 15 patients with extracranial carotid artery aneurysms: surgical and endovascular treatment. Eur J Vasc Endovasc Surg. 2005 Mar;29(3):256-261.
8. Karov I. Spontaneus rupture of an internal carotid artery aneurysm diagnosed as a peritonsillar abscess, a tonsillar and epiphaeryngeal carcinoma with metastasis. Folia Med (Plovdiv). 1996;38(2):65-67.
9. Windfuhr J. Aneurysm of the internal carotid artery following soft tissue penetration injury. Int J Pediatr Otorhinolaryngol. 2001 Nov;61(2):155-159.
10. Kocak HE, Acipayam H, Elbistanli MS, et al. Is corticosteroid a treatment choice for the management of peritonsillar abscess? Auris Nasus Larynx. 2018 Apr;45(2):291-294.
11. Noad RL, O’Donnell ME, McCavert M, Gardner R, Lee B, Lau LL. A carotid artery aneurysm with a twist: case report and review. Ir J Med Sci. 2012 Sep;181(3):321-324.
12. Abud DG, Spelle L, Piotin M, Mounayer C, Vanzin JR, Moret J. Venous phase timing during balloon test occlusion as a criterion for permanent internal carotid artery sacrifice. AJNR Am J Neuroradiol. 2005 Nov-Dec;26(10):2602-2609.