Home 🡪 Case Studies 🡪 Carotid Knuckle: a Potential Hazard During Neck Dissection

Carotid Knuckle: a Potential Hazard During Neck Dissection

Brief history:

75 year old gentleman with cancer of the tongue presented in the OPD for surgical opinion. The tumor was on the left border of the tongue close to the molar teeth.

The MRI done also revealed enlarged nodes in the neck at 2 levels.

Complex head and neck surgeries can be performed safely even in high risk patients when necessary care is taken. Innovative and unique approaches are sometimes necessary for successful surgical outcomes. Optimizing patients’ health before surgery ensures safety and reduces post-operative complications.

Patient concerns:

If he would be able to withstand surgery, considering his age?

What are the complications?

Treatment offered:

Surgery is the best choice of treatment for oral cancers. Hence the patient was offered removal of the tumor from the tongue (with clear margins) along with neck dissection. The defect was planned to be reconstructed using a free flap from the thigh.


The surgery went smoothly. During neck dissection, a carotid knuckle was discovered. A carotid knuckle means a bend in the normal course of carotid artery high in the neck ( at level 2 or 3). Such a bend makes the artery tortuous and lie far outside its natural course. Sometimes it may be mistaken for a lymph node. Inadvertent injury to this artery here leads to massive blood loss and disastrous consequences.

Carotid knuckle at level 3

The carotid knuckle was dissected carefully and neck dissection was completed. The healing was satisfactory with the free flap and patient could go home by day 10.

Take home message:

Neck dissection is a common surgery employed in the treatment of oral cancers. Neck is a place which is filled with vital structures at all sites. Hence meticulous attention is required to preserve these structures while at the same time achieving complete clearance of the nodes. Carotid knuckle is an uncommon anomaly but with potential disastrous outcomes. The presence of such an anomaly has to be considered in old patients and surgeon should carefully look for it during neck dissection at level 2 and 3 to avoid injuries.