Katherine Rivero, Hanasoge Girishkumar, Frank Masella, Sania Thite, Reshma Pydi, Jigyasha Pradhan
Retropharyngeal displacement of the internal carotid artery (ICA) is an uncommon anatomical variant with significant procedural safety implications. The vessel deviates medially into the retropharyngeal space, approaching or contacting the posterior pharyngeal mucosa, placing it at immediate risk of injury during routine pharyngeal instrumentation. We report a 54-year-old woman with type 2 diabetes mellitus, hypertension, and hyperlipidemia who experienced a three-year diagnostic delay before this anomaly was identified. Her presentation of unilateral chronic otalgia and burning throat discomfort sequentially mimicked otitis externa and laryngopharyngeal reflux (LPR), both of which failed to respond to empirical treatment. CT of the neck with intravenous contrast revealed the right ICA approaching the pharyngeal mucosa. Flexible laryngoscopy demonstrated pulsatile submucosal bulging of the posterior pharyngeal wall, highly suggestive of an underlying vascular structure Carotid duplex ultrasonography demonstrated no hemodynamically significant stenosis bilaterally. Conservative management was adopted, with provider notification initiated. At six-month follow-up, the patient remained neurologically intact with stable symptoms. This case highlights the importance of vascular anomaly recognition in patients with unexplained, treatment-refractory otolaryngologic symptoms and the potentially fatal consequences of unrecognized aberrant ICA during pharyngeal procedures.