When the wall pulses: Submucosal retropharyngeal internal carotid artery as an unexpected driver of chronic cough

Anatomical variations of the cervical internal carotid artery (ICA), including a retropharyngeal submucosal trajectory, may mimic submucosal pharyngeal lesions and produce atypical upper aerodigestive symptoms. Failure to recognize these variants carries significant risk, as inadvertent injury during pharyngeal surgery, endoscopy, or intubation can result in catastrophic hemorrhage.

We report the case of a 73-year-old woman with several years of persistent cough and progressive dysphagia. Flexible fiber-optic nasopharyngolaryngoscopy revealed a smooth, pulsatile submucosal bulge of the posterior pharyngeal wall with associated salivary stasis. Contrast-enhanced CT confirmed a retropharyngeal course of the right cervical ICA of normal caliber. Given the absence of alarming features, conservative management with annual endoscopic follow-up was recommended.

This case represents a rare presentation in which a submucosal retropharyngeal ICA manifested predominantly as chronic cough, likely due to repetitive mechanical stimulation of supraglottic sensory pathways. Only two similar cases have been reported. The case expands the recognized symptomatic spectrum of ICA medialization and highlights the importance of targeted endoscopic examination and selective imaging when encountering unexplained chronic cough or atypical pharyngeal anatomy. Awareness of this vascular variant is essential to avoid misdiagnosis and prevent life-threatening iatrogenic injury.