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EXTERNAL CAROTID

ARTERY

N BABA GANAPATHI RAO
Ist P.G

INTRODUCTION
 The arterial supply of head and neck is remarkable in its
richness when compared to other body regions (castelli and
huelke,1965)
 The major branches overlap , collateralize , and even cross
the midline, especially in the nasal and pharyngeal regions
 Vestigial channels from the internal carotid system also
have potential to open into external carotid distribution
 This rich vascularity helps to increase the power of repair
&resistance to infection seen in these tissues
 The primary arterial supply to the maxillofacial structures
come from external carotid artery which is the branch of
common carotid artery

COMMON CAROTID ARTERY
 The common carotid artery
is formed during 3&4
weeks of embryological
development from 3rd aortic
arch
 Right common carotid -
artery is a branch of the
brachiocephalic artery.
 Left common carotid artery
is a branch of the arch of
aorta.
 In the neck,both arteries
have similar course

BIFURCATION OF COMMON
CAROTID ARTERY

 Common carotid artery
bifurcates into external and
internal carotid arteries at the
level of upper border of the
thyroid cartilage.
 Two structures of importance
at the bifurcation are
Carotid sinus
Carotid body

FUNCTION: Carotid sinus acts as a baroreceptor or pressure receptor and regulates pressure.CAROTID SINUS  Carotid sinus is slight dilatation at the termination of the common carotid artery or the beginning of the internal carotid artery. .  It receives a rich innervation from the glossopharyngeal and sympathetic nerves.

such as that occasioned by movement of the head.  Impulses transmitted by the sinus reduce blood pressure and slow the pumping action of the heart. may result in stimulation of the carotid sinus.  Thus decreasing blood supply to the brain and resulting in sudden loss of consciousness  Supra ventricular tachycardia may be controlled by carotid sinus massage due to inhibitory effects of vagus nerve on heart .APPLIED ANATOMY Carotid sinus syndrome  Sudden slight pressure changes.

oval reddish-brown structure situated behind the bifurcation.  It receives nerve supply mainly from the glossopharyngeal nerve. .CAROTID BODY  Carotid body is a small. FUNCTION: Carotid body acts as a chemoreceptor and responds to changes in the oxygen and carbon dioxide and PH content of the blood. vagus and sympathetic nerves.

it lies under cover of the anterior border of the sternocleidomastoid muscle  It runs upwards and slightly backwards laterally and terminates behind the neck of the mandible by dividing into maxillary and superficial temporal arteries .  In the carotid triangle.EXTERNAL CAROTID ARTERY  ECA begins in the carotid triangle at the level of upper border of thyroid cartilage opposite the disc between the third and fourth cervical vertebrae.

.so that it is anteromedial to ICA in it lower part.and anterolateral to the ICA in its upper part.Has slightly curved course.

and superior thyroid veins Deep to the artery— Wall of pharynx Superior laryngeal nerve . RELATIONS IN THE CAROTID TRIANGLE Superficially—Cervical branch of facial nerve .Ascending pharyngeal artery .lingual.Hypoglossal nerve Facial.

Stylopharyngeus. Facial nerve Deep to the artery—ICA Structures passing between ECA and ICA Styloglossus. it is related Superficially—Retromandibular vein.IXth nerve Pharyngeal branch of Xth nerve.Within the gland. Styloid process .ABOVE THE CAROTID TRIANGLE Lies deep in the substance of the parotid gland.

BRANCHES Total of 8 branches  ANTERIOR  POSTERIOR  MEDIAL  TERMINAL .

ANTERIOR BRANCHES .

It is accompanied by same-named vein. .Superior thyroid artery ORIGIN:just below the tip of greater cornua of hyoid bone. COURSE: Runs downwards and forwards parallel and just superficial to the external laryngeal nerve.

BRANCHES: INFRAHYOID ARTERY :Supplies infrahyoid muscles. it serves its muscles. STERNOCLEIDOMASTOID ARTERY :supplying Sterno Cliedo Mastoid on its deep surface. SUPERIOR LARYNGEAL ARTERY : Within the larynx. and mucosa. glands. CRICOTHYROID ARTERY: Supplies cricothyroid muscle .

but diverge slightly near the gland.  Damage to the external laryngeal nerve causes some weakness of phonation due to loss of tightening effect of the cricothyroid on the vocal cords . ligature of superior thyroid artery in thyroid surgery should be made close to the gland in order to avoid injury of the external laryngeal nerve.  So. APPLIED ANATOMY  The artery and external laryngeal nerve are close to each other higher up.

then becoming the linguofacial trunk.LINGUAL ARTERY ORIGIN: Arises from ECA opposite the tip of the greater cornua of hyoid bone. COURSE:Divided into three parts by hyoglossus muscle. . -It may arise in common with the facial artery. extends from origin to the posterior border of hyoglossus. FIRST PART – In carotid triangle.

THIRD PART [ ‘arteria profunda linguae’ ]— Also called as deep lingual artery. -It runs upwards along the anterior Border of hyoglossus.SECOND PART – Deep to hyoglossus. . then horizontally forwards on the undersurface of tongue .

DEEP LINGUAL ARTERY: Terminus of the lingual artery. and anastomosing with its counterpart on the other side. where it will anastomose with its counterpart of the other part. DORSAL LINGUAL ARTERY: supply the palatoglossal arch. to its apex.Passes along the ventral aspect of the tongue. .BRANCHES Has four branches: SUPRAHYOID ARTERY :supplies the muscles in its vicinity. and some of the soft palate SUBLINGUAL ARTERY : It supplies along with adjacent muscles in addition to the mucous membrane of the floor of the mouth and gingiva. accompanied by the lingual nerve. mucous membrane of the tongue. palatine tonsil. immediately deep to the mucous membrane.

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submandibular gland exposed . lifted. first part of artery is ligated before it gives any branches to the tongue or tonsil. platysma.  Muscle divided bluntly. in the gap of its vertical fibers lingual artery found & ligated. hyoglossus muscle visible.  Free border of mylohyoid muscle seen. deep fascia incised. .  Skin.APPLIED ANATOMY  In surgical removal of tongue . hypoglossal nerve identified. LIGATION OF LINGUAL ARTERY :  Incision – circling the lower pole of submandibular gland. tendon of digastric visible. Digastric tendon pulled downwards –enlarges the digastric triangle.

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FACIAL ARTERY ORIGIN: Arises from the ECA just above the tip of greater cornua of hyoid bone. . The course of the artery in both places is tortuous Cervical part : 1st ascends deep to the posterior belly of digastric&stylohyoid muscles Facial part :begins at the anterio inferior angle of masseter Then run upward and forwards to reach point ½ inch lateral to the angle of the mouth .neck as cervical part & face -- facial part. COURSE: Runs upwards in -.

and auditory tube. TONSILLAR ARTERY: supply the palatine tonsil and the posterior tongue. superior pharyngeal constrictor and neighbouring muscles. . BRANCHES CERVICAL PART: ASCENDING PALATINE ARTERY: Originates near the origin of facial artery supply the levator veli palatini. soft palate. tonsils.

SUBMENTAL ARTERY: -It supplies the submental triangle and sublingual salivary gland and forms anastomoses with several arteries in its vicinity. . including the mental and sublingual arteries.GLANDULAR ARTERIES: Distribute as three or four vessels to the submandibular gland to supply it and the adjacent area.

Angular artery: terminal part of facial artery supplying the medial corner of the eye and anastomosing with branches of the opthalamic artery .Facial part: INFERIOR LABIAL ARTERY :supplies lower lip SUPERIOR LABIAL ARTERY :supplies upper lip LATERAL NASAL ARTERY: this supplies ala and dorsum of the nose.

also while attempt to open a buccal abscess or mucocoele. if instrument enters the cheek at inferior vestibular fornix. .. o Can be injured –during operative procedures on lower premolars & molars.APPLIED ANATOMY  Facial Artery Compression: Applying pressure to the facial artery as it passes over the inferior border of the mandible just anterior to the angle will diminish blood flow to that side.

. In mandibular 1st molar region care must be taken not to injure the facial artery while extending the vertical incision down the vestibule during surgical extraction of mandibular impaction  So it is recommended that start vertical incision from the vestibule in upward direction.

platysma and deep cervical fascia cut  Artery is accompanied by facial vein & crossed superficially by marginal mandibular branch of facial nerve  Pulse of facial artery felt. Artery.  Exposed --at the point crossing the lower border of mandible . pulse of facial artery felt at point situated anterior to the attachment of masseter.  Skin.LIGATION OF FACIAL ARTERY. tied .isolated.  Incision .at least half inch below the border of mandible & parallel to it.  Using contracted masseter as a landmark.

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Skin. platysma and deep cervical fascia cut .

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or the facial artery just as it crosses the mandible anterior to the masseter muscle. anesthesiologists use either the superficial temporal artery. . Anaesthetist’s arteries: Rather than using the radial artery for determining pulse rate. accessed anterior to the ear just superior to the zygomatic arch.

POSTERIOR BRANCHES .

OCCIPITAL ARTERY ORIGIN:Arises in carotid triangle from posterior aspect of ECA .digastric etc. COURSE: Passes backwards and upwards along & under cover of lower border of post. Then it runs deep to the mastoid process and muscles attached to sternocleido mastoid .It is crossed at its origin by hypoglossal nerve. Belly of digastric . crossing carotid sheath. . hypoglossal & accessory nerves.opposite the origin of facial artery.

Finally it pierces the trapezius muscle and ascends in a tortuous course in the superficial fascia of the scalp. ..

 MASTOID BRANCH:–Enters cranial cavity through mastoid foramen. supplies dura of posterior cranial fossa. .upper branch accompanies the accessory nerve and lower branch arises near the origin of the occipital artery.. supplies mastoid air cells in the dura and diploe. IN THE POSTERIOR TRIANGLE and SCALP REGION:  AURICULAR BRANCH: Passes superficial to the mastoid process to reach and supply the back of the auricle.BRANCHES IN THE CAROTID TRIANGLE  STERNOMASTOID BRANCHES – Two in no.  MENINGEAL BRANCH – Ascends with the internal jugular vein and enters the skull through jugular foramen & condylar canal. Supplies sternomastoid m.

but superficial to the styloid process.It crosses the base of the mastoid process and ascends behind the auricle.POSTERIOR AURICULAR ARTERY ORIGIN: Arises from the posterior aspect of the external carotid artery just above the posterior belly of the digastric. COURSE:It runs upwards and backwards deep to parotid gland. .

 Auricular  Occipital. Stylohyoideus.BRANCHES  Besides several small branches to the Digastricus. and to the parotid gland. and Sternocleidomastoideus. this vessel gives off three branches:  Stylomastoid. .

MEDIAL BRANCH .

near its orgin COURSE: Ascends vertically between the internal carotid and the side of the pharynx. to the under surface of the base of the skull. ASCENDING PHARYNGEAL ARTERY ORIGIN:The branch arising from the medial side of the external carotid artery. .

. which supply the sympathetic trunk. PALATINE BRANCH: It passes inward upon the superior constrictor of pharynx.BRANCHES PHARYNGEAL BRANCHES :Are three or four in number. the hypoglossal and vagus nerves. Descend to supply the medial and inferior constrictors of pharynx and the Stylopharyngeus. PREVERTEBRAL BRANCHES: Are numerous small vessels. they anastomose with the ascending cervical artery. and the lymph glands. sends ramifications to the soft palate and tonsil. and supplies a branch to the auditory tube.

TERMINAL BRANCHES .

between the ramus of the mandible and the sphenomandibular ligament.MAXILLARY ARTERY ORIGIN: Large terminal branch given off behind the neck of the mandible. . where it lies parallel to and a little below the auriculotemporal nerve. and runs along the lower border of the lateral pterygoid. it crosses the inferior alveolar nerve.  The first or mandibular portion passes horizontally forward. COURSE: Divided into three parts by lateral pterygoid muscle.

 The third or pterygopalatine portion passes between the two heads of the lateral pterygoid and pterygomaxillary fissure. The second or pterygoid portion runs obliquely forward and upward superficial to the lower head of the lateral pterygoid. .to enter into the pterygopalatine fossa where it lies in front of the sphenopalatine ganglion.

First or Mandibular Portion 2. Second or Pterygoid Portion 3.BRANCHES 1.Third or Pterygopalatine Portion .

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.Supplies inner surface of tympanic membrane. dura mater and structures in infratemporal fossa. Anterior tympanic artery :. -It gives a branch to the temporomandibular joint. . MIDDLE MENINGEAL ARTERY (medidural artery):it supply the dura mater.anterior and middle cranial fossa Accessory Meningeal Branch supplies the semilunar ganglion. FIRST or mandibular part Deep auricular artery :supplies its cuticular lining and the outer surface of the tympanic membrane.

hole in the skull over pterion – 4 cm above mid point of zygomatic arch.hole is made 4cm above and behind the external acoustic meatus.  PARIETAL OR POSTERIOR BRANCH – contra lateral deafness APPROACH. .APPLIED ANATOMY  FRONTAL BRANCH – Extradural hemorrhage - hematoma presses on the motor area – hemiplegia of opposite side APPROACH.

Inferior Alveolar Artery ( inferior dental artery):
COURSE: Descends with the inferior alveolar nerve to
the mandibular foramen on the medial surface of the
ramus of the mandible.
It runs along the mandibular canal in the substance of the
bone, accompanied by the nerve, and opposite the first
premolar tooth divides into two branches, incisor and
mental.
The incisor branch is continued forward beneath the
incisor teeth as far as the middle line, where it
anastomoses with the artery of the opposite side;
The mental branch escapes with the nerve at the mental
foramen, supplies the chin, and anastomoses with the
submental and inferior labial arteries.

BRANCHES
BEFORE ENTERING MANDIBULAR CANAL:
 Lingual branch to the tongue.
 Mylohyoid branch to the mylohyoid muscle.
WITHIN THE MANDIBULAR CANAL:
Branches to the mandible
Branches to the roots of each teeth upto midline(dental
branches)
Incisor branch anastomoses with the branch from
opposite side.
AFTER EMERGING FROM MENTAL FORAMEN:
mental branch escapes with the nerve at the mental
foramen, supplies the chin, and anastomoses with the
submental and inferior labial arteries

BRANCHES OF SECOND PART
 Deep Temporal Branches: two in number, anterior
and posterior, ascend on the lateral aspect of the skull
between the Temporalis and the pericranium;
- Supply the muscle, and anastomose with the middle
temporal artery;
 Pterygoid Branches: supplies the medial and lateral
pterygoid.
 Masseteric Artery -It supplies the muscle, and
anastomoses with the masseteric branches of the
external maxillary and with the transverse facial artery.
Buccinator Artery ( buccal artery) :
-It supplies to the outer surface of the Buccinator,

BRANCHES OF THIRD OR
PTERYGOPALATINE PART
BEFORE ENTERING PTERYGOMAXILLARY
FISSURE:
 Posterior Superior Alveolar Artery ( alveolar or
posterior dental artery): .
-Descending upon the tuberosity of the maxilla, it
divides into numerous branches, some of which enter
the alveolar canals, to supply the molar and
premolar teeth and the lining of the maxillary sinus,
while others are continued forward on the alveolar
process to supply the gums.

 Digital pressure can be applied medial and superior to the maxillary tuberosity. .  Prevented by aspirating before giving LA in the site.APPLIED ANATOMY  Site of hematoma during PSA block.  Infratemporal fossa into which bleeding occurs accommodates large amount of blood.

COURSE. Infraorbital Artery : ORIGIN: Arises just before maxillary artery enters the pterygomaxillary fissure. and emerges on the face through the infraorbital foramen.It runs along the infraorbital groove and canal with the infraorbital nerve. BRANCHES: WITHIN THE CANAL (a) orbital branches (b) anterior superior alveolar branches ON THE FACE a) Branch to the lacrimal sac b) Branch to nose .

BRANCHES WITHIN THE PTERYGOPALATINE FOSSA: GREATER PALATINE ARTERY OR DESCENDING PALATINE ARTERY:  The terminal branch of the artery passes upward through incisive canal to anastomose with the sphenopalatine artery. the palatine glands.  While in the pterygopalatine canal it gives off lesser palatine arteries which descend in the lesser palatine canals to supply the soft palate and palatine tonsil. . and the mucous membrane of the roof of the mouth. Branches are distributed to the gums. anastomosing with the ascending palatine artery.

Applied anatomy  In case of abscess from palatal root of first molar. . incision should be made in an antero-posterior direction parallel to the artery.

 During lefort I osteotomy:  Greater palatine artery is easily injured during osteotomy of the medial or lateral maxillary sinus walls. pterygomaxillary dysjunction or during downfracturing of maxilla .

sending into the tympanic cavity a small branch which anastomoses with the other tympanic arteries. and is distributed to the nasopharynx.Passes backward along the pterygoid canal with the corresponding nerve. .  Pharyngeal Branch: It runs backward through the pharyngeal canal with the pharyngeal nerve. . Artery of the Pterygoid Canal . the auditory tube and sphenoidal air cells.It is distributed to the upper part of the pharynx and to the auditory tube.

maxillary. ethmoidal. . and sphenoidal sinuses.Sphenopalatine Artery It supplies the lateral wall of nose and frontal.

. -Contains anastomoses between  Superior labial branch of facial artery  Branch of sphenopalatine artery  Anterior ethmoidal artery  Greater palatine artery This is common site of bleeding from nose or epistaxis.LITTLE’S AREA or KIESSELBACH’S PLEXUS -Near the anteroinferior part or vestibule of the septum.

So it is advisable to remove ankylotic mass in pieces .  Ankylotic mass of TMJ may encircle the artery. .APPLIED ANATOMY OF MAXILLARY ARTERY  Surgeries involving condyle-Avoid injury to maxillary artery as it lies medial to condyle.

 During Le fort I osteotomy procedure- Pterygopalatine portion of maxillary artery may be injured during fracturing the pterygoid plates. .

to be the continuation of ECA. a frontal and a parietal. behind the neck of the mandible. . above this process it divides into two branches.SUPERFICIAL TEMPORAL ARTERY ORIGIN: The smaller of the two terminal branches of the external carotid. COURSE: It runs vertically upwards crossing over the root of the zygomatic process -About 5 cm. It begins in the substance of the parotid gland. appears.

and is accompanied by the auriculotemporal nerve.—. .it is crossed by the temporal and zygomatic branches of the facial nerve and one or two veins. Relations. which lies immediately behind it.

 Parietal .  Anterior Auricular. BRANCHES Besides some twigs to the parotid gland.  Middle Temporal. to the temporomandibular joint. and to the Masseter muscle. its branches are:  Transverse Facial.  Frontal.

Parietal branch Frontal branch Middle temporal artery Transverse facial artery .

ECA -LIGATION Can be done in carotid triangle or in Retromandibular fossa LANDMARKS  Upper border of thyroid cartilage  Carotid bulb  Internal jugular vein  Anterior jugular vein  lower border of mandible  Anterior border of sternocleidomastoid muscle .

-ECA is usually anterior and superficial to ICA but not always. . -Follow the ECA to its 2nd branch.atleast. except for rare exceptions.Ligation in carotid triangle: KEY POINTS: -ICA doesn’t branch in the neck.

-Be certain that vagus nerve. IJV.-Obtain control of CCA below bifurcation before ligation. hypoglossal nerve and superior laryngeal nerve are identified .

The posterior border of the incision is over the SCM. procedure  INCISION:A horizontal skin incision given at the level of hyoid bone and submandibular gland. two to three fingerbreadths below the angle of the mandible. .It is placed in a skin crease.

 The IJV.  identify carotid sheath.platysma. Dissection is carried through skin.then anterior border of SCM is identified and retracted posteriorly.  The CCA is carefully separated from other contents of sheath. . vagus nerve and ansa hypoglossi are retracted posteriorly.

. Usually at this place.a vesicular loop is placed loosely around CCA to obtain control.  Then dissection is carried up along the CCA to the bifurcation area.it should be preserved.  At this point hypoglossal nerve is identified crossing the branches.

-Follow the ECA to its 2nd branch.-ICA doesn’t branch in the neck. -The wound is closed in layers after the removal of vesicular loop from CCA . -ECA is usually anterior and superficial to ICA but not always. .except for rare exceptions.atleast -A 2-0 silk tie is placed between the superior thyroid and lingual arteries.

-Persistence of bleeding due to collateral flow.COMPLICATIONS: -Damage to vital structures. -Retrograde thrombus formation. .

the retromandibular vein or EJV is located.  Branches of great auricular nerve cut -. circling the mandibular angle.permit mobilization of cervical lobe of parotid gland.  Skin incision--. tied & cut. . continuing forward below the mandible one inch.  Skin & posterior fibers of platysma are cut.at line starting at the tip of mastoid process .LIGATION IN RETROMANDIBULAR FOSSA: Done when there are maxillary artery injuries.

widens the entrance into retromandibular fossa .  This movement--. tenses the stylomandibular ligament.  Pulsations of ECA are felt . Above this stylomandibular ligament can be palpated if lower jaw of the patient is pulled forward. isolated & tied. Parotid gland retracted . .stylohyoid muscle is visible. Attachment of parotid capsule to the anterior border of sternomastoid severed with scalpel.  post. Belly of digastric .

6(2):111–114. Homze co et al(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997.VOL 3  DANIEL M . . 1887.LASKIN TEXTBOOK OF ORAL AND MAXILLO FACIAL SURGERY –VOL 1  NEELIMA ANIL MALIK TEXTBOOK OF ORAL AND MAXILLO FACIAL SURGERY –VOL 3  TEXTBOOK OF HISTOLOGY –GP PAL  Extraoral ligation of the lingual artery An anatomic study by  Eric J.83:321-4)  4. Ann Surg. A synopsis of five successful cases.D. Ligation of the external carotid artery. Wyeth JA.REFERENCES  B.CHAURASIA’S HUMAN ANATOMY.