these lesions though may cause life threatening hemorrhage , watchful observation is still considered as a treatment option in these patients . a 71-year - old male presented with pulsatile swelling over the right side of face and over the forehead in october 2009 . patient is a known diabetic and hypertensive for the past 9 years on regular medications . patient was evaluated with computed tomography ( ct ) angiogram , which showed aneurysm of the external carotid artery with thrombus within and multiple aneurysm of the branches of external carotid arteries . treatment option of excising the aneurysm with ligation of external carotid aneurismal branches was discussed with the patient . since the swelling was asymptomatic for the past 34 years , patient was not willing for any procedure . he is assessed with clinical examination on each visit and ultrasound examination performed once in a year to assess the size of the aneurysm . the patient has been on follow up for the past 4 years without any new symptoms or increase in size of the aneurysm . aneurysm of the external carotid artery and its branches have been described in cases due to trauma , iatrogenic injury , dental extraction , and also due to head and neck cancer because of tumor infiltration or due to radiation therapy . geriatric patients with aneurysm are first consulted by a primary care physician and hence primary care physician at the community level has a major role in following these patients and referring these patients to specialized vascular centre . increase in size of the aneurysm or impending rupture necessitates the need for referral to specialized center . the need for surgical intervention or endovascular stenting does not arise in our patient who has this aneurysm for 34 years and was on follow up for the past 4 years without any symptoms [ figure 1 ] . pulsatile swelling over the face , forehead , and scalp in this setting , the role of primary care physician is important to decide upon surgical or conservative management after having discussion with the patient . multiple aneurysm of external carotid artery this case was discussed for the rarity of idiopathic multiple aneurysm [ figure 3 ] of the external carotid artery [ figure 4 ] and the need for individualized treatment protocol to be followed , as in this case , only watchful observation . in this world of evolving surgical techniques and newer treatment modalities , conservative treatment still has a role to play . even in the era of advanced medical technology practices , treatment should be individualized and the choice rests with the patient . primary care physicians have a major role in follow up of these patients and decide upon referring these patients to specialized vascular center thus lessen the burden of vascular centre in following these patients .
aneurysms of external carotid artery are rare . 
 treatments for these are undertaken for the prevention of complications like hemorrhage or rupture , and embolism . 
 we present a 71-year - old male with idiopathic multiple aneurysm for the past 34 years on conservative management and regular follow up for the past 4 years . 
 this case was discussed for the rarity of idiopathic multiple aneurysm of the external carotid artery and the need for individualized treatment protocol to be followed as in this case , only watchful observation considering the age and patient compliance . in this world of evolving surgical techniques and newer treatment modalities , conservative treatment still has a role to play . 
 primary care physicians at the community level have a major role in following these patients and referring them as and when the need arises .