Conventional textbooks on anatomy emphasize the consistency in the pathway of the cervical internal carotid artery (ICA) from the carotid bifurcation to the skull base. Deviations in its route as result of developmental and acquired conditions have received little attention in the literature. A case of a tortuous cervical ICA presenting as pharyngeal pulsatile swelling is presented. The differential diagnosis includes an enlarged ascending pharyngeal artery, aneurysm of the cervical ICA, and displacement of the cervical ICA by a tumour. Its presence warrants radiological assessment to establish a diagnosis and modify any planned surgery. Inadvertent injury or ligation of a tortuous cervical ICA can result in serious if not fatal complications. Clinical, radiological and cadaver studies on the tortuosity of the cervical ICA are reviewed.
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