<p>Neck dissection is a cornerstone in the surgical management of head and neck cancers, requiring meticulous dissection to achieve oncological clearance while preserving vital structures. A carotid knuckle, defined as a sharp bend or tortuosity in the carotid artery, is a rare but significant anatomical anomaly that poses a risk of inadvertent injury during surgery. Misidentification of a carotid knuckle as a lymph node can lead to catastrophic hemorrhage and life-threatening complications. We report an our experience with patients undergoing neck dissection for oral squamous cell carcinoma in which a carotid knuckle was encountered at level II of the neck. The tortuous internal carotid artery lay superficially and outside its expected course, initially mimicking a lymph node. Intraoperative identification based on its pulsatile nature and careful dissection prevented vascular injury. The carotid knuckle, though uncommon, is a well-documented vascular anomaly with significant surgical implications. It is frequently associated with older age and conditions such as hypertension and atherosclerosis. Literature emphasizes the critical role of preoperative imaging, such as computed tomography angiography (CTA), in identifying this anomaly. Intraoperatively, surgical techniques such as gentle dissection and identification of pulsatile structures are crucial to avoid adverse outcomes. The carotid knuckle represents a potential hazard during neck dissection, requiring heightened awareness, precise surgical technique, and preoperative imaging for identification and management. This case, coupled with a review of the literature, underscores the importance of recognizing such anomalies to ensure safe and effective surgical outcomes in head and neck oncology.</p>