Arterial supply of head and neck

ARTERIAL SUPPLY OF HEAD AND
NECK.
Guided by
Dr. Rudresh K B
Reader
Dept of Oral and Maxillofacial Surgery
Presented by -
Dr. Avinash Rathore
Post Graduate
Dept of Oral and Maxillofacial Surgery

CONTENTS-
• EMBRYOLOGY
• HISTOLOGY
• COMMON CAROTID ARTERY
• EXTERNAL CAROTID ARTERY
• INTERNAL CAROTID ARTERY
• SUBCLAVIAN ARTERY
• LIGATIONS OF ARTERIES
• REFRENCES
DEVELOPMENT

Aortic arches
The aortic arches are a series of six paired embryological vascular structures which give rise
to several major arteries.
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
• The proximal part of the sixth right arch persists as the proximal part of the
right pulmonary artery while the distal section degenerates
The sixth left arch gives off the left pulmonary artery and forms the ductus
arteriosus; this duct remains pervious during the whole of fetal life, but then
closes within the first few days after birth due to increased O2concentration

• The outermost layer is known as
the tunica externa also known
as tunica adventitia and is
composed of connective
tissue made up ofcollagen fibers.
• Inside this layer is the tunica
media, or media, which is made up
of smooth muscle cells and elastic
tissue (also called connective tissue
proper).
• The innermost layer, which is in
direct contact with the flow of
blood is the tunica intima,
commonly called theintima. This
layer is made up of
mainly endothelial cells. The hollow
internal cavity in which the blood
flows is called the lumen.
Arteries form part of the circulatory
system. They carry blood that is
oxygenated after it has been
pumped from the heart. Arteries
also aid the heart in pumping
blood. Arteries carry oxygenated
blood away from the heart to the
tissues, except
for pulmonary arteries,which carry
blood to the lungs for oxygenation.

The Structure of Blood
VesselsA Comparison of a Artery and a Vein-
Figure 13-1

• MAJOR ARTERIES
OF HEAD AND
NECK
1. COMMON
CAROTID ARTERIES
2. EXTERNAL
CAROTID ARTERIES
3. INTERNAL
CAROTID ARTERIES
 ADDITIONAL
ARTERIES
- BRANCHES OF
SUBCLAVIAN
ARTERY

15
Cervical part of common carotid artery
 Carotid arteries are generally symmetric and approximately of same
size unlike vertebral arteries.
 In 75% individuals ,CCA bifurcates at the level of C3-C4,roughly at
the upper border of thyroid cartilage.
 In children,the carotid bifurcates one vertebral level higher.
 Variation in the level of bifurcation
Highest seen in –C1 to C2
Lowest seen in –T1 to T2
Common carotid artery

16
CAROTID BODY(CHEMORECEPTORS)
 It is normally 2.5x 5mm to 4 x
7mmflattened structure on the
median and deep side of the upper
end of the common carotid artery.
 Blood supply-from small vesssels
usually from ECA,termed as GLOMIC
ARTERY OR ASCENDING
PHARYNGEAL ARTERY.
 NERVE SUPPLY-9TH 10TH 12TH CN

17
CAROTID SINUS (BARORECEPTORS)
 At the bifurcation of
common carotid artery
 Responsive to changes in the
arterial blood pressure.It
acts as a
baroreceptor(pressure
receptor) and regulates
blood pressure.
 BLOOD SUPPLY-ICA
 NERVE SUPPLY-carotid sinus
nerve or nerve of hering.

RELATION OF COMMON CAROTID
ARTERY
LATERAL-IJV
ANTEROLATERALLY
SKIN,FASCIA,SCM,STERNOHYOID,STERNOTH
YROID,SUP BELLY OF OMOHYOID
POSTEROLATERALLY-
VAGUS NERVE
MEDIAL
PHARYNX, LARYNX, TRACHEA
,OESOPHAGUS
LOBE OF THYROID GLAND
POSTERIOR
Transverse process of C3 C4
PREVERTBRAL FASCIA
SYMPATHETIC TRUNK

APPLIED ANATOMY
Carotid sinus syndrome
• Loss of consciousness due to simple head
movements.
• Hypersensitivity of the carotid sinus due to an
unknown etiology.
• Sudden slight pressure changes, such as that
occasioned by movement of the head, may result in
stimulation of the carotid sinus.
• Impulses transmitted by the sinus reduce blood
pressure and slow the pumping action of the heart.
Thus decreasing blood supply to the brain and
resulting in sudden loss of consciousness.
While supporting the mandible care should be taken
not to apply pressure on the carotid sinus.

21
External carotid artery (Facial carotid)

External carotid artery
• Generally,it lies anterior to the internal
carotid artery.
• It is the chief artery of supply to
structures in the front of the neck and in
the face.

SURFACE MARKING
• ECA is marked by joining
the following two points.
-A) point on the anterior
border of the
sternocleidomastoid
muscle at the level of the
upper border of the
thyroid cartilage.
-B) second point on the
posterior border of the
neck of the mandible.
The artery is slightly convex
forwards in its lower half
and slightly concave
forwards in its upper half.
B
A

COURSE
• 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.
• In the carotid triangle,it lies
under cover of the anterior
border of the
sternocleidomastoid muscle
• As the artery ascends,it
passes deep to the post.
Belly of digastric and
stylohyoid muscle and
terminates behind the neck
of the mandible by dividing
into the maxillary and
superficial temporal
arteries.

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

28
External carotid artery
Superficial
temporal
Maxillary
Facial
Lingual
Superior thyroid
Posterior
auricular

30
Origin and course:
Arises from ECA immediately above the
bifurcation of CCA
Curves anteriorly and downwards to
enter Thyroid gland

31
Branches
Anterior Posterior
Superior thyroid artery

RELATION WITH EXTERNAL LARYNGEAL NERVE

APPLIED ANATOMY
• The arch of superior thyroid artery is characteristic –
diagnostic landmark
• The artery and external laryngeal nerve are close to
each other higher up, but diverge slightly near the
gland.
- So, 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.
-Damage to the external laryngeal nerve causes some
weakness of phonation due to loss of tightening
effect of the cricothyroid on the vocal cord.
• Intra-arterial infusion chemotherapy for laryngeal
and hypopharyngeal cancers.

Lingual Artery
Origin-
 Lingual Artery arises from the ECA
opposite the tip of greater cornu of the
hyoid bone
Course-
 First 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

APPLIED ANATOMY
• In surgical removal of tongue , first part of
artery is ligated before it gives any branches to
the tongue or tonsil.
LIGATION OF LINGUALARTERY :
Incision – circling the lower pole of
submandibular gland.
- Skin, platysma, deep fascia incised,
submandibular gland exposed , lifted, tendon of
digastric visible.

- Free border of mylohyoid muscle seen,
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.

SUBLINGUALARTERY
Injury occurs in premolar
& molar region, when
sharp instrument or rotating
disks slips off a lower
molar & injure the floor of
mouth.
-May present problems to
the surgeon attempting to
ligate its source because it
may arise from the
submental branch of the
facial artery rather than
from the lingual artery.

For Implants, CBCT to
localise the vascular
canal,injuries to arteries in
vascular canal can cause
sublingual haematoma
leading to blockage of
airway.

Facial Artery
Facial artery is the chief artery of the face
Origin :
 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”

•SURFACE MARKINGS-ANTERO INFERIOR BORDER OF MASSETER
• 1.25 CM LATERAL TO ANGLE OF MOUTH
• MEDIAN ANGLE OF EYE
•TORTUOUS COURSE
•PULSATIONS FELT AT- LOWER BORDER OF MANDIBLE
ORAL CAVITY

Branches of Cervical part
1. Ascending palatine artery- it supplies to root of tongue & tonsil.
2. Tonsillar artery
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.

ASCENDING
PALATINE ARTERY
• ORIGIN FROM HIGHEST POINT OF
FACIAL ARTERY
• COURSES CRANIALLY ALONG THE
SUPERIOR CONSTRICTOR OF
PHARYNX TO REACH SOFT PALATE
• SMALL BRANCH TO PHARYNGEAL
MUSCLES
• TONSILLAR BRANCH SUPPLYING
PALATINE TONSIL(MAY ARISE
DIRECTLY FROM FACIAL ARTERY)
TERMIAL BRANCHES SUPPLY SOFT
PALATE
TONSILLAR A RTERY:
Passes between the styloglossus and
medial pterygoid muscles and
pierces the superior pharyngeal
constrictor muscle to supply the
palatine tonsil and the posterior
tongue.

SUBMENTAL ARTERY
• RUNS HORIZONTALLY BELOW
THE INFERIOR BORDER OF
MANDIBLE
• TRAVERSES HORIZONTALLY TO
REACH MYLOHYOID MUSCLE
• SUPPLIES SUBMANDIBULAR
NODES,MYLOHYOID AND
SURROUNDING MUSCLE
• ANASTAMOSE WITH
SUBLINGUAL AND INFERIOR
LABIAL ARTERY

Branches of facial part
1. 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.

FACIAL PART:
INFERIOR LABIAL
ARTERY: Originates near
the corner of the mouth,
passes deep to the depressor
anguli oris muscle, and
pierces the orbicularis oris
muscle.
-The artery courses
superficial to that muscle,
supplying it as well as the
substance of the lower lip.
-It forms an anastomosis
with its counterpart of the
other side and with branches
of the mental and submental
arteries.

SUPERIOR LABIALARTERY:
Arises just above the inferior labial artery. It passes
superficial to the orbicularis oris muscle in the
upper lip to serve that muscle as well as the
substance of the upper lip.
- It sends a small twig, the SEPTAL BRANCH to
supply anteroinferior part of the nasal septum and
another one, the ALAR BRANCH, into the wing of
the nose.
-The terminus of the vessel will anastomose with its
counterpart of the opposite side.

LATERAL NASALARTERY: Small
branch arising at and passing into the
wing and bridge of the nose.
-This supplies ala and dorsum of the
nose. This vessel will anastomose with
various other arteries in its vicinity.
ANGULAR ARTERY: Is the terminal
continuation of the facial artery,
supplying the tissues in the vicinity of
the medial corner of the eye and
anastomosing with dorsal nasal branch
of the ophthalmic artery.

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.
o 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 or
mucocoele.

• In mand. 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.
• While excising the
submandibular gland,the facial
artery should be ligated at two
points and should be secured
before dividing it, otherwise it
may retract through
stylomandibular ligament causing
serious bleeding.

Ascending Pharyngeal Artery
 A small branch arises from
medial side of ECA
 Long, slender vessel, deeply
seated in the neck
 COURSE: Ascends vertically
between the internal carotid and
the side of the pharynx, to the
under surface of the base of the
skull, lying on the Longus
capitis.

BRANCHES
• PHARYNGEAL
BRANCHES
• PALATINE BRANCH
• PREVERTEBRAL
BRANCH
• INFERIOR
TYMPANIC ARTERY
• MENINGEAL
BRANCHES

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

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

Then crosses the rectus
capitus
lateralis,superior
oblique,and
semispinalis capitus
muscle at the apex of
the posterior triangle.
Finally it pierces the
trapezius muscle and
ascends in a tortuous
course in the superficial
fascia of the scalp.
Its terminal portion
comes to lie along the
greater occipital nerve.

BRANCHES
IN THE CAROTID TRIANGLE
• STERNOMASTOID BRANCHES – Two
in no.,upper branch accompanies the
accessory nerve and lower branch arises
near the origin of the occipital artery.
Supplies sternomastoid m.
IN THE POSTERIOR TRIANGLE and
SCALP REGION:
• AURICULAR BRANCH: Passes
superficial to the mastoid process to reach
and supply the back of the auricle.

• MASTOID BRANCH:–
Enters cranial cavity through
mastoid foramen, supplies mastoid
air cells in the dura and diploe.
• MENINGEAL BRANCH –
Ascends with the internal
jugular vein and enters the skull
through jugular foramen &
condylar canal, supplies dura of
posterior cranial fossa.
• MUSCULAR BRANCH-
Supply the Digastric,
Stylohyoideus, Splenius, and
Longissimus capitis.

DESCENDING BRANCH :
• The largest branch of the occipital, descends on
the back of the neck, and divides into a
superficial and deep portion.
-The superficial portion runs beneath the
Splenius, giving off branches which pierce that
muscle to supply the Trapezius and anastomose
with the ascending branch of the transverse
cervical artery.
-The deep portion runs down between the
Semispinales capitis and colli, and anastomoses
with the vertebral and with the a. profunda
cervicalis, a branch of the costocervical trunk.

• The terminal branches of
the occipital
artery(occipital branches)
are distributed to the back
of the head: they are very
tortuous, and lie between
the integument and
Occipitalis, anastomosing
with the artery of the
opposite side and with the
posterior auricular and
temporal arteries, and
supplying the Occipitalis,
the integument, and
pericranium

APPLIED ANATOMY
Superficial branch anastomosis with
ascending branch of transverse cervical
artery. Deep branch of descending br of
occipital artery anastomosis with deep
cervical artery.

 Larger of the two terminal
branches
 Arises behind the neck of the
mandible, and is embedded
in the substance of the
parotid gland
 It supplies the deep
structures of the face
Maxillary Artery

Branches
1st 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 supply
Branches
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

APPLIED ANATOMY
• 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.(approx
2 finger breadth above zygomatic arch)
• PARIETAL OR POSTERIOR BRANCH -
contralateral deafness
APPROACH- hole is made 4cm above and
4cm behind the external acoustic meatus.

Inferior alveolar artery
 Runs downward & 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.

BRANCHES
BEFORE ENTERING
MANDIBULAR CANAL:
• Lingual branch to the tongue.
• Mylohyiod branch to the mylohyiod
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

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

B. Second part
Branches
1.Deep temporal
2.Pterygoid
3.Masseteric
4.Buccal
Distribution
Temporalis
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 PART
Branches
1.Post superior alveolar
2.Infraorbital
3.Greater palatine
4.Pharyngeal
4.Artery of pterygoid canal
5.Sphenopalatine(terminal
part)
Foramina
Alveolar canals in the body of
maxilla
Infraorbital fissure
Greater palatine canal
Pharyngeal canal
Pterygoid canal
Sphenopalatine foramen
Distribution
Upper 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.

APPLIED ANATOMY
• Site of hematoma during PSA block.
• Produces largest and most esthetically
unappealing hematoma.
• Blood effuses until extravascular pressure
exceeds intravascular pressure or clotting
occurs.
• Infratemporal fossa into which bleeding occurs
accommodates large amount of blood.
• Prevented by aspirating before giving LA in the
site.
• Digital pressure can be applied medial and
superior to the maxillary tuberosity.

Applied anatomy
• In case of abscess
from palatal root of
first molar,incision
should be made in a
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 down fracturing of maxilla.
• The average distance from the piriform rim to
the descending palatine artery is 35.4 mm, range
is 31 to 42 mm.
• The average length of the greater palatine canal
above the nasal floor is 10mm, range is 6 to 15
mm.
• The average distance between the
pterygomaxillary fissure and the greater palatine
foramen is 6.6mm.

GUIDELINES TO AVOID INJURY:
• Osteotomy of lateral wall of
maxillary sinus should extend
just beyond the second molar.
• Osteotomy of medial wall of
maxillary sinus should usually
extend 30mm posterior to the
piriform rim in females,in males
it can be carried back to 35mm -
--O’ RYAN
• Because the descending palatine
artery travels in an anterior-
inferior direction as it enters the
greater palatine canal ,injury can
be prevented by closely adapting
the cutting edge of the
osteotome or the saw to the
pterygomaxillary fissure.

APPLIED ANATOMY OF
MAXILLARY ARTERY
• Surgeries involving
condyle-Avoid injury to
maxillary artery as it lies
medial to condyle.
• Ankylotic mass of TMJ
may encircle the artery.So
it is advisable to remove
ankylotic mass in pieces
rather than in toto.
• Trismus involving lateral
pterygoid comprises blood
supply to the nose.

• During Le fort I
osteotomy procedure-
Pterygopalatine
portion of maxillary
artery may be injured
during fracturing the
pterygiod plates if
Tessier’s osteotome is
directed backwards.
-It should be directed
downwards and
medially.

• Can be used as arterial donor in repair
of ICA dissections and aneurysms, due
to close proximity of the artery to the
cranial base.
• Control of epistaxis---If epistaxis is not
controlled after nasal packing,it can be
controlled by ligating IMA via
endonasal,transantral or intraoral
approach.

LITTLE’S AREA or
KIESSELBACH’S
PLEXUS
-Near the anteroinferior part
or vestibule of the septum.
-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.

 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

Parietal branch
Frontal branch
Middle temporal artery
Transverse facial artery

 Transverse facial branch
 Anterior auricular branch
 Frontal branch
 Parietal branch
 Zygomatico- orbital branch
Branches

Transverse Facial Artery:
ORIGIN:From STA before it leaves parotid gland.
COURSE: Running forward through the
substance of the gland, it passes transversely
across the side of the face, between the parotid
duct and the lower border of the zygomatic arch.
This vessel rests on the Masseter, and is
accompanied by one or two branches of the
facial nerve.
SUPPLIES: The parotid gland and duct, the
Masseter, and the integument, and anastomose
with the external maxillary, masseteric,
buccinator, and infraorbital arteries.

Middle Temporal Artery: Arises immediately above
the zygomatic arch, and, perforating the temporal
fascia, gives branches to the Temporalis,
anastomosing with the deep temporal branches of
the internal maxillary artery.
- It occasionally gives off a zygomaticoorbital
branch, which runs along the upper border of the
zygomatic arch, between the two layers of the
temporal fascia, to the lateral angle of the orbit.
-This branch, which may arise directly from the
superficial temporal artery, supplies the Orbicularis
oculi, and anastomoses with the lacrimal and
palpebral branches of the ophthalmic artery.

• Anterior
Auricular
Branches :
Distributed to the
anterior portion
of the auricle, the
lobule, and part
of the external
meatus,
anastomosing
with the posterior
auricular.

Frontal Branch :
Runs tortuously upward and
forward to the forehead,
supplying the muscles,
integument, and
pericranium in this region,
and anastomosing with the
supraorbital and frontal
arteries.
Parietal Branch:
Larger than the frontal, curves
upward and backward on the
side of the head, lying
superficial to the temporal
fascia, and anastomosing with
its fellow of the opposite side,
and with the posterior
auricular and occipital
arteries.

APPLIED ANATOMY
• Control of temporal
haemorrhage.
• Anaesthetist’s artery
• Placement of incisions in
craniotomy
• In reduction of zygomatic arch
fractures – Gilli’s approach
-A 2cm incision is placed in the
temporal region at an angle 45
degree to the zygomatic arch,
between two branches of the
superficial temporal artery and
parallel to the anterior branch.

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 disc of third
and fourth cervical vertebra.

• It supplies two of the four major arteries
supplying blood to the brain.
• CCA CAROTID CANAL(petrous part of
temporal bone) MIDDLE CRANIAL
FOSSA(dorsum sellae of sphenoid bone)
Supplies the hypophsis cerebri,orbit,and most
of the supratentorial part of the brain.

BRANCHES and SEGMENTS
• 1996 –bouthillier divided ICA into 7 anatomical
segments viz.
• C1-Cervical part in the neck
• C2-Petrous part in the petrous temporal bone
• C3-lacerum
• C4-Cavernous part in the cavernous sinus
• C5-clinoid
• C6-opthalmic
• C7-communicating
CEREBRAL PORTION

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 dilatation, carotid sinus. Which acts
as a baroreceptor.

PETROUS PART• Within the petrous part of the
temporal bone,in the carotid
canal runs upward forward &
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
Branches
1.Ophthalmic.
2.Anterior Cerebral.
3.Middle Cerebral.
4.Posterior Communicating.
5. Ant. choroidal
On angiogram internal
carotid show ‘S’ shaped
figure ( carotid siphon )

Opthalmic artery
• Arises medial to anterior clinoid
process near optic canal
• In orbit lie inferolateral to optic
nerve
Branches:
1. Central artery of retina
2. Large lacrimal artery
3. Dorsal nasal artery
• Supratrochlear
• Supraorbital
• Posterior ethmoidal
• Anterior ethmoidal
• Palpebral branch
• Recurrent meningeal a.
• Muscular a.

SUBCLAVIAN ARTERY
• MAIN ARTERY OF
UPPER LIMB
ORIGIN-
1.RIGHT-
BRACHIOCEPHALIC
ARTERY
2.LEFT -ARCH OF
AORTAE
COURSE
1.MEDIAL
2.POSTERIOR
3.LATERAL

Circle of Willis
The circle of Willis is a circulatory
anastomosis that supplies blood to
the brain and surrounding structures.
It is named after Thomas Willis (1621–
1675), an English physician
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)
Basilar artery
IMPORTANCE: The arrangement of the
brain's arteries into the circle of Willis
creates collaterals in the cerebral
circulation. 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.

Anastomoses ICA ECA
Dorsal Nasal Artery and
Angular Artery
Dorsal Nasal Artery
(branch of the
Ophthalmic artery)
Angular Artery (branch of
the Facial Artery)
Supraorbital Artery and Frontal
Artery
Supraorbital Artery
(branch of the
Ophthalmic)
Frontal Artery (terminal
branch of the Superficial
Temporal Artery)
Zygomatico Artery and
Transverse facial artery
Zygomatico (branch
Lacrimal Artery)
Transverse Facial Artery
(branch of Superficial
Temporal Artery)
Branches of the Posterior
Ethmoidal Artery and branches
of the Sphenopalatine Artery
Posterior Ethmoidal
Artery
Sphenopalatine
Artery(branch of the
Internal Maxillary)
Cavernous branches and
Middle Meningeal artery
Cavernous branches
from the cavernous
portion of the ICA
Middle Meningeal Artery
(branch of the Internal
Maxillary)

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 Path.Dec 2009; 3(4): 303–306.
Carotid Body

• Definition
• Why ligate?
• Procedure
Individual artery ligation
-External Carotid Artery
-Lingual
-Sublingual
-Facial
-Maxillary
-Sphenopalatine
-Greater Palatine
-Ant./Post. Ethamoidal
-Internal Carotid Artery

• LIGATION Means act of binding or
tying of blood vessels with sutures or wires is
called Ligation…
First ligation was done by AMBROSE
PARE in amputation procedure.

WHY WE LIGATE VESSELS???
1.AFTER AMPUTATION TO ARREST THE
BLOOD FLOW.
2.IN WOUNDS OF ARTERIES WHERE
HAEMMORRHAGE CAN’T BE CONTROLLED.
3.IN SECONDARY HAMMORAGHE WHERE
THEY CAN’T BE CONTROLLED BY OTHER
MEANS.
4.IN LOCAL HYPERTROPHIES TO ARREST THE
NUTRITIONAL SUPPLY TO THAT AREA.

• IN CASE OF ANEURYSMS
• IN CASE OF MALIGNANT TUMOUR TO STOP THE
BLOOD FLOW
• IN ACUTE INFLAMMATION WHERE NEITHER
RESECTION NOR AMPUTATION IS POSSIBLE
• IN VARIOUS OPERATIVE PROCEDURES WHEN WE
ENCOUTER VESSELS TO REDUCE BLOOD FLOW TO
THAT REGION .

PROCEDURE FOR LIGATION
1. EXPOSE THE SHEATH OF VESSEL
2. ISOLATE THE VESSEL
3. PLACE THE LIGATURE

LIGATION OF EXTERNAL
CAROTID
ARTERY

EXPOSED AT TWO SITES
1. IN THE CAROTID TRIANGLE -AT ITS ORIGIN FROM THE
COMMON CAROTID ( ABOVE THE ORIGIN OF SUPERIOR
THYROID ARTERY)
2. IN THE RETROMANIBULAR FOSSA HERE WE LIGATE IT
BEHIND THE ANGLE OF LOWER JAW ( DEALS WITH THE
HAEMORRHAGE FROM ONE OF THE BRANCHES OF
MAXILLARY ARTERY)

• CONTINUE DOWNWARDS / TO
THE ANTERIOR BORDER UP TO
THE LEVEL OF CRICOID
CARTILAGE
• AFTER PENETRATING SKIN,
PLATYSMA SUPERFICIAL SHEATH
OF STERNOCLEDIOMASTOID IS
INCISED
EXPOSURE OF GREAT VESSEL
• WITH BLUNT DISSECTION
ANTERIOR BORDER IS EXPOSED,
MUSCLE IS RETRACTED AND DEEP
LAYER IS SEEN
• IN THIS PART Internal Juglar Vein
IS EXPOSED

IDENTIFICATION OF EXTERNAL CAROTID ARTERY
• THE JUGULAR VEIN IS MOBILIZED BY OPENING
THE CAROTID SHEATH & FREE THE JUGULAR
VEIN.
• RETRACT POSTERIORLY VEIN TO VISUALIZE
ARTERY

EXPOSURE OF THE CAROTID BULB AND EXTERNAL
CAROTID ARTERY
• AS THE DISSECTION
PROCEED
POSTERIORLY THE
CAROTID BULB IS
IDENTIFIED AND
BIFURCATION IS
SEEN
• MANIPULATION OF
BULB AT THIS STAGE
LEAD TO
ARRYTHEMIA AND
ANAESTHESIST
SHOULD BE
INFORMED

• LIGATION
EXTERNAL CAROTID ARTERY IS IDENTIFIED
& LIGATED ABOVE THE SUPERIOR THYROID
ARTERY
• CLOSURE OF WOUND
A VACCUM DRAIN IS PLACED AND WOUND
IS SUTURED IN LAYERS

COMPLICATIONS
• HAMEORRHAGE DUE TO IJV OR ECA( profuse bleeding)
• DAMAGE TO VAGUS NERVE (posteriomedially)
• LIGATION OF ICA( contra lateral hemiplegia & blindness
on the same side)
• HEMATOMA FORMATION
• INFECTION

• INCISION
• STARTS THE TIP OF
MASTOID PROCESS AND
CIRCLING THE
MANDIBULAR ANGLE,
CONTINUING
FORWARD BELOW THE
MANDIBLE FOR ABOUT
ONE INCH
• INCISION SHOULD BE
AT EQUAL DISTANCE
FROM THE POSTERIOR
AND INFERIOR BORDER
OF MANDIBLE

EXPOSURE
• AFTER THE BLUNT
DISSECTION OF SKIN, SOME
POST. FIBERS OF PLATYSMA,
RETROMANDIBULAR VEIN OR
EJV IS LOCATED, CUT & TIED
• BRANCHES OF GREATER
AURICULAR NERVE IS CUT &
TIED TO PERMIT THE
MOBILIZATION OF CERVICAL
LOBE OF PAROTID GLAND
• ATTACHMENT OF PAROTID
WITH STERNOMASTOID AT
ANTERIOR BORDER IS
SEVERED & GLAND IS
RETRACTED ANTERIORLY &
UPWARDS

IDENTIFICATION
• UNDERNEATH THE PAROTID GLAND & POST. BELLY OF DIGASTRIC,
SMALL THIN PART OF STYLOHYOID MUSCLE IS VISIBLE
• ABOVE THIS- STYLOID PROCESS & STYLOMANDIBULAR LIGAMENT
IS PALPATED
• NOW MOVING THE JAW FORWARD ENTRANCE TO
RETROMANDIBULAR FOSSA IS WIDENED & PULSE OF ECA IS FELT,
ISOLATE & LIGATE IT

LIGATION OF LINGUAL ARTERY
INCISION
• INCISION GIVEN BELOW
THE LOWER BORDER OF
MANDIBLE AFTER
PALPATING THE
SUBMANDIBULAR
GLAND.
• THE POSTERIOR PART OF
INCISION SHOULD BE
TOWARDS THE TIP OF
MASTOID PROCESS AND
ANTERIOR SHOULD
POINT TOWARDS THE
CHIN

EXPOSURE OF ARTERY
• AFTER BLUNT
DISSECTION
SUBMANDIBULAR
GLAND IS EXPOSED
• POST BELLY OF
DIGASTRICS
IDENTIFIED,
MYLOHYOID MUSCLE
REACHED,
HYPOGLOSSAL NERVE
AND ACCOMPANYING
VEIN IDENTIFIED

LIGATION OF ARTERY
• DIGASTRICS TENDON
PULLED DOWNWARD ,
HYOGLOSSUS MUSCLE
DISSECTED AND LINGUAL
ARTERY IS FOUND AND
LIGATED
• FIBERS OF HYOGLOSSUS
MUSCLE SHOWS VERTICAL
COURSE (THIN & FINE)
WHILE THAT OF MYLOHYOID
SHOWS OBLIQUE COURSE
(THICK)

LIGATION OF SUBLINGUAL ARTERY
INDICATIONS
• INJURY IS OBSERVED
WHEN SHARP INSUMENTS
OR ROTATING DISC ARE
SKIPPED ON FLOOR OF THE
MOUTH
• IN VARIOUS SURICAL
PROCEDURE LIKE RANULA
AND TUMOURS OF
SALIVARY GLANDS

• DIFFICULT TO LIGATE
SUBLINGUAL ARTREY MAY BE A BRANCH OF
1. LINGUAL ARTERY
2. SUBMENTAL ARTERY

• INCISION
• IN THE SUBLINGUAL GROOVE
• STRUCTURES IN CLOSE
ASSOCIATION
• SUBLINGUAL GLAND(MED.
&INF.)
• SUBMANDIBULAR DUCT
• LINGUAL NERVE(MED.& INF.)
• HYPOGLOSSAL NERVE AND
SUBLINGUAL VEIN

LIGATION OF FACIAL ARTERY
INCISION
½ INCH BELOW & PARALLEL TO THE LOWER BORDER OF
MANDIBLE
EXPOSURE
THE SKIN, PLATYSMA MUSCLE AND DEEP FACIA ARE CUT,
SOFT TISSUE IS BLUNTLY CUT AND RETRACTED

LIGATION
PULSE OF FACIAL ARTERY IS FELT & ARTERY IS
ISOLATED AND LIGATED.
• FACIAL ARTERY CROSSES THE LEVEL OF INFERIOR
VESTIBULAR FORNIX IN THE REGION OF 1ST
MANDIBULAR MOLAR.
• DURING BUCCAL SPACE INFECTION THE ARTERY
IS DISLOCATED
• AVOID DEEP INCISION, INCISION SHOULD BE
DOWNWARDS & INWARDS INSTEAD OF
STRAIGHT UPWARDS.

• Incision - at least half inch below the
border of mandible & parallel to it.

Skin,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- isolated, tied & cut

LIGATION OF MAXILLARY ARTERY
LIGATION CAUSES DECREASE IN INTRA VASCULAR
PRESSURE GRADIENT, RESULTING IN HOMEOSTASIS
APPROACHES:
CAN BE DONE BY
1. TRANSANTRAL APPROACH &
2. INTRAORAL APPROACH

TRANSANTRAL APPROACH
BY CALD WELL LUC APPROACH
PROCEDURE
A LATERALLY BASED U SHAPE MUCOSAL
INCISION IS CREATED
POSTERIOR WALL OF MAXILLARY SINUS IS
IDENTIFIED
POSTERIOR MAXILLARY WALL IS REMOVED

EXPOSURE & LIGATION
• AREA IS ENLARGED,ARTERY IS IDENTIFIED
&LIGATED
SUCCESS RATE
• 87% SUCCESS RATE

INTRA ORAL APPROACH
• THIS PROCEDURE IS GIVEN IN 1984 BY
MACERI & MAKILSKI
• LIGATE INFRATEMPORAL PORTION OF
MAXILLARY ARTERY

INDICATION:
- IN CHILDREN AS AN ALTERNATE TO
EMBOLIZATION & EXTERNAL ARTERY
LIGATION FOR REMOVAL OF VASCULAR
TUMOR
- TO CONTROL BLEEDING IN VARIOUS
MAXILLECTOMY PROCEDURES WHERE
CALD WELL LUC IS CONTRAINDICATED

PROCEDURE:
- BY EXPOSING THE POSTERIOR PORTION OF
MAXILLA THROUGH A POST.
GINGIVOBUCCAL INCISION
- A FINGER IS INSERTED INTO THE DEPTH OF
WOUND TO PALPATE THE MAXILLARY
ARTERY
- THE NERVE HOOK IS USED FOR LIGATION

LIGATION OF
SPHENOPALANTINE
ARTERY

LIGATION OF SPEHNOPALATINE ARTERY
• CAN BE DONE BY TWO METHODS
1. TRANSANTRAL LIGATION
2. ENDOSCOPIC LIGATION

TRANSANTRAL APPROACH
• DESCRIBED BY SIMPSON et al. IN 1982
• APPROACH CALD WELL LUC
• AVOID ENTRANCE TO PTERYGOPALATINE
FOSSA
• MEDIAL, POSTERIOR & INFERIOR WALL IS
REMOVED
• SPHENOPALATINE & VIDIAN NERVE IS
DISSECTED & LIGATION OF ARETRY IS
DONE

ENDOSCOPIC LIGATION FOR SPHENOPALANTINE
ARTERY
• DESCRIBED BY WHITE (MODIFICATION OF
SIMPSONS TECH)
• APPROACH THROUGH
1. MEATAL ANTROSTOMY &
2. CANINE FOSSA
• NOT USING WIDELY AS COSTLY
• ADVANTAGES
1. REDUCE PATIENT DISCOMFORT AND
2. DURATION OF HOSPITALIZATION

LIGATION OF GREATER
PALANTINE ARTERY

LIGATION OF GREATER PALATINE
ARTERY
ENDANGERED DURING MINOR SURGERY PROCEDURES AND DURING
DENTAL TREATMENT
• INCISION
--FROM THE LINGUAL ROOT OF FIRST MOLAR IN AN ANTERIO
POSTERIOR LINE IT SHOULD BE AS NEAR TO THE FREE
MARGINS OF THE GINGIVA AS POSSIBLE
--THE KNIFE EDGES SHOULD BE DIRECTED OUTWARDS AND
UPWARDS , NOT STRAIGHT UPWARDS

ANTERIOR AND
POSTERIOR
ETHMOIDAL ARTERY

LIGATION OF ANTERIOR AND POSTERIOR ETHMOIDAL
ARTERY
INDICATION
1. WHEN LOCAL HAMEORRHAGE CAN’T BE
CONTROLLD BY OTHER MEASURES
2. TO DECREASE BLOOD FLOW TO UPPER NASAL
VAULT FROM THE INTERNAL CAROTID SYSTEM
GENERALLY PERFORMED IN CONJUGATION WITH
MAXILLARY ARTERY OR ECA

FIRST DESCRIBED BY :
KIRCHNER et al. IN 1961
INCISION
A CIRCUMLINEAR
INCISION IS NORMALLY
MADE BETWEEEN THE
INNER CANTHUS OF EYE
AND MIDDLE OF
NOSE(LYNCH INCISION)

• PROCEDURE
• THE PERIOSTEUM IS INCISED
AND ELEVATED
• THE FRONTOETHMOIDAL
SUTURE LINE IS FOLLOWED IN A
POSTERIOR DIRECTION ABOUT
14-22mm TO THE ANTERIOR
ETHMOIDAL ARTERY AND ITS
FORAMEN
• THE POSTERIOR ARTERY IS LIES
AT FURTHER AT VARIABLE
DISTANCE
• THE OPTIC NERVE LIES 4-7mm
POSTERIOR TO POSTERIOR
ETHMOIDAL FORAMEN

LIGATION OF INTERNAL
CAROTID ARTERY

LIGATION OF ICA
GENERALLY IT IS NOT DONE AS THE CHANCES
OF BRAIN DAMAGE (CONTRALATERAL SIDE
HEMIPLEGIA) ARE THERE, BUT IN SOME
SELECTIVE CASES WE HAVE TO LIGATE THE ICA AS
IN CASES OF ICA ANEURYSMS AND HEAD
INJURIES.

WHY EVEN AFTER LIGATION OF CAROTID ARTERY
BLEEDING PERSISTS????
• COLLATERAL CIRCULATION OF COMMON CAROTID OCCURS
AS FOLLOWS:
1 OCCIPITAL ANASTOMOSIS---
B/W THE TRANSVERSE CERVICAL & DEEP CERVICAL
BRANCHES OF SUBCLAVIAN ARTERY AND OCCIPITAL ARTERY
2 ANASTOMOSIS IN & AROUND THYROID GLAND B/W
SUPERIOR THYROID BRANCH & INFERIOR THYROID BRANCH
3 ANASTOMOSIS B/W MIDDLE LINE B/W THE BRANCHES OF
EXTERNAL CAROTID ARTERIES OF BOTH SIDES

REFERENCES:
• SICHER’S ORAL ANATOMY- 8TH EDITION
• LORE AND MEDINA-6TH EDITION
• PRINCIPLES OF SURGERY BY EDWARD WARN
HEAD AND NECK SURGERY- OTOLARYNGOLOGY BY
BYRON. J. BAILEY- 2ND EDITION
• Human Anatomy by B.D. Chaurasia, 6th Edition,Vol 3.
• Grey’s Anatomy
• Netter atlas
• JOURNAL OF MAXILLOFACIAL AND ORAL SURGERY-
LOCATION OF DESCENDING PALATINE ARTERY DURING
LEFORT I OSTEOTOMY
• Int. JOURNAL OF Oral Maxillofac. Surg. 2017; 46: 845–850
http://dx.doi.org/10.1016/j.ijom.2017.03.005,

Arterial supply of head and neck

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