BACKGROUND: The prevalence of aberrant internal carotid artery (ICA) is extremely low in the general population. It commonly occurs in the neck. Close proximity of the pulsatile submucosal mass of the aberrant ICA to the nasopharyngeal wall is dangerous. The complications include severe or fatal hemorrhage resulting from a missed diagnosis before intervention in this area, including tonsillectomy, adenoidectomy, eustachian tube dilation, oropharynx biopsy or resection, tracheal intubation, and neck surgery. We report the case of a 66-year-old woman who had a pulsatile mass of the kinked ICA in close proximity to the lateral nasopharyngeal wall, and provide a review of the literature.

CASE REPORT: The patient presented to our Ear, Nose, and Throat Clinic with persistent cough with phlegm. Endoscopic examination revealed an abnormal pulsatile mass in the lateral nasopharyngeal wall. Subsequent contrast-enhanced computed tomography angiography confirmed the presence of unilateral acute maxillary sinusitis, and a high-grade kinked submucosal mass of the ICA in the ipsilateral nasopharyngeal wall, concomitant with stenosis of the left ICA and left middle cerebral artery occlusion.

CONCLUSIONS: Pulsating and extremely high-grade kinking of the ICA in the lateral nasopharyngeal wall is a particularly dangerous condition. Clinicians must always consider the possibility of hemorrhage during surgery, especially in older women with arteriosclerosis. Otolaryngologists should perform comprehensive visual examinations before deciding on surgery or other medical interventions in the neck, to prevent severe or fatal hemorrhage as far as possible.

Keywords: Carotid Artery Diseases, Pathological Conditions, Anatomical, Carotid Artery, Internal, carotid stenosis, computed tomography angiography, Cough, Infarction, Middle Cerebral Artery, Nasopharynx