Tonsillectomy is one of the most common surgical procedures performed in the United States with approximately 339,000 ambulatory tonsillectomies performed in 2010. Of these, an estimated 299,000 tonsillectomies were performed on patients less than 15 years of age. Damage to the internal carotid artery during routine tonsillectomy is a rare but feared complication of this relatively routine surgical procedure. We present the case of a medialized internal carotid artery encountered prior to pediatric tonsillectomy, as well as a review of the literature on internal carotid artery development and anatomic variations.
Tonsillectomy is one of the most common surgical procedures performed in the United States with approximately 339,000 ambulatory tonsillectomies performed in 2010 [ ]. Of these, an estimated 299,000 tonsillectomies were performed on patients less than 15 years of age [ ]. Tonsillectomy is commonly the first-line treatment for children with obstructive sleep apnea and is also performed for children with recurrent tonsillitis who meet Paradise criteria. Damage to the internal carotid artery (ICA) during routine tonsillectomy is a rare but feared complication of this relatively routine surgical procedure. In fact, damage to the ICA during tonsillectomy was first described in the 1780s [ ]. Damage to the ICA can lead to hemorrhage and death. We present the case of a medialized ICA encountered prior to pediatric tonsillectomy.
We present a patient with an aberrant retropharyngeal ICA discovered during aborted tonsillectomy and adenoidectomy. The patient was a 4 year old boy with significant past medical history of birth at 25 weeks gestational age. He was intubated at birth and remained intubated for the first 2 months of life. The patient presented for surgical consultation for the treatment of obstructive sleep apnea. A preoperative polysomnogram demonstrated an Apnea/Hypopnea Index of 11.8 and oxygen nadir of 85.7%. The patient was taken to surgery for ambulatory tonsillectomy and adenoidectomy. Upon placement in suspension, a pulsatile mass was seen in the right posterior oropharynx ( Fig. 1 ). A medialized carotid artery was suspected, and the surgery was aborted. Prior to extubation, a computed tomography angiogram of the head and neck was obtained to evaluate the course of the suspected medialized carotid artery. The right ICA was noted to take a medial course into the retropharyngeal space, 2.6 mm deep to the oropharynx ( Fig. 2 ). The child’s parents were counseled that all future surgical and anesthesia staff should be made aware of his anatomic variant should he require surgery in the future, as his anatomic variant places him at greater-than-average risk for catastrophic bleeding.