Good Morning

Blood supply of head and neck

By A. Vamsi krishna II M. D. S

Contents Functional morphology

Embryology

Common carotid artery

External carotid artery

Internal carotid artery

Venous drainage of face

Venous sinuses

Applied anatomy

Conclusion

References

FUNCTIONAL MORPHOLOGY

Junction between endothelial cells in capillaries

Tight junctions- in brain. Permits smaller molecules

Gap junctions- in skeletal, cardiac & smooth muscle capillaries. Permits molecules up to 10 nm

Fenestrations- in kidneys, endocrinal glands, intenstinal villi. Permits molecules up to 20-100 nm.

FEATURES

Tunica Intima-Endothelium

Internal elastic membrane

Tunica media

External elastic membrane

Tunica externa

Artery

Usually rippled due vessel constriction

Present

Thick, dominated by smooth muscle cells and elastic fibers

Present

Collagen and elastic fibers

Vein

Often smooth

Absent

Thin, Dominated by smooth muscle cells and collagen fibers

Absent

Collagen, elastic fibers and smooth muscle cells

Aortic arches

Aortic arches are short vessels connecting ventral and dorsal aortae on each side they run within branchial (pharyngeal) arches are based gradually in the 4th and 5th week, in 6 pairs in total.The first, second and fifth pairs soon disappear

The 1st aortic arch – disappears (a small portion persists and forms a piece of the maxillary artery)

The 2nd aortic arch – disappears (small portion of this arch contributes to the hyoid and

stapedial arteries)

The 3rd aortic arch - has the same development on the right and left side it gives rise to the initial portion of the internal carotid artery

The external carotid is derived from the cranial portion of the ventral aorta

The common carotid corresponds to a portion of the ventral aorta between exits of the third and fourth arches

The 4th aortic arch - has ultimate fate different on the right and left side

On the left - it forms a part of the arch of the aorta between left common carotid and left subclavian artery

On the right - it forms the proximal segment of the right subclavian artery

The 5th aortic arch - is transient and soon obliterates

The 6th aortic arch - pulmonary arch - gives off a branch on each side that grows toward the developing lung bud

On the right side, the proximal part transforms into the right branch of the pulmonary artery and the distal part disappears

On the left side, the distal part persists as the ductus arteriosus during intrauterine life and the proximal part gives rise to the left branch of the pulmonary artery

COMMON CAROTID ARTERY

External Carotid Artery

ECA is one of the terminal branches of the CCA.

Chief artery of supply to structures in front of the neck and in the face.

Generally arises medial and anterior to the ICA

In 15% ECA originates lateral to the ICA, this variation occurs more frequently on the right (3:1)

Branches of ECA Anterior

Superior thyroid Lingual Facial

Posterior Posterior auricular Occipital

Terminal Superficial temporal Maxillary

Medial Ascending pharyngeal

Superior Thyroid Artery

First branch

Arises just below the level of the greater cornu of the hyoid bone

Ends in the thyroid gland.

Hyoid

Superior Laryngeal

Sternocleidomastoid

Cricothyroid

Branches

Lingual ArteryOrigin : Lingual Artery arises from the ECA opposite the tip of greater cornu of the hyoid bone

CourseFirst part of artery lies in the carotid triangle

Second part of artery lies deep to the hyoglossus muscle which separates it from the hypoglossal nerve

Third Part or deep part : runs upwards along the anterior margin of the hyoglossus

Branches of Lingual Artery

Suprahyoid Br

Dorsal Lingual Br

Deep Lingual Artery

Sublingual Artery

Facial Artery

Facial artery is the chief artery of the faceOrigin :Arises from the ECA just above the greater cornu of the hyoid bone

It has two parts, first cervical part in the neck and facial part.

It enters the face by winding around the base of the mandible

At the anteroinferior angle of the masseter muscle, it can be palpated here and is called as an “anaesthetist’s artery”

Branches of Cervical part1. Ascending palatine artery- it supplies to root of tongue & tonsil.

2. Tonsillar.

3. Submental artery- it is a large artery which accompanies the mylohyoid nerve, and supplies the submental triangle and sub lingual salivary gland.

4. Glandular branches that supplies submandibular salivary gland and submental lymph nodes.

Branches of facial part1. Superior labial- supplies to

upper lip & antero-inferior part of nasal septum.

2. Inferior labial- supplies to lower lip.

3. Lateral nasal- to the ala & dorsum of nose.

4. Angular – supplies the lacrimal sac and orbicularis oculi.

Ascending Pharyngeal Artery

A small branch arises from medial side of ECA

Long, slender vessel, deeply seated in the neck

It runs vertically upwards between the side wall of the pharynx, the tonsil, the medial wall of the middle ear and , the auditory tube.

Posterior Auricular Artery

Small and arises above the posterior belly of digastric

It runs upwards and backwards deep to the parotid gland, crosses the base of the mastoid process and ascends behind the auricle.

Stylomastoid branch

Arises from the posterior part of the external carotid, opposite the facial

Ends in the posterior part of the scalp

May arise from Internal carotid artery.

Occipital Artery

Mastoid Meningeal Muscular

Larger of the two terminal branches

Arises behind the neck of the mandible, and is imbedded in the substance of the parotid gland

It supplies the deep structures of the face

Maxillary Artery

Branches1st part (mandibular) : Lies medial to mandible, it runs along the lower border of

lateral pterygoid muscle

Deep auricular artery

Ant.tympanic artery

Middle meningeal artery

Accessory meningeal artery

Inferior alveolar artery

Branches of first and its supplyBranches

1.Deep auricular

2.Anterior tympanic

3.Middle meningeal

4.Accessory meningeal

5.Inferior alveolar

Foramen transmitting

Foramen in the floor of external acoustic meatus

Petrotympanic fissure

Foramen spinosum

Foramen ovale

Mandibular foramen

Distribution

External acoustic meatus,outer surface of tympanic membrane

Inner surface of tympanic membrane

5th and 7th nerve, middle ear, tensor tympani

Meninges, Structures in the infra temporal fossa

Lower teeth and mylohyoid muscle

Largest artery that supplies the dura

It ascends to the foramen spinosum through which it enters the cranium

Divides into two branches, anterior and posterior.

It supplies the dura mater (the outermost meninges) and the calvaria.

Middle Meningeal Artery

Inferior alveolar artery Runs downword & forward

medial to ramus of mandible to reach mandibular foramina

Before entering mandibular foramina gives off lingual and mylohyoid arteries

In canal gives branches to mandibular teeth

After coming out of canal supply chin via mental artery.

2nd part (pterygoid part) : Artery runs forward &upward superficial to the lower head

of the lateral pterygoid muscle

B. Second part

Branches1.Deep temporal

2.Pterygoid

3.Masseteric

4.Buccal

DistributionTemporalis

Lateral and medial pterygoid

Masseter

Buccinator

3rd part (pterygopalatine):

Terminal portion of the artery passes between the two heads of the lateral pterygoid muscle

Third partBranches1.Post superior alveolar

2.Infraorbital

3.Greater palatine

4.Pharyngeal

4.Artery of pterygoid canal

5.Sphenopalatine(terminal part)

ForaminaAlveolar canals in the body of maxilla

Infraorbital fissure

Greater palatine canal

Pharyngeal canal

Pterygoid canal

Sphenopalatine foramen

DistributionUpper molar and premolar teeth ; maxillary sinus

Lower orbital muscles, lacrimal sac ,max sinus

Soft palate, tonsil, palatine glands and mucosa,upper gums

Root of nose , pharynx, auditory tube,sphenoidal sinus

Auditory tube, upper pharynx, middle ear

Lateral and medial wall of nose and air sinuses.

Smaller of the two terminal branches

It begins in the substance of the parotid gland, behind the neck of the mandible

Divides into two branches, a frontal and a parietal

Superficial Temporal Artery

Transverse facial branch

Anterior auricular branch

Frontal branch

Parietal branch

Zygomatico- orbital branch

Branches

INTERNAL CAROTID ARTERY

Origin- It is one of the terminal branch of common carotid artery originates along with external carotid artery at the upper border of thyroid cartilage at the disk of third and fourth cervical vertebra.

Branches Cervical part in the neck

Petrous part in the petrous temporal bone

Cavernous part in the cavernous sinus

Cerebral part in relation to base of brain

Cervical part

It ascends vertically in the neck from its origin to the base of skull to reach the lower end of the carotid canal. This part is enclosed in carotid sheath along with internal jugular and vagus nerve. No branches arises from the internal carotid artery in the neck.

Its initial part shows slight dilation, carotid sinus. Which acts as a baroreceptor.

PETROUS PART Within the petrous part of the temporal bone,in the carotid canal runs upword forword & medially at rt. Angle.

Branches

1) Caroticotympanic- enter middle ear & anastomose with ant. & post. Tympanic branches

2) Artery of the Pterygoid Canal- anastomose with greater palatine artery

CAVERNOUS PART

Within the Cavernous Sinus

Branches 1) Artery to trigeminal

ganglion

2) Superior & inferior Hypophyseal artery

CEREBRAL PART Lies at the base of the brain

after emerging from the cavernous sinus

Branches1.Ophthalmic.2.Anterior Cerebral.3.Middle Cerebral.4.Posterior Communicating.5. Ant. choroidal

On angiogram internalcarotid show ‘S’ shaped figure ( carotid siphon )

Circle of Willis

Veins of The Head and Neck

Venous drainage from the face is entirely superficial

All the venous drainage from the head and neck terminate in the internal jugular vein which join the subclavian vein to form the brachiocephalic vein behind the medial end of the clavicle

Veins of the Head and neck

It receive blood from the brain, face and the neck.

It emerges through the jugular foramen, as a continuation of the sigmoid sinus descend down in the neck, first behind then lateral to the internal carotid artery inside the carotid sheath

Internal jugular vein

Tributaries

Is formed by the union of the supraorbital and supratrochlear veins to form the angular vein

Communicate with the cavernous sinus through the ophthalmic vein via the supraorbital

Facial vein

• Runs downwards and backwards behind the facial artery to the lower border of the mandible

• To be joined by the anterior division of the retromandibular vein

Joins the: Pterygoid plexus through deep

facial vein Cavernous sinus through

superior ophthalmic vein

Formed by the union of superficial temporal and maxillary vein from the pterygoid plexus

Passes downwards in the substance of the parotid gland emerging from its lower border & divide into two divisions

Retromandibular vein

Anterior division joins the facial vein

Posterior division: pierces the deep fascia and

join the posterior auricular to form the external jugular.

It empty into the subclavian vein

Retromandibular vein

A short trunk accompany the first part of the artery.

Formed by confluence of the veins of the pterygoid plexus.

It passes backward between the sphenomandibular ligament and the neck of the mandible

Unite with the superficial temporal vein to form the retromandibular vein.

The maxillary vein

A network of very small veins, lie around and within the lateral pterygoid muscle in the infratemporal region

Receive some of the veins that correspond to the maxillary vein, inferior ophthalmic vein (internal carotid blood) and the deep facial vein.

Pterygoid plexus

Drain into a pair of large, short maxillary veins which join the superficial temporal vein to form the retromandibular.

Deep facial vein drain the plexus into the facial vein if the maxillary is occluded

Pterygoid plexus

Begins behind the angle of the mandible by the union of the posterior auricular and posterior division of the retromandibular veins.

It descend obliquely, deep to the platysma, receive the posterior external jugular vein

Pierce the deep fascia just above the clavicle and drain into the subclavian vein

External jugular vein

Posterior auricular vein Posterior division of retro mandibular vein

Posterior external jugular vein

Transverse cervical vein

Suprascapular vein

Anterior jugular vein

Tributaries

Anomalies in the usual termination pattern

The external jugular vein was formed by the continuation of undivided

retromandibular vein.

The facial vein presented a normal course from its origin up to the base of the

mandible lying posterior to the facial artery at the anterior border of masseter muscle.

It joined with submental vein in submandibular region and ultimately drained into

external jugular vein. JK SCIENCE Vol. 12 No. 4, Oct-December 2010 203-4

Journal of Clinical and Diagnostic Research. 2011 Feb, Vol-5(1):24-27

Of the 35 specimens that were studied, 29 of the common facial veins were found to confirm to the

normal pattern of formation and drainage. 6 specimens showed variations in their terminations.

In one cadaver, there was no division of the retromandibular veins into the anterior and posterior veins

on both sides. The common trunk of the retromandibular veins joined with the anterior facial veins to

form the common facial veins The external jugular veins were absent bilaterally. The common facial

vein terminated directly into subclavian vein of respective side

Undivided retromandibular vein forming external jugular vein and drainage of common facial vein into internal jugular

In three specimens, the common facial vein opened into the external jugular vein.

Journal of Clinical and Diagnostic Research. 2011 Feb, Vol-5(1):24-27

Venous sinuses

Unpaired sinuses Paired sinuses

Superior sagittal Transeverse

Inferior sagittal Sigmoid

Straight Cavernous

Occipital Superior petrosal

Anterior intercavernous Inferior petrosal

Posterior intercavernous Spheno-parietal

Basilar venous plexus Petro-squamous

Middle meningeal

Superior sagittal sinus It lies within the convex attached margin of the falx cerebri.

The sinus begins at the crista galli and is continuous with the right transeverse sinus.

Communications

With the veins of the scalp through the parietal emissary vein. A vein from the nose through the foramen caecum. Cavernous sinus through superior anastomotic vein.

Thrombosis of the superior sagittal sinus may take place due to spread of infection from the nose and scalp.

This will lead to increased intracranial tension resulting in defective absorption of C. S. F.

Inferior sagittal sinus It occupies the posterior two thirds of the lower free margin

of the falx cerebri. It collects blood from the falx ceribri, medial surfase of the

cerebrum and terminates into the straight sinus.

Cavernous sinuses These paired sinuses are situated on each side of the body of

sphenoid bone Extend from superior orbital fissure in front to the apex of

petrous temporal behind.

Structures passing through the sinus

Internal carotid artery Abducent nerve Occulomotor nerve Trochlear nerve Ophthalmic nerve Maxillary nerve

Septic thrombosis of cavernous sinus may be caused by the numerous communications from the dangerous area of face, orbit and pharynx.

If the internal carotid artery is ruptured as a result of fracture of the base of skull.

Manifested by pulsating exophthalmos, oedema of the eye lids and loud systolic murmur.

Applied Anatomy

Facial artery -During the surgical removal of the submandibular salivary gland the incision is made ½ inch below the lower border of the mandible parallel to mandibular branch of facial nerve.

Facial artery can be severed during the attempts to open buccal abscess of the first molar.

An adult female presented with a 22-year history of pain on the right side of her jaw. Digital palpation over the facial artery at the inferior border of the mandible elicited and exacerbated the pain. Surgical exploration revealed a coiled, tortuous facial artery. Removal of the aberrant artery provided complete pain relief.

J Craniomandib Disord1992 Fall;6(4):296-9.

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

Superior thyroid artery- The artery and External laryngeal nerve are close to each other above the gland but diverge slightly near the gland. So the artery is ligated as near to the gland as possible

Superficial temporal artery- crossing the zygomatic arch the artery is palpable through the skin and fascia and easily compressed here to control the temporal hemorrhage.

This vessel is well protected by dense tissue. Its branches anastomose so freely that a partially detached scalp may be successfully replaced as long as one vessel is intact.

Middle meningeal artery- It get injured in head injuries resulting in extradural hemorrhage.

The frontal or anterior branch is commonly involved. The hematoma presses the motor area, giving rise to hemiplegia of the opposite side.

The anterior division can be approached surgically by making hole in the skull over the pterion,4 cm above the zygomatic arch.

Rarely parietal or posterior branch is implicated, causing contra lateral deafness. In this case hole is made 4 cm above and 4 cm below the acoustic meatus.

Common carotid artery- It can be compressed against the carotid tubercle, the anterior tubercle of the transverse process of vertebra C6 which lies at the level of cricoid cartilage.

Carotidynia is a syndrome characterized by

unilateral (one-sided) tenderness of the carotid artery, near the bifurcation.

Carotid Sinus

Present at the termination of CCA. (or beginning of ICA.)

Tunica media is thin, tunica adventia is thick Acts as BARORECEPTOR/PRESSURE

RECEPTOR.

Carotid sinus hypersensitivity (CSH) is an exaggerated response to carotid sinus baroreceptor stimulation. It results in dizziness or syncope from transient diminished cerebral perfusion.

For these individuals, even mild stimulation to the neck results in marked bradycardia and a drop in blood pressure.

Carotid Siphon of Angiogram

Siphon region is the most common site for atherosclerotic plaque formation in carotid artery

Carotid body situated behind the bifurcation of CCA Act as a chemoreceptor & respond to change in the O2, CO2 and pH

content of the blood

Carotid body paragangliomas are vascular lesions, and this is reflected in their imaging appearance. These lesions splay apart the internal (ICA) and external carotid arteries (ECA), and as it enlarges, it will encase, but not narrow the ICA and ECA.

Head Neck Pathol. Dec 2009; 3(4): 303–306.

Carotid Body

The facial vein is devoid of valves and rests directly on the facial muscle.

The movement of facial muscles might facilitate the spread of septic emboli from the infected area of upper lip and lower part of the nose in retrograde direction.

Cause thrombosis of cavernous sinus with serious complication.

Danger Area of Face

Occlusive disease

It is the obstruction or blockage of the body's blood vessels, including arteries in the head and neck.

Occlusive disease is caused by atherosclerosis The most common symptom of occlusive disease affecting the

brain is a transient ischemic attack (TIA), or "mini stroke."

Temporal arteritis

Temporal arteritis occur when one or more arteries become inflammed, swollen, and tender.

Temporal arteritis commonly occurs in the the arteries around the temples (temporal arteries).

These vessels branch off from the carotid artery in the neck.

PHACE syndrome

Patients can have abnormalities of the arteries that carry blood to the brain either in the head (cerebral) or neck (cervical).

These blood vessels can have abnormal shapes, sizes or paths through the neck and head.

Dysgenesis Narrowing Non-visualization Abnormal course or origin Persistent fetal arteries

Shaken baby syndrome (SBS)

It is a form of child abuse. It refers to brain injury that happens to the child.

It occurs when someone shakes a baby or slams or throws a baby against an object. A child could be shaken by the arms, legs, chest, or shoulders.

What causes the brain injury? Shaking or throwing a child, or

slamming a child against an object, causes uncontrollable forward, backward, and twisting head movement.

Brain tissue, blood vessels, and nerves tear. The child's skull can hit the brain with force, causing brain tissue to bleed and swell.

Mild injuries may cause subtle symptoms. A child may vomit or be fussy or grouchy, sluggish, or not very hungry. More severe injuries may cause seizures, a slow heartbeat, trouble hearing, or bleeding inside one or both eyes

Human Anatomy Vol 3 Head,Neck & Brain - BD Chaurasia’s 4th Edition

Textbook of Anatomy Vol3 - Inderbir Singh 3rd Edition

Anatomy of the Head & Neck - M J. Fehrenbach, S W. Herring 3rd Edition

Operative maxillofacial Surgery - Jhon. D.Langdon & Mohan F. Patel

Textbook of Anatomy- A. W. Rogers

Deaver JB Surgical Anatomy of Human body - Blakiston, Philadelphia

www.wikipedia.org

References