Carotid Artery and Globus. How Are They Related?

Throat discomfort or globuspharyngeus or “lump in the throat” is one of the common symptoms for which a patient is referred to an otorhinolaryngology clinic. The causes may vary according to the region of involvement along the upper aero-digestive tract. The lesions may involveposterior nasopharynx such as in cases of post nasal drip, oropharynx as a result oftonsillar hypertrophy, elongated uvula in supraglottic region, vallecular or epiglottic cyst in glottic region, laryngopharyngeal reflux, pedunculated vocal cord cyst, or post-cricoid or oesophageal carcinoma. It can also be due to external compression by surrounding structures such as thyroid gland enlargement, a mass, or lymph nodes.  Due to a wide range of differential diagnosis, a thorough ear, neck and throat (ENT) examination is often needed with a detailed history, clinical examination and direct visualization of upper airway with endoscopy. Imaging procedures such as barium swallow, computed tomography (CT) and magnetic resonance imaging (MRI) are useful for diagnosis. We report an unusual endoscopy finding during workupof globuspharyngeus in a patient that was due to kinking of the internal carotid artery (ICA).

A 55-year-old woman with a history of high-grademucoepidermoid carcinoma of the right parotid gland presented for a routinefollow-up examination. She had undergone right parotidectomy, followed by radiation therapy in 2003 for treatment of her cancer. Five years later, she presented with left nodular goiter and underwent left thyroid lobectomy. During the routine follow up visit, she complained of throat discomfort and a feeling of foreign body sensation upon swallowing. She did not have any accompanying pain, shortness of breath or history of foreign body ingestion. She denied nasal symptoms, post nasal drip, gastroesophageal reflux or neurological symptoms. On inspection and palpation, a 4 x 3 cm anterior neck swelling was noted, which was non tender, firm and did not move with tongue protrusion. There was no palpable cervical lymphadenopathy. On endoscopy, a pulsatile mass with smooth overlying pharyngeal mucosa was noted at the left posterior pharyngeal wall, extending from the left posterior pharyngeal pillar to the left pyriform fossa. The supralaryngeal structures and the laryngeal inlet were normal without any pooling of saliva or presence of foreign body (Figure 1). A computed tomography angiography (CTA) of the carotid artery from brain to upper thorax found medial deviation withkinked appearance of the cervical segment of left internal carotid artery at the level of C1/C2 vertebra causing medial bulging ofleft lateral pharyngeal wall and associated narrowing of pharynx in supraglottic region. Otherwise, both internal and external carotid arteries were well opacified without any filling defects (Figure 2A & 2B). A fine needle aspiration for cytology (FNAC) of the right thyroid swelling was also obtained and showed colloid goiter with cystic degeneration. This patient opted for watchful waiting and is under routine follow-up.

Globus, as a psychosomatic disorder, remains a diagnosis of exclusion [1]. Often, globus is not a stand-alone symptom and is mostly associated with other signs and symptoms suggestive of organic lesions. Globus is associated with organic lesions in only 3.7% patients and such lesions include oesophageal and pharyngeal cancer, and Zenker’s diverticulum [2]. In our patient, a secondary malignancy of oropharynx and hypopharynx, apart from a thyroiddisorder, was in the differential diagnosis, particularly with a history of previous neck radiation for treatment of high-grademucoepidermoid carcinoma. Radiation therapy for head and neck tumors has its own complication such as thyroid disorder, secondary malignancy, polyneuropathy, weakening of vasculature walland so forth. Among thyroid disorders, hypothyroidism, thyroid nodules, thyroiditis and even malignant transformation can occur within five years of radiation [3,4]. The cervical portion of ICA mostly runs a straight course from the base of skull. In 1965, Weibel and Fields first introduced a classification of abnormalities of tortuosity- a non-rectilinear stretch of an artery with angulation >90°, coiling- loop or a 360° angulation of an artery, and kinking- the infection of 2 or more segments of an artery with internal angle of 90°in ICA [5]. Ozgur et al [6] had studied the course of ICA bilaterally in cadaveric dissections in 50 Anatolian male cadavers. In his study, he classified the course of ICA as: straight, tortuosity, kinking and coiling. ICA abnormalities were found in 30% of cases, with 18% on the left. Kinking was found in five cases and two cases were located near the pharyngeal wall.

The mechanism of kinking of ICA is often associated with changes attributed toarteriosclerotic changes in arterial wall in adults. The increase in arterial pressure can cause alteration to the arterial wall over time [7,8]. Radiation causes direct damage to the arterial wall as is likely the case in our patient. In addition, radiation may also accelerate the progression of arteriosclerotic changes [9]. Congenital or idiopathic kinking of ICA is unlikely as symptoms arose much later in life.

Finding a definite cause for globuspharyngeus has always been challenging and difficult. However, this should not deter a physician from a diligent diagnostic workup. In cases of pulsatile mass in pharyngeal region, CTA of carotid artery plays an important role in diagnosis. Globus pharyngeus in our patient due to a kink in the internal carotid artery is an unusual and interesting presentation.

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