Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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May 23, 2016
Lingual Artery Pseudoaneurysm and Neopharynx Dehiscence Status Post Total Laryngectomy
- Background:
- Pseudoaneurysms of the external carotid artery and its branches are a rare entity typically encountered following surgery or trauma, with the even rarer occurrence of mycotic pseudoaneurysm in the setting of parapharyngeal abscess.
- In a series of 8837 patients who underwent tonsillectomy, Windfuhr et al reported three cases of pseudoaneurysms presenting with delayed postoperative bleeding.
- Pseudoaneurysms have also been reported at the sites of arterial anastomosis following free flap reconstruction and surgical ligation.
- Clinical Presentation:
- Hemoptysis
- Pulsatile neck mass
- Key Diagnostic Features:
- Contrast-enhanced CT is an ideal modality for evaluating the posttreatment neck, particularly in the setting of suspected complications, given its widespread availability, speed, and superior spatial resolution, which assisted in this case in depicting the subcentimeter vascular lesion.
- Contrast extravasation may be seen in the setting of active hemorrhage.
- Digital subtraction angiography is the gold standard for the diagnosis of cervical arterial vascular injury, and treatment may follow diagnostic evaluation, with the potential for rapidly achieving hemostasis utilizing interventional techniques.
- Differential Diagnosis:
- A lobulated collection in continuity with an arterial vessel demonstrating blood pool density and enhancement characteristics is pathognomonic of an aneurysm/pseudoaneurysm.
- Postoperative fluid collections in the setting of laryngectomy may reflect contained perforations, abscesses, or seromas. However, the demonstration of a collection's continuity with the neopharyngeal lumen, and the contained debris seen in this case, are compatible with a contained perforation and developing abscess.
- Treatment:
- Endovascular therapy using coils, PVA particles, and n-butyl cyanoacrylate
- Ultrasound-guided percutaneous thrombin injection
- Surgical resection
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