Arterial Suppply of Head&Neck

8/13/2019 Arterial Suppply of Head&Neck

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ARTERIAL SUPPLY OFTHE HEAD AND NECK

MADE BY :DR. PRAVEEN YADAVPG Ist YEARORAL AND MAXILLOFACIAL SURGERY


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Pulmonary trunk

Major arteries

Right brachiocephalicartery

Left common carotidartery

Left subclavianartery

Right commonCarotid artery

Right subclavianartery

Aorta


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External Carotid - exterior of head ,face and neck.

Internal Carotid - cranial and orbital

contents .


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Right commoncarotid artery

Left commoncarotid artery

Origin

Bifurcation of thebrachiocephalictrunk

Arch of aorta

Termination At the level of upper border of thyroidcartilage


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The courses of the left andright common carotids aresimilar.

Both start behind thecorresponding sternoclavicular joints running laterally upwardsat the level of upper border of

thyroid cartilage.

Here it terminates by dividinginto external and internal

carotids.


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Common carotid arteryis enclosed in the carotidsheath , 3 contents of thesheath are

The common carotidmedially.

internal jugular veinlaterally.

vagus in b/w artery andthe vein posteriorly.


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The common carotid is related :

MEDIALLY: Thyroid gland , larynx, pharynx,trachea, oesophagus.

LATERALLY: Internal jugular vein and the

vagus nerve.


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CAROTID SINUS : The termination of the common carotid arteryor the beginning of the internal carotid artery

shows a slight dilatation , known as carotidsinus.Here the tunica media is thin, and theadventitia is thicker which recieves a richinnervation by the 9 th nerve and sympatheticnerves .It acts as a baroreceptor or a pressure receptorand regulates blood pressure.


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It is a small reddish brown structure situatedbehind the bifurcation of the commoncarotid.

Recieves nerve supply from the 9 th , 10 thand the sympathetic nerves.

Acts as a chemoreceptor and responds tochanges in oxygen, carbon dioxide and pHcontent of the blood.


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Begins lateral to the upperborder of the thyroidcartilage , level with theintervertebral disc b/w the3rd & 4th cervical vertebrae.

Passes midway b/w the tip ofmastoid process & the angleof the mandible , in thesubstance of parotid glandbehind the neck of themandible it divides intoterminal branches.


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The external carotid artery has a slightlycurved course , so that it is anteromedialto the internal carotid artery in its lowerpart and anterolateral to the internalcarotid artery in its upper part.


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Anterior : Superior thyroidLingualFacial

Posterior: OccipitalPosterior auricular

Medial: Ascendingpharyngeal

Terminal: MaxillarySuperficial

temporal


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LIGATION OF ECA

Done at 2 pointsArtery exposed at its origin &ligature above superior thyroidartery upper part of neck,superficial & deep structures ofneck .Ligation higher up, behind theangle of lower jaw- maxillaryartery injuries.UNILATERAL LIGATION willnot stop hemorrhage


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A] LIGATION OF ECA IN CAROTID TRIANGLE:-Skin incision-- at the level of angle of mandiblebehind anterior border of sternocleidomastoid

muscle ,continued downward to the level ofcricoid cartilage.

-- Platysma, superficial sheath of sternomastoidincised, muscle exposed & retracted ,deep layerof sternomastoid head is visible & IJV through it.-- Fascia in front of vein is cut to expose thearteries.


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Arises from the externalcarotid artery just below thelevel of the greater cornua of

the hyoid bone.Runs downwards and parallelsuperficial to external

laryngeal nerve to reach theupper pole of thyroid gland.


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The artery and the external larygeal nerve are in closeapproximation higher up but diverge near the gland.

To avoid injury to the external laryngeal nerve, thesuperior thyroid artery is ligated as near to the glandas possible whereas in case of inferior thyroid artery , it isligated as far away from the gland as possible to save

the reccurent laryngeal nerve.

Its relationship to the external laryngeal nerve isimportant during thyroid surgeries.


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Origin begins at the anteromedial part ofexternal carotid artery at tip of greater cornu ofhyoid bone between superior thyroid and facial

arteries.

Course after short course lies deep to

hyoglossus muscle , finally leaves the muscle inthe tongue to anastomose with the lingual arteryof opposite side.


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The course is divided into 3parts by hyoglossus muscle.The first part lies in thecarotid triangle .It forms a characteristicupward loop which is

crossed by the hypoglossalnerve .The lingual loop permitsfree movements of the

hyoid bone.


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The 2nd part lies deepto the hyoglossusalong the upper border

of hyoid bone.

It is superficial to themiddle constrictor of

pharynx.

Covered by hyoglossusand mylohyoid.


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The 3rd part - also calledthe arteria profundalinguae or the deeplingual artery. Extends from anterior

border of hyoglossus tothe tip of tongue.

The horizontal part ofthe artery isaccompanied by lingualnerve.


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During surgical removal of thetongue, the first part of the artery isligated before it gives any branch tothe tongue or the tonsil.


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2] sublingual artery -- injury occurs inpremolar & molar region, when sharp

instrument or rotating disks slips off a lowermolar & injure the floor of mouth.


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Incision circling the lowerpole of submandibulargland.

Posterior part towards tipof mastoid ; anterior part towards chin.

Skin, platysma, deep fasciaincised, submandibulargland exposed ,lifted,tendon of diagastricvisible.


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Free border of mylohyoid muscle ascertained, hypoglossalnerve identified.

Digastric tendon pulled downwards enlarges the digastric

triangle, hyoglossus muscle visible.Muscle divided bluntly, in the gap of its vertical fibers lingualartery found & ligated.


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Arises from the external carotid just above thetip of the greater cornua of the hyoid bone.

It runs upwards in the neck first as a cervical partand then as facial part.

The course of the artery is tortuous in bothplaces . The tortuosity allows free movements ofthe pharynx during degluttion. On the face itallows free movements of the mandible , thelips and the cheek.


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The facial artery has twoparts:

Facial part

Cervical part


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Supralabial to the upper lip.

Infralabial to the lower lip and anteroinferiorpart of the nasal septum.

Lateral nasal - to the ala and dorsum of thenose.


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It runs upwards on thesuperior constrictor ofpharynx, deep to posteriorbelly of digastric.

It forms two loops - firstwinding over the

submandibular gland andthen over the base of themandible.


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1. Ascending Palatine : supplies the tonsil androot 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 submandibularsalivary gland and the lymph nodes.


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During injury of the face bleeding from thefacial artery can be stopped by compressing

the artery against the lower border of themandible.

The pulsation of the artery can be felt alongthe lower border of the mandible near theantero-inferior angle of the masseter muscle.


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facial artery can be injured duringoperative procedures on lower premolars &

molars, if instrument enters the cheek atinferior vestibular fornix., also while attemptto open a buccal abscess.


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

Using contracted masseter as

a landmark, pulse of facialartery felt at point situatedanterior to the attachment ofmasseter.

Artery is accompanied byfacial vein & crossedsuperficially by marginalmandibular branch of facialnerve.


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Taking this into consideration, incision -- atleast half inch below the border of mandible

& parallel to it.

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


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1. Arises from the posterior aspect of externalcarotid just above the posterior belly of digastric.

2.Course : lies superficial to styloid process andcrosses the base of the mastoid process, ascendingbehind the auricle .

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


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1. Stylomastoid : suppliesthe middle ear, mastoidantrum and semicircularcanals .

2. Auricular : supplies thelateral aspect of auricle.

3. Occipital : supplies thescalp above and behind theear.


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

ASCENDINGPHARYNGEAL ARTERY


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1. Arises from the posterior aspect of the external carotidartery, opposite the origin of the facial artery.

2.It is crossed at its origin by the hypoglossal nerve. In thecarotid triangle the artery gives two sternomastoidbranches.

3. The upper branches accompany the accessory nerve &the lower arises near the origin of the occipital artery.


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1. Meningeal. 2. Sternomastoid. 3. Mastoid. 4.Auricular .

Essentially suppliesthe back of the neck

and the scalp alongwith posterior part ofthe ear.

OCCIPITALARTERY


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Superficial branch anastomosis withascending branch of transverse cervical

artery. Deep branch of descending br of occipitalartery anastomosis with deep cervical artery (costo-cervical trunk )

Important for neurosurgeons


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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.


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Passes between themandibular neck and thesphenomandibularligament.

It crosses the inferioralveolar nerve & passes

around the lower borderof the mandible.


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1. Deep Auricular andAnterior Tympanic - supplythe ear and tympanicmembrane , TMJ.

3. Middle Meningeal-supplies the bone andmeninges of temporal

region , 5th

and 7th

nerves.

4. Accessory meningeal-meninges and

infratemporal fossa.


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5. Inferior Alveolar Supplies the lower teethand mylohyoid muscle.


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Gives off mainly muscularbranches.

Deep temporal totemporalis.

Pterygoid to thepterygoid muscles.

Massetric to masseter

Buccal artery - to buccinator.


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Passes between the heads ofpterygoid and throughpterygomaxillary fissureinto the pterygopalatinefossa.BRANCHES:

1.Posterior superior alveolar-

molars, premolars andmaxillary sinus.2. Infraorbital- the incisors,canines, nose and upper lip


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Greater Palatine- emerges through greaterpalatine foramen to supply the palate and gums.

Pharyngeal- nasopharynx , auditory tube andsphenoidal sinus.

Artery of pterygoid canal- pharynx , tympanic

membrane.Sphenopalatine- lateral wall of the nose and nasalseptum.


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Fractures involving the ramus of themandible injures the inferior alveolar

artery and cause profuse bleeding.


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MIDDLE MENINGEAL ARTERY ( frontal branch )

extradural hemorrhage hematoma presses onthe motor area hemiplegia of opposite sideAPPROACH- hole in the skull over pterion 4 cmabove mid point of zygomatic arch MMA ( parietal or posterior branch )-contralateral deafnessAPPROACH- hole is made 4cm above and 4cmbehind the external acoustic meatus.


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POSTERIOR SUPERIOR ALVEOLAR ARTERY-site of hematoma during PSA block.

- prevented by aspirating before giving LA in thesite.GREATER PALATINE AND ANTERIOR PALATINEARTERY. case of abscess from palatal root offirst molar,incision should be made in a antero-posterior direction ,then transversly. Incision made near free margin of gingiva.Edge of knife directed outward, upward.


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It is the smaller of the two terminal branches ,begins in the parotid gland behind neck of themandible.

It crosses the posterior root of zygomaticprocess of temporal bone, divides intoanterior and posterior branches which supply

the temple and the scalp.


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The pulsations of the artery can be felt on thezygomatic arch as it crosses the root of zygomaor pre-auricular point.

Anastomoses freely ; partially detached withscalp , in case of injury heals with reasonably

well.

In reduction of zygomatic arch fractures Gillis

temporal approach the artery is encountered.


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A] Arteries endangered during minor surgicalprocedures or dental treatment :

1. anterior palatine artery2. sublingual artery3. facial artery


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B] ARTERIES ENDANGERED DURINGORTHOGNATHIC SURGERIES : Pterygopalatineportion of maxillary artery during Le fort I

osteotomy procedureIn mandibular orthognathic surgery, collateralblood supply is central to preservation ofosteotomised segments.Carotid A. may be susceptible to damage duringorthognathic surgery.Thrombosis of ICA can occur after surgery due toexcessive extension of head & neck.


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


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


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MUSCLE FLAPS They carry their blood supplywith 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 areaof carotid bulb.

-- myocutaneous flaps --- standard techniques inintraoral reconstruction. lap levator scapulae


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DERMAL GRAFTS : Alternative method ofprotection.Standard split skin graft used,removing astrip of underlying dermis & replacing theskin graft in its original site. Dermal strip along entire length of carotidprovide extra layer of protective collagen.


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It arises in the neck as one of the terminalbranches of the common carotid artery at thelevel of the upper border of the thyroid

cartilage opposite the disc between the C3 and C4& ends inside the cranial cavity by supplying thebrain.Its course is divided into the following 4 parts :CervicalPetrousCavernousCerebral


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It ascends vertically in the neck from its origin atthe base of the skull to reach the lower end of thecarotid canal .

It is enclosed within the carotid sheath.

No branches arise from the internal carotid arteryin the neck.


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Its initial part usually shows a dilatation , thecarotid sinus which acts as baroreceptor.

The lower part of the artery is comparativelysuperficial. The upper part, above the posteriorbelly of the digastric , is deep to the parotid gland,the styloid apparatus & many other structures.


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Relations

Posteriorly -sup cervical ganglion,sup laryngealnerve Medially - ascending pharyngeal arteryAnterolaterally - sternocleidomastoid muscleInferiorly-digastric, hypoglossal nerveAt the level of digastric - stylohyoid muscle,posterior branches of ECAAbove the digastric - styloid process,deeper partof parotid gland Internal carotid artery


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In the cervical regionthe internal carotid isrelated to the 9 th , 10th

and 11th

cranialnerves, sternomastoidmuscle, common facialvein, lingual veinand external carotidartery.


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It is that part located entirely in the petrouspart of the temporal bone.

From the posterior wall of foraman lacerum ,it turns upwards and medially.

Here it is related to the middle ear, auditorytube and trigeminal ganglion.


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Relations

Surounded by venous and sympatheticplexuses Posterolaterally-middle ear and cochlea Anterolaterally- auditory tube and tensortympaniSuperiorly- trigeminal ganglion Internalcarotid artery


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a) Caroticotympanic enters middle ear andanastomoses with ant. andpost. tympanic arteries.

b) Pterygoid branch -enters the pterygoid canal

and anastomoses with thegreater palatine artery.


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The internal carotid ascends to the posteriorclinoid process and emerges through the dorsalroof of the cavernous sinus.

Here it gives off the following branches :a) Cavernous branches to trigeminal ganglion.

b) Superior and inferior hypophyseal branchesto the hypophysis cerebri.


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Lies at the base of the brain after emerging fromthe cavernous sinus.

Gives off the following arteries:

1) Ophthalmic

2) Anterior cerebral

3) Middle cerebral


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4) Posterior communicating5) Anterior choroidal.

Of these the ophthalmicsupplies structures in theorbit ; while the otherssupply the brain.


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The curvature of the petrous, cavernous and thecerebral parts of the internal carotid arterytogether form an S shaped figure , called the

Carotid siphon of angiograms.


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The Circle of Willis (also called Willis' Circle,cerebral arterial circle , arterial Circle of Willis, andWillis Polygon ) is a circle of arteries that supply

blood to the brain.

It is named after Thomas Willis (1621 1673) , an

English physician.


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The Circle of Willis comprises the followingarteries :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)


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If one part of the circlebecomes blocked ornarrowed (stenosed) orone of the arteriessupplying the circle isblocked or narrowed,blood flow from the other

blood vessels can oftenpreserve the cerebralperfusion well enough toavoid the symptoms of

ischemia.


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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 proximalstenosis (narrowing) of the subclavian artery, an

artery supplied by the aorta which is also the samevessel that eventually feeds the Circle of Willis viathe common carotid artery.


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LINGUAL TOUNGE FLAP-


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Posteriorly based dorsal tongue flap- dorsallingual artery

Anteriorly based dorsal tongue flap- ranine arch which is


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Anteriorly based dorsal tongue flap ranine arch which isa terminal branch from the forward continuation of thelingual artery

Transverese dorsaltongue flap- is created in


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tongue flap is created inbipedical form such thatflap is transveredanteriorly from thetoung to the floor of themouth

Perimeter flap- may beuni or bipedical in design- used for repair of lip

vermilion defects.

Ventral based flaps-limited usefulnessbecause there thickness

is minimum.

Lateral thigh flap prof nda femoris arter


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Lateral thigh flap- profunda femoris artery

PEDICALED MYOCUTANEOUS FLAPS

Sternocledomastoid myocutaneous flap occipital artery


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Sternocledomastoid myocutaneous flap-occipital arterysuperior thyroid arteryinferior thyroid arterya branch from thyrocervical trunk

Temporalis/ forehead flap- anterior and posterior deeptemporal arteries.

Auriculomastoidfasciocutaneous island


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fasciocutaneous islandflap-- parietal branches ofsuperficial temporal artery- occipital artery- posterior auricular artery

Trapezius myocutaneousflap-

- transverse cervical artery,a branch fromthyrocervical trunk.

Platysmal myocutaneousflap- submental branch of


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flap submental branch offacial artery

Latissimus dorsimyocutaneous flap-thoraco dorsal artery,which is a terminal branch

of scapular artery thatcomes from third divisionof axillary artery.

Deltopectoralis majormyocutaneous flap-- thoracoacromial artery- lateral and superiorthoracic artery


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C.J.Romanes Cunnighams manual of practicalanatomy 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.


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Arterial Suppply of Head&Neck

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