Purpose <p>To report a case of tongue cancer with an exceptionally rare bilateral retropharyngeal course of the common, internal, and external carotid arteries, and to underscore the critical role of preoperative imaging for performing a safe neck dissection.</p> Methods <p>An 81-year-old woman was diagnosed with squamous cell carcinoma of the right tongue. Preoperative contrast-enhanced computed tomography revealed a unique vascular anomaly, with the bilateral carotid systems coursing retropharyngeally. Based on this detailed radiological assessment, she underwent a partial glossectomy and a modified radical neck dissection under general anesthesia.</p> Results <p>Guided by the preoperative three-dimensional anatomical evaluation, the carotid arteries were identified and preserved early in the procedure, which was completed without abnormal hemorrhage (estimated blood loss: 76&#xa0;mL). The final pathological diagnosis was pT2N0M0. The patient’s postoperative course was complicated by multiorgan failure secondary to sepsis, unrelated to any vascular injury, and she ultimately expired. The cervical wound healing was uneventful.</p> Conclusion <p>Neck dissection can be performed safely even in the presence of complex carotid artery anomalies. Meticulous preoperative radiological evaluation and tailored surgical planning are indispensable for averting catastrophic vascular complications. Head and neck surgeons must maintain a high index of suspicion for such anatomical variations.</p>