ARTERIAL SUPPLY OF HEAD AND NECK

 PRESENTED BY
Dr Suman B Godi
1st MDS
Department of OMFS
 CONTENTS
 INTRODUCTION
 THE BLOOD VESSELS
 EMBRYOLOGY
 THE COMMON CAROTID ARTERY
 THE EXTERNAL CAROTID ARTERY
 THE INTERNAL CAROTID ARTERY
 APPLIED ANATOMY
 DIAGNOSTIC AIDS IN ARTERIAL SYSTEM
 HEMORRHAGE CONTROL IN MAXILLOFACIAL
REGION
 CONCLUSION
INTRODUCTION
 Arteries of head and neck regions are mainly the branches
of External Carotid Artery with a few exceptions.
 ECA Known as Facial Carotid Artery as it supplies
superficial and deep structures of face.
 Only parts of nasal cavity and upper parts of face receive
branches of Internal Carotid Artery
 ICA also known as Cerebral Carotid Artery as it supplies
blood almost exclusively to brain.
 External and Internal carotid arteries are branches of
Common Carotid Artery.
 THE BLOOD VESSELS
Arteries :- Carries oxygenated blood away from here to tissue.
As they move away from heart diameter of vessels get
reduced

Branches off into Arterioles

Arterioles becomes Capillaries

Diameter increases when vessels bring deoxygenated blood

back to heart

Capillaries become venules

 EMBRYOLOGY
AORTIC ARCHES known as pharyngeal arch arteries or branchial
arches
 Formed sequentially within pharyngeal arches

 Present during 4th and 5th week of IUL

 6 Pairs in total
 1st ,2nd and 5th pair disappear soon
 COMMON CAROTID ARTERY
 COMMON CAROTID ARTERY

RIGHT SIDE - BRACHIOCEPHALIC ARTERY

LEFT SIDE – DIRECT BRANCH OF ARCH OF AORT

BRANCHES OF COMMON CAROTID ARTERY
 Runs lateral to trachea and larynx to level of upper
border of thyroid cartilage
 Divide above, rarely below the level of superior border
of thyroid cartilage
 ICA - posteromedial
 ECA - anterolateral
CAROTID SINUS
 Slight dilation at termination
of CCA or beginning of ICA
 Tunica media is thin ,
adventia is thick
 Rich innervation fron
glossopharyngeal &
sympathetic nerve
 Baroreceptor – regulates
blood pressure
CAROTID BODY
 Small, oval reddish brown
structure situated behind the
bifurcation of CCA
 Rich nerve supply from
glossopharyngeal , vagus and
sympathetic nerves
 Chemoreceptor –responds to
changes in oxygen ,carbon
dioxide & pH content of blood
EXTERNAL CAROTID ARTERY
 One of the terminal branches of CCA
 Arise under cover of anterior border of sternocleidomastoid
muscle, soon after become superficial
 Covered by –Investing layer of deep cervical fascia,
platysma,subcutaneous tissue / superficial fascia & skin
 Slightly Curved course – it is anteromedial to ICA in lower part
anterolateral to ICA in upper part
 In the Carotid triangle – ECA is superficial
Deep to artery – Wall of pharynx ,superior laryngeal nerve
ascending pharyngeal artery
 Above Carotid triangle – ECA Deep in substance of parotid gland
Deep to the artery – ICA
Structures passing b/w ICA & ECA
 Styloglossus, stylopharyngeus , glosopharyngeal nerve , pharygeal
branch of vagus nerve
Structures deep to ICA
 Superior laryngeal nerve ,superior cervical sympathetic ganglion
BRANCHES OF EXTERNAL CAROTID ARTERY
ANTERIOR BRANCHES

SUPERIOR THYROID ARTERY

 Arise at or immediately above bifurcation of CCA
 Curves anteriorly & downwards to reach thyroid gland and
divides into
Anterior branch and Posterior branch ( Send secondary branch to
thyroid gland )
 This arch is characteristic & serves as diagnostic landmark in
surgical exposure of ECA
BRANCHES OF SUPERIOR THYROID ARTERY

 HYOID ARTERY / INFRAHYOID BRANCH

 STERNOCLEIDOMASTOID ARTERY

 SUPERIOR LARYNGEAL ARTERY

 CRICOTHYROID ARTERY
LINGUAL ARTERY
 Arise at opp to tip of greater cornua of hyoid bone
 Tortuous in course
 Divided into 3 parts by hyoglossus muscle
1st part – lies in Carotid triangle
2nd part - lies deep to hyoglossus along the upper border of hyoid
bone
3rd part - arteria profunda / deep lingual artery
Branches- Suprahyoid
Dorsal lingual
Sublingual
FACIAL ARTERY
 Arise just below posterior belly of digastric muscle
 Has a common origin with lingual artery (linguofacial trunk)
 Crosses posterior belly of digastric muscle & stylohyoid muscle
to enter submandibular triangle where it is covered by
submandibular salivary gland
 From superior border of gland it travels through angle of
mandible to reach lower pole of palatine tonsil
 Reaches lower border of mandible , where it swings around the
border under antegonial notch to enter face
 In face lies superficially, covered by platysma,superficial fascia
& skin

( Pulse of artery can easily be felt ar lower border of mandible

or slightly above it & infront of masseter muscle )
CERVICAL BRANCHES FACIAL BRANCHES
 ASCENDING PALATINE  SUPERIOR LABIAL

 TONSILAR ARTERY  INFERIOR LABIAL

 SUBMENTAL ARTERY  LATERAL NASAL

 GLANDULAR BRANCHES  ANGULAR ARTERY

POSTERIOR BRANCHES

OCCIPITAL ARTERY
 Arise at the same leve as that of the facial artery
 Travels to lower border of posterior belly of digastric muscle &
reaches space between transverse process of atlas & mastoid
process
 Crosses mastoid process
 Perforates aponeurotic connection between tendons of trapezius
& sternocleidomastoid muscle
 Artery become superficial & divides to supply posterior part of
scalp & deep musculature of neck
 STERNOCLEIDOMASTOID BRANCH

Arise from 1st part of occipital artery

Loops around hypoglossal nerve

Enters sternocleidomastoid muscle

POSTERIOR AURICULAR ARTERY
 Arise in retromandibular fossa just above stylohyoid muscle
 Reaches groove between cartilage of outer ear and mastoid
process
 Partly supplies outer ear & adjacent area of scalp
 Anastomoses with occipital artery & auricular branches of
superficial temporal artery
 BRANCH – STYLOMASTOID ARTERY
Enters stylomastoid foramen
Runs along facial nerve to supply tympanic cavity
MEDIAL BRANCHES

ASCENDING PHARYNGEAL ARTERY

 Only medial branch of ECA
 Arises from medial or posteromedial wall of external carotid
immediately above division of common carotid
 May arise as a branch of occipital artery
 Supply – wall of pharynx , stylopharyngeus muscle, tensor &
levator palati muscle , deep muscles in front of vertebral columns
 Travels from lateral pharyngeal wall to base of skull
 Travels from lateral pharyngeal wall to base of skull
 At base of skull, anastomose with pterygoid artery of maxillary
artery

( enter the cavity of the skull along with trigeminal ,vagus &
hypoglossal nerve )
TERMINAL BRANCHES

SUPERFICIAL TEMPORAL ARTERY

 Continues the course of ECA in retromandibular fossa
 Crosses posterior root of zygomatic arch in front of outer ear

After emerging from parotid gland it is superficial

Pulse of artery is felt here

 Before leaving parotid gland release - Transverse Facial Artery at

level of mandibualr neck
BRANCHES
 PARIETAL ARTERY

 FRONTAL ARTERY
 ZYGOMATICO – ORBITAL
 MIDDLE TEMPORAL ARTERY
IN BRIEF
MAXILLARY ARTERY
 Larger terminal branch of ECA
 Arise below the neck of mandible in substance of parotid gland

SUPPLY
 External & middle ear , auditory tube

 The dura mater

 Upper and lower jaws
 Muscle of temporal and infratemporal regions

 Nose and paranasal air sinus

 Palate & roof of pharynx
FIRST/MANDIBULAR PART SECOND/PTERYGOID PART
 DEEP AURICULAR  MASSETRIC
 ANTERIOR TYMPANIC  DEEP TEMPORAL
 MIDDLE MENINGEAL  PTERYGOID
 ACCESSORY MENINGEAL  BUCCALS
 INFERIOR ALVEOLAR PTERYGOPALATINE PART
THIRD / MAXILLARY PART  DESCENDING PALATINE
 POSTERIOR SUPERIOR  ARTERY OF PTERYGOID
ALVEOLAR CANAL
 INFRAORBITAL  SPHENOPALATINE
INTERNAL CAROTID ARTERY

 Arise along lateral wall of pharynx & travels to the base of skull

 At base of skull , passes through carotid canal to enter cranial

cavity where it is present above fibrocartilage which fills and
close foramen lacerum

 Initially lies medial to ECA but in its course moves away from
ECA
CERVICAL PART
 Enclosed in sheath
 No branches
 Initial part shows dilation
 Lower part is superficial
 Upper part above post belly
of digastric is deep to parotid
gland
PETROUS PART
 Emerges at petrous temporal
bone in posterior wall of
foramen lacerum
 Branches
 CAROTICOTYMPANIC
BRANCHES- Enter middle ear
and anastomoses with ant &
post tympanic artery
 PTERYGOID BRANCH-
Enters pterygoid canal &
anastomoses with greater
palatine artery
CAVERNOUS PART CEREBRAL PART
 Covered by lining Divided into
endothelium of veins  Opthalmic artery
 Surrounded by sympathetic  Anterior cerebral
plexus:  Middle cerebral artery
occulomotor, trochlear,  Posterior communicating
opthalmic & abducens  Anterior choroidal artery
OPTHALMIC ARTERY
 Supply – eyeball ,its muscles, lacrimal gland
 Sends branches into eyelid and upper part of face
 BRANCHES :

1-Central artery of retina 2- Posterior ciliary artery

3-Supraorbital artery 4- Med Palpebral artery
5-Ant & post Ethmoidal artery 6-Anterior ciliary artery
7-Supratrochlear artery 8-Dorsal nasal artery
9-Lacrimal artery
APPLIED ANATOMY

Anterior palatine artery

 Major palatine foramen- situated at palatal to last molar of maxilla
& at the border between the inner plate of alveolar process the &
roof of oral cavity
PRECAUTIONS
 Incision of palatine abscess should be given in anteo posterior line
, never in tranverse direction
 Incision – given near free gingival margin without missing abscess

 Edge of knife should be directed outward & upward & not straight
upwards
Sublingual artery
 Injury due to sharp instruments / rotating discs slips off a lower
tooth & injure floor of mouth
 Injury in region of premolar / first molar , sublingual artery may
be severed where it is in considerable volume
 The hemorrhage from thid artery may then be serious incident

MANAGEMENT
 Local clamping of artery attempted ( difficult)
 To stop bleeding at place of injury fail , lingual artery must be
ligated
Facial artery
 Performing operative procedures on lower premolar & molars the
facial artery can be severed accidentally if an instrument enters
the buccal region
 Deep incisions may endanger the facial artery

PRECAUTIONS
The incision should be made downward & outward instead of
straight downward
Knife should not be allowed to penetrate the lateral or inferior wall
of abscess
DIAGNOSTIC AIDS IN ARTERIAL SYSTEM

MAGNETIC RESONANCE ANGIOGRAPHY (MRA)

 MRI examination of blood vessels

 Detection of heart disorders , stroke & blood vessel abnormalities

CT ANGIOGRAPHY (CTA)
 Less invasive , more patient friendly
 Uses x-rays to visualise blood flow in arterial and venous vessels
 Contrast material injected into small peripheral vein using small
needle / catheter
SONOGRAPHIC VASCULAR IMAGING
 Imaging extracranial carotid vessels

 Used to measure blood velocity in the middle cerebral & other

intracranial arteries

 Grey scale imaging used to visualise the vessels & to document

state of vessel wall

 Doppler spectral analysis – determine blood flow velocity

DIRECT INTRA –ARTERIAL ANGIOGRAPHY
 Originally performed by percutaneous puncture of CCA in neck

 Nowadays performed by transfmoral approach

 CAUTION – In middle – elder patients , in passing catheters into

the ICA , Particularly if there is any suspicion of atheromatous
internal carotid artery stenosis
HEMORRHAGE CONTROL IN MAXILLOFACIAL
REGION ( LIGATION OF ARTERY )

LIGATION OF FACIAL ARTERY

 Facial artery – easily exposed at point of lower border of
mandible to pass from submandibular region into face

 Facial artery is crossed superficially by the marginal mandibular

branch of facial nerve

 Operation should be planned such that nerve is not in danger of

being cut
 By giving end incision atleast ½ inches below lower border of
mandible and parallel to mandible

Skin ,platysma ,muscle , deep fascia are cut & then soft tissues
are bluntly retracted until pulse of facial artery is felt

Artery then can be isolated , tied & cut

LIGATION OF LINGUAL ARTERY
 The submandibular gland is palpated through the skin & an incision
is made that circles the lower pole of this gland
 Posterior part of incision should point towards – tip of mastoid process
 Anterior part of incision should point towards the chin

 Skin , platysma & deep fascia are incised the lower pole of the
submandibular gland is exposed

 If gland is lifted from its bed by blunt dissection & entire flap is
retracted upward the tendon of the digastrics muscle becomes
visible
 Following the tendon anteriorly the free border of mylohyoid
muscle is easily ascertained where it is crossed by tendon above
the tendon above the hyoid bone

 The lingual triangle between digastric tendon , posterior

mylohyoid border & the hypoglossal nerve has been circumscribed

 Pulling the digastric tendon downward help to enlarge triangle

 At the floor of which vertical fibres of hyoglossus muscle is

visible

 In the gap between its vertical fibres the lingual artery is found &
ligated
LIGATION OF ANTERIOR ETHMOIDAL ARTERY

 Branch of opthalmic artery in orbit

 Passes through medial orbital wall into upper nasal cavity

 Accessed through local incision

 Following incision & dissection , vessel is identified

 Vessel is then ligated ,clipped or cauterized depending on its size

LIGATION OF EXTERNAL CAROTID ARTERY

2 Points at which artery can be exposed & ligated

 Exposure in carotid triangle

 Exposure in retromandibular fossa

EXPOSURE IN CAROTID TRIANGLE
 Incision of skin starts at level of mandible just behind the
anterior border of the sternocleidomastoid muscle

 Continued downwards , parallel to the border of the muscle to the

level of the cricoid cartilage

 After penetrating skin & platysma muscle

 superficial sheath of the sternocleidomastoid muscle is incised

 Bluntly the anterior border of muscle is exposed & the muscle is

retracted
 Thus the deep layer of sternocleidomastoid sheath becomes
visible and through it internal jugular vein

 Infront of this vein the fascia is cut to expose the arteries

 The ECA is identified by its first ant branch , superior thyroid

artery

 Isolated & tied few millimeters above origin of superior

thyroid artery

 Care should be taken not to injure hypoglossal nerve

EXPOSURE IN RETROMANDIBULAR FOSSA

 ECA is ligated in the retromandibular fossa behind the angle of

mandible

 ECA crosses stylomandibular ligament on its lateral side

 Also called “ ligation of ECA at stylomandibular ligament”

 Simple and less dangerous than exposure of ECA in neck

 The skin is incised in a line starting at a tip of mastoid process

encircling the mandibular angle
 Continuing forward below the mandible for about 1 inch

 Incision is kept at an equal distance from the posterior and

inferior borders at the mandible

 Scalpel has passed through the skin and some of the posterior
fibres of platysma muscle ,

 External jugular vein or retromandibular vein is located ,tied &

cut

 To this end the attachment of parotid capsule to the anterior border

of the sternocleidomastoid muscle has to be severed with scalpel
 The flap of soft tissue consisting of skin & parotid gland is retracted
anteriorly & upward

 Immediately underneath the parotid gland the post belly of digastric

muscle becomes visible

 Slightly above it the thin round flesh of styloid muscle becomes visible

 Above muscle styloid process and stylomandibular ligamet can be

palpated

 At this line pulse of ECA can be felt & it is easy to isolate the artery & tie
it
CONCLUSION

The anatomy of thr arteries of the head and neck has

many significant applications in maxillofacial surgery
Understanding these important anatomic relations –
variations enables surgeons to perform surgical
procedures safely
Knowledge of these concepts helps us to recognize
the problems & complications as and when they occur
and manage them accordingly.
REFERENCES