ARTERIAL SUPPLY OF THE HEAD AND NECK

MADE BY :DR. PRAVEEN YADAV PG Ist YEAR ORAL AND MAXILLOFACIAL SURGERY

Major arteries
Pulmonary trunk
Aorta

Left common carotid artery Right brachiocephalic artery

Right common Carotid artery Right subclavian artery
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Left subclavian artery

 External Carotid -

exterior of head ,

face and neck.

Internal Carotid contents.

cranial and orbital

Right common carotid artery

Left common carotid artery

Origin

Bifurcation of the brachiocephalic trunk

Arch of aorta

Termination

At the level of upper border of thyroid cartilage

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The courses of the left and right common carotids are similar. Both start behind the corresponding sternoclavicular joints running laterally upwards at the level of upper border of thyroid cartilage. Here it terminates by dividing into external and internal carotids.

Common carotid artery is enclosed in the carotid sheath , 3 contents of the sheath are The common carotid medially. internal jugular vein laterally. vagus in b/w artery and the vein posteriorly.

The common carotid is related :

MEDIALLY: Thyroid gland , larynx, pharynx, trachea, oesophagus. LATERALLY: Internal jugular vein and the vagus nerve.

CAROTID SINUS : The termination of the common carotid artery or the beginning of the internal carotid artery shows a slight dilatation , known as carotid sinus. Here the tunica media is thin, and the adventitia is thicker which recieves a rich innervation by the 9th nerve and sympathetic nerves . It acts as a baroreceptor or a pressure receptor and regulates blood pressure.

It is a small reddish brown structure situated behind the bifurcation of the common carotid. Recieves nerve supply from the 9th , 10th and the sympathetic nerves. Acts as a chemoreceptor and responds to changes in oxygen, carbon dioxide and pH content of the blood.

Begins lateral to the upper border of the thyroid cartilage , level with the intervertebral disc b/w the 3rd & 4th cervical vertebrae. Passes midway b/w the tip of mastoid process & the angle of the mandible , in the substance of parotid gland behind the neck of the mandible it divides into terminal branches.

The external carotid artery has a slightly curved course , so that it is anteromedial to the internal carotid artery in its lower part and anterolateral to the internal carotid artery in its upper part.

Anterior : Superior thyroid Lingual Facial Posterior: Occipital

Posterior auricular

Medial: Ascending pharyngeal Terminal: Maxillary Superficial temporal

LIGATION OF ECA
Done at 2 points Artery exposed at its origin & ligature above superior thyroid artery upper part of neck, superficial & deep structures of neck . Ligation higher up, behind the angle of lower jaw- maxillary artery injuries. UNILATERAL LIGATION will not stop hemorrhage

A] LIGATION OF ECA IN CAROTID TRIANGLE:Skin incision-- at the level of angle of mandible behind anterior border of sternocleidomastoid muscle ,continued downward to the level of cricoid cartilage.
-- Platysma, superficial sheath of sternomastoid incised, muscle exposed & retracted ,deep layer of sternomastoid head is visible & IJV through it. -- Fascia in front of vein is cut to expose the arteries.

Arises from the external carotid artery just below the level of the greater cornua of the hyoid bone.
Runs downwards and parallel superficial to external laryngeal nerve to reach the upper pole of thyroid gland.

The artery and the external larygeal nerve are in close approximation higher up but diverge near the gland. To avoid injury to the external laryngeal nerve, the superior thyroid artery is ligated as near to the gland as possible whereas in case of inferior thyroid artery, it is ligated as far away from the gland as possible to save the reccurent laryngeal nerve. Its relationship to the external laryngeal nerve is important during thyroid surgeries.

Origin begins at the anteromedial part of external carotid artery at tip of greater cornu of hyoid bone between superior thyroid and facial arteries. Course after short course lies deep to hyoglossus muscle , finally leaves the muscle in the tongue to anastomose with the lingual artery of opposite side.

The course is divided into 3 parts by hyoglossus muscle. The first part lies in the carotid triangle . It forms a characteristic upward loop which is crossed by the hypoglossal nerve . The lingual loop permits free movements of the hyoid bone.

The 2nd part lies deep to the hyoglossus along the upper border of hyoid bone. It is superficial to the middle constrictor of pharynx.

Covered by hyoglossus and mylohyoid.

The 3rd part - also called the arteria profunda linguae or the deep lingual artery. Extends from anterior border of hyoglossus to the tip of tongue. The horizontal part of the artery is accompanied by lingual nerve.

During surgical removal of the tongue, the first part of the artery is ligated before it gives any branch to the tongue or the tonsil.

2] sublingual artery -- injury occurs in premolar & molar region, when sharp instrument or rotating disks slips off a lower molar & injure the floor of mouth.

Incision circling the lower pole of submandibular gland. Posterior part towards tip of mastoid ; anterior part towards chin. Skin, platysma, deep fascia incised, submandibular gland exposed , lifted,tendon of diagastric visible.

Free border of mylohyoid muscle ascertained, hypoglossal nerve identified.

Digastric tendon pulled downwards enlarges the digastric triangle, hyoglossus muscle visible. Muscle divided bluntly, in the gap of its vertical fibers lingual artery found & ligated.

Arises from the external carotid just above the tip of the greater cornua of the hyoid bone. It runs upwards in the neck first as a cervical part and then as facial part. The course of the artery is tortuous in both places . The tortuosity allows free movements of the pharynx during degluttion. On the face it allows free movements of the mandible , the lips and the cheek.

The facial artery has two

parts:
Facial part Cervical part

It enters the face by winding around the base of the mandible and by piercing the deep cervical fascia at the anteroinferior angle of the masseter . Here it can be palpated and is called the anaesthetists artery. It lies between the superficial and deep muscles of the face.

Supralabial to the upper lip.

Infralabial to the lower lip and anteroinferior part of the nasal septum.

Lateral nasal - to the ala and dorsum of the nose.

It runs upwards on the superior constrictor of pharynx, deep to posterior belly of digastric. It forms two loops - first winding over the submandibular gland and then over the base of the mandible.

1. Ascending Palatine : supplies the tonsil and root of the tongue. 2. Tonsillar Branch : supplies the tonsil. 3. Submental Branch : supplies the submental triangle and sublingual salivary gland. 4. Glandular Branch: for the submandibular salivary gland and the lymph nodes.

During injury of the face bleeding from the facial artery can be stopped by compressing the artery against the lower border of the mandible.
The pulsation of the artery can be felt along the lower border of the mandible near the antero-inferior angle of the masseter muscle.

facial artery can be injured during operative procedures on lower premolars & molars, if instrument enters the cheek at inferior vestibular fornix., also while attempt to open a buccal abscess.

Exposed --at the point crossing the lower border of mandible .

Using contracted masseter as a landmark, pulse of facial artery felt at point situated anterior to the attachment of masseter.

Artery is accompanied by facial vein & crossed superficially by marginal mandibular branch of facial nerve.

Taking this into consideration, incision -- at least half inch below the border of mandible & parallel to it.

Skin, platysma, deep fascia are cut , soft tissues retracted, pulse of facial artery felt. Artery-- isolated, tied & cut.

1. Arises from the posterior aspect of external carotid just above the posterior belly of digastric. 2.Course : lies superficial to styloid process and crosses the base of the mastoid process, ascending behind the auricle .

3.Distributes partly to the ear and partly to the scalp.

1. Stylomastoid : supplies the middle ear, mastoid antrum and semicircular canals . 2. Auricular : supplies the lateral aspect of auricle. 3. Occipital : supplies the scalp above and behind the ear.

It is the smallest and the only medial branch of the external carotid.

ASCENDING PHARYNGEAL ARTERY

1. Arises from the posterior aspect of the external carotid artery, opposite the origin of the facial artery. 2.It is crossed at its origin by the hypoglossal nerve. In the carotid triangle the artery gives two sternomastoid branches. 3. The upper branches accompany the accessory nerve & the lower arises near the origin of the occipital artery.

1. Meningeal. 2. Sternomastoid. 3. Mastoid. 4.Auricular . Essentially supplies the back of the neck and the scalp along with posterior part of the ear.
OCCIPITAL ARTERY

Superficial branch anastomosis with ascending branch of transverse cervical artery. Deep branch of descending br of occipital artery anastomosis with deep cervical artery ( costo-cervical trunk )
Important for neurosurgeons

It is the larger terminal branch of external carotid, arises behind and below the mandibular neck, within the substance of parotid gland.

Its course is divided into 3 parts for convenience: 1. Mandibular. 2. Pterygoid. 3. Pterygopalatine.

Passes between the mandibular neck and the sphenomandibular ligament.

It crosses the inferior alveolar nerve & passes around the lower border of the mandible.

1. Deep Auricular and Anterior Tympanic- supply the ear and tympanic membrane , TMJ.
3. Middle Meningealsupplies the bone and meninges of temporal region , 5th and 7th nerves. 4. Accessory meningealmeninges and infratemporal fossa.

5. Inferior Alveolar Supplies the lower teeth and mylohyoid muscle.

Gives off mainly muscular branches. Deep temporal to temporalis. Pterygoid to the pterygoid muscles. Massetric to masseter Buccal artery- to buccinator.

Passes between the heads of pterygoid and through pterygomaxillary fissure into the pterygopalatine fossa.

BRANCHES:

1.Posterior superior alveolarmolars, premolars and maxillary sinus. 2. Infraorbital- the incisors, canines, nose and upper lip

Greater Palatine- emerges through greater palatine foramen to supply the palate and gums. Pharyngeal- nasopharynx , auditory tube and sphenoidal sinus. Artery of pterygoid canal- pharynx , tympanic membrane. Sphenopalatine- lateral wall of the nose and nasal septum.

Fractures involving the ramus of the mandible injures the inferior alveolar artery and cause profuse bleeding.

MIDDLE MENINGEAL ARTERY ( frontal branch ) extradural hemorrhage hematoma presses on the motor area hemiplegia of opposite side APPROACH- hole in the skull over pterion 4 cm above mid point of zygomatic arch MMA ( parietal or posterior branch )contralateral deafness APPROACH- hole is made 4cm above and 4cm behind the external acoustic meatus.

POSTERIOR SUPERIOR ALVEOLAR ARTERYsite of hematoma during PSA block. - prevented by aspirating before giving LA in the site. GREATER PALATINE AND ANTERIOR PALATINE ARTERY. case of abscess from palatal root of first molar,incision should be made in a anteroposterior direction ,then transversly. Incision made near free margin of gingiva. Edge of knife directed outward, upward.

It is the smaller of the two terminal branches , begins in the parotid gland behind neck of the mandible.
It crosses the posterior root of zygomatic process of temporal bone, divides into anterior and posterior branches which supply the temple and the scalp.

1. Frontal branch -supplies the scalp. 2. Parietal branch - the temple region.
3.Middle temporal - runs over temporal fossa deep to temporalis.

4.Transverse facial- supplies the facial muscles.

The pulsations of the artery can be felt on the zygomatic arch as it crosses the root of zygoma or pre-auricular point. Anastomoses freely ; partially detached with scalp , in case of injury heals with reasonably well. In reduction of zygomatic arch fractures Gillis temporal approach the artery is encountered.

A] Arteries endangered during minor surgical procedures or dental treatment : 1. anterior palatine artery 2. sublingual artery 3. facial artery

B] ARTERIES ENDANGERED DURING ORTHOGNATHIC SURGERIES : Pterygopalatine portion of maxillary artery during Le fort I osteotomy procedure In mandibular orthognathic surgery, collateral blood supply is central to preservation of osteotomised segments. Carotid A. may be susceptible to damage during orthognathic surgery. Thrombosis of ICA can occur after surgery due to excessive extension of head & neck.

Vessels requiring special protection during & following neck dissection are carotids, common & internal. Rupture of carotid system is reffered as carotid blow-out. Common adverse circumstance previous exposure to ionising radiation.

Vessel damaged by radiotherapy is subjected to added insult of wound breakdown & exposure, & liable to rupture. Two methods of protecting: Modified skin incisions Covering of vessels using muscle flaps or graft of dermis.

MUSCLE FLAPS They carry their blood supply with them in transfer. - the group of muscles behind the carotids , scalenes & levator scapulae are used for cover. Most effective flap levator scapulae. -Transected at a suitable level above the clavicle , mobilised & swung anteriorly to cover the area of carotid bulb. -- myocutaneous flaps --- standard techniques in intraoral reconstruction. lap levator scapulae

DERMAL GRAFTS : Alternative method of protection. Standard split skin graft used,removing a strip of underlying dermis & replacing the skin graft in its original site. Dermal strip along entire length of carotid provide extra layer of protective collagen.

It arises in the neck as one of the terminal branches of the common carotid artery at the level of the upper border of the thyroid cartilage opposite the disc between the C3 and C4 & ends inside the cranial cavity by supplying the brain. Its course is divided into the following 4 parts : Cervical Petrous Cavernous Cerebral

It ascends vertically in the neck from its origin at the base of the skull to reach the lower end of the carotid canal .
It is enclosed within the carotid sheath.

No branches arise from the internal carotid artery in the neck.

Its initial part usually shows a dilatation , the carotid sinus which acts as baroreceptor. The lower part of the artery is comparatively superficial. The upper part, above the posterior belly of the digastric , is deep to the parotid gland, the styloid apparatus & many other structures.

Relations
Posteriorly -sup cervical ganglion,sup laryngeal nerve Medially - ascending pharyngeal artery Anterolaterally - sternocleidomastoid muscle Inferiorly-digastric, hypoglossal nerve At the level of digastric - stylohyoid muscle, posterior branches of ECA Above the digastric - styloid process,deeper part of parotid gland Internal carotid artery

In the cervical region the internal carotid is related to the 9th, 10th and 11th cranial nerves, sternomastoid muscle, common facial vein, lingual vein and external carotid artery.

It is that part located entirely in the petrous part of the temporal bone. From the posterior wall of foraman lacerum , it turns upwards and medially. Here it is related to the middle ear, auditory tube and trigeminal ganglion.

Relations

Surounded by venous and sympathetic plexuses Posterolaterally-middle ear and cochlea Anterolaterally- auditory tube and tensor tympani Superiorly- trigeminal ganglion Internal carotid artery

a) Caroticotympanic enters middle ear and anastomoses with ant. and post. tympanic arteries.
b) Pterygoid branchenters the pterygoid canal and anastomoses with the greater palatine artery.

The internal carotid ascends to the posterior clinoid process and emerges through the dorsal roof of the cavernous sinus.
Here it gives off the following branches : a) Cavernous branches to trigeminal ganglion. b) Superior and inferior hypophyseal branches to the hypophysis cerebri.

Lies at the base of the brain after emerging from the cavernous sinus. Gives off the following arteries:
1) Ophthalmic 2) Anterior cerebral

3) Middle cerebral

4) Posterior communicating 5) Anterior choroidal.

Of these the ophthalmic supplies structures in the orbit ; while the others supply the brain.

The curvature of the petrous, cavernous and the cerebral parts of the internal carotid artery together form an S shaped figure , called the Carotid siphon of angiograms.

The Circle of Willis (also called Willis' Circle, cerebral arterial circle , arterial Circle of Willis, and Willis Polygon ) is a circle of arteries that supply blood to the brain.

It is named after Thomas Willis (16211673) , an English physician.

The Circle of Willis comprises the following arteries : Anterior cerebral artery (left and right)
Anterior communicating artery Internal carotid artery (left and right) Posterior cerebral artery (left and right)

Posterior communicating artery (left and right)

If one part of the circle becomes blocked or narrowed (stenosed) or one of the arteries supplying the circle is blocked or narrowed, blood flow from the other blood vessels can often preserve the cerebral perfusion well enough to avoid the symptoms of ischemia.

Subclavian steal syndrome: In subclavian steal syndrome, blood is "stolen" from the Circle of Willis to preserve blood flow to the upper limb. Subclavian steal syndrome results from a proximal stenosis (narrowing) of the subclavian artery, an artery supplied by the aorta which is also the same vessel that eventually feeds the Circle of Willis via the common carotid artery.

1. lliac graft- deep circumflex iliac artery 2. Rectus abdominis free flap- deep inferior epigastric vessels

LINGUAL TOUNGE FLAPPosteriorly based dorsal tongue flap- dorsal lingual artery

Anteriorly based dorsal tongue flap- ranine arch which is a terminal branch from the forward continuation of the lingual artery

Transverese dorsal tongue flap- is created in bipedical form such that flap is transvered anteriorly from the toung to the floor of the mouth Perimeter flap- may be uni or bipedical in design - used for repair of lip vermilion defects.

Ventral based flapslimited usefulness because there thickness is minimum.

Lateral thigh flap- profunda femoris artery

PEDICALED MYOCUTANEOUS FLAPS Sternocledomastoid myocutaneous flap-occipital artery superior thyroid artery inferior thyroid artery a branch from thyrocervical trunk

Temporalis/ forehead flap- anterior and posterior deep temporal arteries.

Auriculomastoid fasciocutaneous island flap- parietal branches of superficial temporal artery - occipital artery - posterior auricular artery Trapezius myocutaneous flap- transverse cervical artery, a branch from thyrocervical trunk.

Platysmal myocutaneous flap- submental branch of facial artery Latissimus dorsi myocutaneous flapthoraco dorsal artery, which is a terminal branch of scapular artery that comes from third division of axillary artery. Deltopectoralis major myocutaneous flap- thoracoacromial artery - lateral and superior thoracic artery

C.J.Romanes Cunnighams manual of practical anatomy 15th edition Grays anatomy 39th edition. I.B.SinghText book of anatomy 3rd edition.

Textbook Of Anatomy by Richard Snell

B D Chaurasia.Human Anatomy 4th edition vol 3.