Head and Neck receives the majority of its blood supply through the carotid and vertebral arteries.

1. ARTERIES OF
HEAD AND NECK
Dr HIMANSHU SONI
Fellow in Head & Neck Surgical Oncology - FHNO
Fellow in Cranio-Maxillo-Facial Trauma – AOMSI
Oral and Maxillofacial Surgeon

2. Contents
INTRODUCTION
• Embryology and Development
• Carotid system
• Internal carotid artery
• External carotid artery
[ branches , relations, applied significance in head and
neck surgery]

3. DEFINITION
BLOOD VESSELS-These are cell lined tubes and spaces which surround the tissues
and provide continuous perfusion of body fluids.
• It consists of three layers
1 Tunica intima
2 Tunica media
3 Tunica adventitia
Arteries:
A vessel in which blood flows away from the heart, in the systemic circulation carrying
oxygenated blood.
-Dorland’s Pocket Medical Dictionary 27th Edition

5. THE BASIC CONDUCTING SYSTEM
HEART
ARTERIES
ARTERIOLES
CAPILLARIES/
SINUSOIDS
VENULES
VEIN

6. EMBRYOLOGY
• During the fourth and
fifth weeks of embryological
development, when the
pharyngeal arches form, the
aortic sac gives rise to arteries
– the aortic arches.
• The aortic sac is the
endothelial lined dilation, it is
the primordial vascular channel
from which the aortic arches
arise.
• In the initial stage there are
pairs of aortic arches, which are
numbered I, II, III, IV, and
V.

7. 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
AORTIC ARCHES

8. The ventral part of the aortic sac ,left horn and the left
fourth arch artery, form the “Arch of Aorta”.
The right horn of the aortic sac forms the brachia-
cephalic or innominate artery.
The right fourth arch artery forms the proximal part of
the right subclavian artery. On the left side, the
subclavian artery is derived entirely from the
seventh cervical intersegmental artery.
As the right third and fourth arch arteries arise from the
right horn of the aortic sac, the common carotid and
subclavian arteries becomes branches of brachia-
Cephalic artery.
The external carotid artery arises as a bud from the
third arch artery.
The pulmonary arteries are derived from the part of
sixth arch arteries.
DEVELOPMENT OF ARTERIES

9. ARCH OF AORTA
Branches of Arch
of Aorta
1. Left Subclavian artery.
2. Left Common Carotid
artery.
3. Brachiocephalic
trunk.
-Right subclavian
artery.
-Right common carotid
artery.
9

10. VARIATIONS IN THE BRANCHES OF
THE ARCH OF AORTA
COMMON ORIGIN OF BRACHIOCEPHALIC AND CCA
COMMON STEM FOR THE RIGHT VESSELS
LEFT VERTEBRAL FROM AORTA
RIGHT SUBCLAVIAN ARISES FROM BELOW AORTIC ARCH

11. INTRODUCTION
• The arteries of the oral apparatus and
adjacent regions are, with few
exceptions, branches of the external
carotid artery.
• Only parts of the nasal cavity and the
upper parts of face are supplied by the
internal carotid artery.
• The external carotid artery sometimes
termed as facial carotid while internal
carotid artery is termed as cerebral
carotid.

12. COMMON CAROTID ARTERY
Right CCA is a branch of
brachiocephalic artery & it begins
in the neck behind the right
sternoclavicular joint.
Left CCA is a branch of the arch
of aorta & it begins in the thorax
in front of trachea, little left to the
center of the manubrium.
At the level of the upper border
of thyroid cartilage the artery
dividing into the external and
internal carotid arteries.

13. Relations Of The Common Carotid Artery
• Anterolaterally: skin, fascia,
sternocleidomastoid muscle,
sternohyoid, superior belly of
omohyoid.
• Posteriorly: transverse processes of
the lower four cervical vertebrae,
prevertebral muscles, sympathetic
trunk, vertebral vessel in the lower
part of the neck.

14. • Medially: larynx, pharynx,
trachea, esophegus,
thyroid gland.
• Laterally: internal jugular vein,
vagus nerve
posterolaterally.
Relations Of The Common Carotid Artery

16. VARIATIONS IN COMMON CAROTID ARTERY BIFURCATIONS

17. Carotid Sinus-
• The termination of CCA or beginning of the internal
carotid artery shows a slight dilatation known as carotid
sinus.
• Acts as a baroreceptor
(pressure receptor)
& regulates blood pressure.
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

18. • Small, oval reddish brown
structure situated behind
the bifurcation of CCA.
• Receive nerve supply from
glossopharyngeal & vagus
nerve.
• Act as a chemoreceptor &
responds to change in the
O2 & CO2 content of
blood.
Carotid Body

19. Carotid Pulse: Common carotid can be compressed against the carotid tubercle of
transverse process of C6 vertebra (carotid tubercle of CHASSAIGNAC) about 4 cm
above the sternoclavicular joint.
.
Carotid Body
Paragangliomas are vascular
lesions. 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.
APPLIED SIGNIFICANCE

20. INTERNAL CAROTID ARTERY
• Origin- at the upper border of thyroid
cartilage, at the disk of third and fourth
cervical vertebra and ascend to reach the
base of the skull where it enters the carotid
canal
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

21. • 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.
Cervical Part

22. Petrous Part
Branches-
1) Carotico-tympanic- enter
middle ear & anastomose with
ant. & post. Tympanic
branches
2) Artery of the Pterygoid
Canal- anastomose with
greater palatine artery
Within the petrous part of the temporal bone, in the carotid canal runs
upward forward & medially at right angle.

23. Cavernous Part
Within the Cavernous
Sinus
• Branches
1) Artery to trigeminal
ganglion
2) Superior & inferior
Hypophyseal artery

24. 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. Anterior choroidal
On angiogram, this part of
internal carotid artery show
‘S’ shaped figure
(carotid siphon)

25.  Central artery of retina- first branch of
ophthalmic
 Lacrimal artery- largest branch
 Post & ant ciliary
 Supraorbital- supplies skin of forehead
 Ant & post. Ethmoidal- supplies
ethmoidal sinus
 Medial palpebral- supplies eyelids
 Dorsal nasal- supplies the nose.
a) Zygomaticofacial artery-
• It is branch of lacrimal branch of the
ophthalmic artery.
• Enters the face through the
zygomaticofacial foramen.
• Supplies the area of the face over the
zygomatic bone.
OPHTHALMIC ARTERY

26. CIRCLE OF WILLIS

27. • It lies anterior to the internal carotid
artery.
• Chief artery that supply the face and
front of the neck.
COURSE & RELATION
• It begins in the carotid triangle at
the level of upper border of thyroid
cartilage (C3-C4).
• It runs upward & slightly backwards
,laterally & terminates behind the
neck of the mandible by dividing
into-
- Maxillary artery
- Superficial temporal artery
EXTERNAL CAROTID ARTERY

28. • Anteromedial to the ICA in its lower part.
• Anterolateral to the ICA in its upper part.
In 15% ECA originates lateral to the ICA, this
variation occurs more frequently on the
right (3:1)
a) In the carotid triangle-
Superficially- Cervical branch of facial nerve
Hypoglossal nerve
superior thyroid veins
Deep to the artery- Wall of pharynx
Superior laryngeal nerve
Ascending pharyngeal artery

29. b) Above the carotid triangle-
Lies deep in the substance of the parotid triangle.
Superficially—Retromandibular vein
Facial nerve
Deep to the artery—ICA
Structures passing between ECA and ICA
Styloglossus
Stylopharyngeus
IXth nerve
Pharyngeal branch of Xth nerve
Styloid process

30. BRANCHES

31. Superior Thyroid Artery
First branch
Arises just below the
level of the greater cornu
of the hyoid bone
It runs downwards and
forwards deep to the
infrahyoid muscles to the
upper pole of the thyroid
gland.

32. Branches

33. Applied Anatomy
• The artery and the external laryngeal nerve are close to each other
higher up, but diverge near the gland. To avoid injury to the nerve, the
superior thyroid artery is ligated as near to the gland as possible..
• Intra-arterial infusion chemotherapy for laryngeal and
hypopharyngeal cancers.
• Origin and branching pattern of STA is highly variable.
A total of 25 angiograms were evaluated, including 14 right and 11 left. On the right
side, STA was noted to arise from ECA in 10 (71.5%), bifurcation of CCA in 3
(21.5%), and CCA in 1 (7%) patient. Left STA was seen to arise from ECA in 8
(72.5%), bifurcation of CCA in 2 (18.5%), and internal carotid artery (ICA) in 1 (9%)
patient. Type III branching pattern (non-bifurcation, non-trifurcation) was found to be
the most frequent (52%).

34. Lingual Artery
Origin :
 Lingual Artery arises from the ECA
opposite the tip of greater cornu of the
hyoid bone
Course- is divided into 3 parts by the
hyoglossus muscle.
 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

35.  Suprahyoid Br- it runs along the hyoid’s
upper border
 Dorsal Lingual Br- arise medial to the
hyoglossus to supply tongue, palotoglossal
arch, tonsil, soft palate and epiglottis.
 Sublingual Artery- supplies the sublingual
gland, mylohyoid and the lingual and gingival
mucous membrane.
 Deep lingual artery- Terminus of the
lingual artery. Passes along the ventral aspect
of the tongue, accompanied by the lingual
nerve, to its apex.
Branches

36. Applied Anatomy
• During the surgical removal of the tongue, the first part of the artery is ligated
before it gives of any branch to the tongue or tonsil.
• Submandibular gland is palpated first and extent is noted
• Incision is made from little below and external to symphysis menti curving down to
point near cornu of hyoid bone then again extending upward to terminate below and
in front of angle of mandible.
• Skin, superficial fascia, platysma and deep fascia are separated
• The submandibular gland which is exposed is separated from its deep attachments
and retracted upward on to the face.
• This exposes the digastric triangle, mylohyoid and anterior belly of digastric
anteriorly, posterior belly of digastric posteriorly, hyoglossus muscle as floor.

37. Applied Anatomy
• Running along the floor we get
hypoglossal nerve and ranine
veins which are then displaced
upwards and digastric tendon
downwards.
• A small transverse blunt incision
is made on the hyoglossus
muscle (along the fibers) parallel
to the ranine vein
• Lingual artery comes into view
once the whole thickness of the
muscle is divided.

38. Applied Anatomy
• Variation in origin of lingual artery has been documented in
various articles.
Lingual artery arising from
common carotid
Common lingual-facial trunk

39. 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, cervical part in the neck
and facial part.
 At the antero-inferior angle of the masseter
muscle, it can be palpated here and is called as
an “anesthetist's artery”
Tortuous course—In neck allows free movements of pharynx during deglutition, on face -- free movements of
mandible , lips, & cheek during mastication & facial expressions, escapes traction & pressure during movements

40. Branches of Cervical part
1. Ascending palatine artery- supplies to the levator veli palatini, superior
pharyngeal constrictor and neighboring muscles, soft palate, tonsils, and auditory
tube.
2. Tonsillar- supply the palatine tonsil and the posterior tongue.
3. Submental artery- Arises from the facial artery near the anterior border of the
masseter muscle. it 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.

41. Branches Of Facial Part
1. Superior labial- passes superficial to
the orbicularis oris muscle, supplies to
upper lip & antero-inferior part of
nasal septum.
2. Inferior labial- Originates near the
corner of the mouth, passes deep to
the depressor anguli oris muscle, and
pierces the orbicularis oris muscle,
supplies to lower lip.
3. Lateral nasal- to the ala & dorsum of
nose.
4. Angular – supplies the lacrimal sac
and orbicularis oculi.

42. 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.
oCan 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.

43. Ligation Of Facial Artery
• The facial artery can be easily exposed at the point where it crosses
the lower border of the mandible to pass from the submandibular
region into the face.
• Contracted masseter muscle is used as a landmark
Procedure
• The incision is made at least half inch below the border of the
mandible and parallel to it.
• The skin, platysma muscle, and deep fascia are cut, and then the soft
tissues are bluntly retracted upward until the palpating finger can feel
the pulse of the facial artery.
• The artery then can be isolated, tied and cut.

45. ASCENDING PHARYNGEALARTERY
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.

46. Branches
• Pharyngeal arteries- supply the constrictors and the
stylopharyngeus. It gives minute branches to the tonsil and one
to auditory tube.
• Inferior tympanic artery - supply the tympanic cavity’s
media wall.
• Meningeal branches are small vessels to the nerves,
duramater and adjacent bone, entering the cranium through the
foramen lacerum, jugular foramen and hypoglossal canal.

47. Applied anatomy
• Trauma- The ascending pharyngeal artery plays an important role in the healing
process of Le Fort I osteotomies, because it supplies the attached posterior palatal
soft-tissue pedicle and also in closure of cleft palates.
• Epistaxis- Ascending pharyngeal artery Embolization plays an increasing role in the
management of epistaxis
• High-Grade Head and Neck Tumors- Intra-arterial embolization i.e. Super
selective microcatheter infusion of the ascending pharyngeal artery is necessary for
successful embolization
• Vascular Lesions- At the skull base, the ascending pharyngeal artery can be a
major feeder to arteriovenous fistulas or arteriovenous malformations.
.
• Collaterals to Agenetic or Occluded Internal Carotid Artery- The ascending
pharyngeal artery can function as collaterals to an agenetic internal carotid artery
The ascending pharyngeal artery can also be recruited in case of an occluded
internal carotid artery

48.  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.
POSTERIOR AURICULAR ARTERY

49. Branches
• Stylomastoid artery- enters the stylomastoid foramen to supply
the facial nerve, tympanic cavity mastoid antrum and air cells and
semi auricular canals.
• Auricular branch- ascending deep to auricular posterior ramifies
on the cranial aspect of the auricle; some branches pierces thin,
others curve round it to supply its lateral aspect.
• Occipital branch- passes laterally across the mastoid process
turning back over the Sternocleidomastoid to supply the occipital
belly of the occipital frontalis and scalp above and behind the ear, it
anastomoses with the occipital artery.

50. Arises from the posterior part of
the external carotid, opposite the
facial artery.
Ends in the posterior part of the
scalp
May arise from Internal carotid
artery.
• Relations:
• Posterior belly of digastric muscle
• Atlas and mastoid process
• Trapezius and sternocleidomastoid
muscle
OCCIPITALARTERY

51. Branches
IN THE CAROTID TRIANGLE
• STERNOMASTOID BRANCHES – Two. Upper branch accompanies
the accessory nerve and lower branch arises near the origin of the
occipital artery. Supplies sternomastoid muscle.
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

52. Branches
• 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 Digastricus, Stylohyoideus, Splenius, and
Longissimus capitis.
• DESCENDING BRANCH- 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
-The deep portion runs down between the Semispinales capitis and colli.

53. APPLIED ANATOMY
Ligation of occipital artery
Indication- wound of the vessel (stab, gun shot etc) and cirsoid
aneurysm of scalp
Steps-
An oblique incision 2 inches long extending from the tip of the mastoid
process towards the external occipital protuberance is made.
The superficial structures are separated and the sternocleidomastoid
insertion is exposed.
The occipital artery is found lying in the space between the mastoid
process and the transverse process of atlas under posterior belly of
digastric
Then the needle is passed and is ligated

54.  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

56. Branches
1st part (mandibular) :
Lies medial to mandible, passes between the ramus of the
mandible and the sphenomandibular ligament, where it lies
parallel to and a little below the auriculotemporal nerve; it
crosses the inferior alveolar nerve, and runs along the
lower border of the lateral pterygoid.
BRANCHES
 Deep auricular artery
 Anterior tympanic artery
 Middle meningeal artery
 Accessory meningeal artery
 Inferior alveolar artery

57.  Largest artery that supplies
the dura
 It ascends between the
sphenomandibular
ligament and the lateral
pterygoid muscle between
the two roots of the
auriculotemporal nerve to
the foramen spinosum
through which it enters the
middle cranium
 Divides into two branches,
anterior and posterior.
Middle meningeal artery
(medidural artery)

58. BRANCHES
ANTERIOR BRANCH OR
FRONTAL BRANCH:
Crosses the great wing of the
sphenoid, reaches the groove, in
the sphenoidal angle of the
parietal bone, and then divides
into branches which spread out
between the dura mater and
internal surface of the cranium.
POSTERIOR BRANCH OR
PARIETAL BRANCH:
Curves backward on the squama of
the temporal bone, and divides
into branches which supply the
posterior part of the dura mater
and cranium.

59. APPLIED ANATOMY
• 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 behind the acoustic meatus.

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

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

62. 2nd part (pterygoid part) :
 Artery runs forward & upward superficial to the lower
head of the lateral pterygoid muscle

63. 3rd part
(pterygopalatine):
 Terminal portion of the
artery passes between the
two heads of the lateral
pterygoid muscle

64. Infraorbital Artery
ORIGIN: Arises just before maxillary artery enters the
pterygomaxillary fissure.
COURSE;It runs along the infraorbital groove and
canal with the infraorbital nerve, and emerges on the
face through the infraorbital foramen, beneath the
infraorbital head of the Quadratus labii superioris.

65. 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.
 Prevention – pressure pack, Silver nitrate pack if fails
 Surgical ligation of sphenopalatine artery or ECA or ethmoidal arteries.

66. APPLIED ANATOMY OF MAXILLARY ARTERY
• Surgeries involving condyle- Injury to maxillary artery can occur as
it lies medial to condyle.
• 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.

67. LIGATION OF MAXILLARY ARTERY
Two approaches:
• 1.Transantral approach
• 2.Intraoral approach

68. TRANSANTRAL APPROACH
• Transmaxillary approach by Calwell Luc
method.
• Most widely used for controlling
posterior epistaxis.
• PROCEDURE
• Incision is made at canine mucobuccal
fold.
• Following an incision into the soft tissue over the
maxillary sinus, the bony face of this sinus is exposed.

69. • Fenestration of the bony
face of the maxillary
sinus
• Anterior wall of
maxillary sinus is
removed taken special
care not to damage the
infraorbital nerve.

70. • Posterior wall of sinus
is identified and
laterally based
mucosal u flap is
elevated.
• Position of posterior
wall is removed to
gain access to
pterygopalatine fossa
and branches of
maxillary artery.

71. • In most cases branches
are visualized by
operating microscope.
• Descending palatine
and Sphenopalatine are
important for ligation.

72. INTRAORAL APPROACH
• It provides access to the 1st and 2nd parts of the
maxillary artery without opening the maxillary
sinus.
• It does not require any microscope to operate.
• The site of ligation is more proximal than
transantral approach so more chance of
collateral circulation and failure.

73. PROCEDURE
• Incision at upper gingivo buccal sulcus at the level
of 2nd and 3rd molars and continued inferiorly
along the ramus of mandible.
• Buccal pad of fat is retracted medially or removed
and attachments of temporalis muscle to the
coronoid process is identified.
• Blunt dissection reveals the maxillary artery which
is clipped or ligated

74.  It begins in the substance of the
parotid gland, behind the neck of
the mandible
 Divides into two branches, a frontal
and a parietal
COURSE: It runs vertically upwards
crossing over the root of the zygomatic
process
-about 5 cm. above this process it divides
into two branches, a frontal and a
parietal.
SUPERFICIAL TEMPORAL ARTERY

75. • Relations.—As it crosses
the zygomatic process, it is
covered by the Auricularis
anterior muscle, and by a
dense fascia.
• It is crossed by the
temporal and zygomatic
branches of the facial
nerve, and is accompanied
by the auriculotemporal
nerve, which lies
immediately behind it.

76.  Transverse facial branch
 Anterior auricular branch
 Frontal branch
 Parietal branch
 Zygomatic- orbital branch
 Middle temporal branch
Branches

77. APPLIED ANATOMY
• Control of temporal haemorrhage.
• Placement of incisions in craniotomy
• In reduction of zygomatic arch fractures – Gilli’s approach
Temporal arteritis occur when
one or more arteries become
inflammed, swollen, and tender.

78. LIGATION
• 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.
• This exposes the artery with
auriculo temporal nerve lying in
front and temporal vein behind

79. EXTERNAL CAROTID ARTERY LIGATION
Can be done in carotid triangle or in retromandibular fossa.
INDICATION:
Bleeding from oral malignancies
Diminishment of blood supply to the area of the tumor bed
Involvement of vessel or major branch in tumor
Injuries causing carotid blow-outs
SPECIAL INSTRUMENTS:
Vascular loops and sutures
Vascular clamps

80. LANDMARKS
1)Upper border of thyroid
cartilage
2)Carotid bulb
3)Internal jugular vein
4)lower border of
mandible
5)Anterior border of
sternocleidomastiod
muscle

81. CONSIDERATIONS BEFORE LIGATION-
-To Obtain control of CCA below bifurcation before ligation.
-Be certain that vagus nerve, IJV, hypoglossal nerve and
superior laryngeal nerve are identified .
-Bradycardia is common with carotid bulb manipulation.
So1% lidocaine without epinephrine may be injected into the
areolar tissue around bulb.

82. Procedure
INCISION:
• A horizontal skin incision is
outlined and crosshatched at the
level of hyoid bone and
submandibular gland, two to three
fingerbreadths below the angle of
the mandible.
• It is placed in a skin crease.
• The posterior border of the
incision is over the SCM.

83. • Dissection is carried through skin, platysma, then anterior border of
SCM is identified and retracted posteriorly.
• A clamp is used to dissect anterior to the muscle parallel to great
vessels ,to identify carotid sheath.
• The CCA is carefully separated from other contents of sheath.
• The IJV, vagus nerve and ansa hypoglossi are retracted posteriorly.

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

85. -ECA is usually anterior
and superficial to ICA
but not always.
-A 2-0 silk tie is placed
between the superior
thyroid and lingual
arteries.
-The wound is closed in
layers after the removal
of vesicular loop from
CCA .

86. COMPLICATIONS:
-Damage to vital structures.
-Retrograde thrombus formation.
-Persistence of bleeding due to collateral flow.
-Rarely blindness may occur if ophthalmic
artery arises from middle meningeal artery of
ECA.

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

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

89. ARTERIES OF NECK
 Subclavian artery&its branches.
 Vertebral artery
 Internal thoracic artery
 Thyrocervical trunk
◦ Inferior thyroid artery
◦ Transverse cervical artery
◦ Suprascapular artery
 Dorsal scapular artery
 Costocervical trunk
◦ Deep cervical artery
◦ Superior intercostal artery

90. The Subclavian System of Arteries
ORIGIN –
• Right subclavian art. Arises from the brachiocephalic
trunk.
• Left subclavian art. arises from the arch of aorta.

91. THE SUBCLAVIAN ARTERIES
The left subclavian artery arises from the arch of
the aorta and after a short course in the thorax it
enters the neck. The right suclavian artery arises
from the brachiocephalic (innominate) artery.
In the neck the scalenus anterior muscle crosses
in front of the artery and subdivides it into three
parts –
first, second and third.
The first part extends from its origin to the
medial border of the scalenus anterior,
the second part lies under the cover of the
scalenus anterior
while the third part extends from the lateral
border of the scalenus anterior or the outer
border of the first rib where it is continued as
the axillary artery. The first portion of the left
subclavian artery is longer than the right.

92. Branches of Subclavian
• Vertebral,
• Internal thoracic
• Thyrocervical trunk.
• Costo cervical trunk.
• Dorsal scapular artery.

93. Vertebral Artery
93
• Origin-- from the upper surface of
the first part of SC A.passes through-
- foramina transversaria of upper six
cervical vertebrae, winds backward
around the lateral mass of atlas,enters
the cranial cavity through foramen
magnum, and at the lower border of
pons. unites with similar artery of
opposite side forms-- the basilar
artery.
BLOODSUPPLYTOHEAD
ANDNECK

94. Branches
94
• Cervical branches –
◦ spinal branches – enter the
vertebral canal through
intervertebral foramina ;
supplies spinal cord,meninges,
vertebra.
◦ muscular branches – from 3rd
part ; supply sub-occipital
muscles.
B] cranial branches
◦ meningeal branches
◦ posterior spinal artery
◦ ant. Spinal artery.,
◦ post. Inferior cerebellar artery,
◦ medullary arteries.
BLOODSUPPLYTOHEAD
ANDNECK

95. Internal ThoracicArtery
95
• Arises from the inferior surface
of 1st part of SCA, opposite the
origin of thyrocervical
trunk.,2cm above the sternal
end of clavicle.
• BRANCHES ---
• Pericardico-phrenic artery.
• Mediastinal branches.
• Pericardial branches
• Sternal branches
• Ant. Inter-costal artery.
• Perforating artery.
• Musculo-phrenic artery.
• Superior epigastric artery.
BLOODSUPPLYTOHEAD
ANDNECK

96. Thyro Cervical Trunk
96
• Arises from the upper
surface of 1st part of
SCA, just distal to the
origin of vertebral art.
•3 branches :
inferior thyroid art.
asc. Cervical art.
inf laryngeal art.
tracheal, oesophageal,
laryngeal br.
Transverse cervical art.
suprascapular art.
BLOODSUPPLYTOHEAD
ANDNECK

97. Costo-Cervical Trunk
97
•Arises from the back of 1st part of SCA on
left side2nd part of same art. On rt. Side.
Branches –
• deep cervical artery
• superior intercostal art.
BLOODSUPPLYTOHEAD
ANDNECK

98. Dorsal ScapularArtery
98
Arises from 3rd part of SCA. Passes laterally
b/w upper & middle or middle & lower trunks
of bracheal plexus. supply the rhomboids &
enters in formation of scapular anastamoses.
BLOODSUPPLYTOHEAD
ANDNECK

99. CLINICAL SIGNIFICANCE
• Pulse and bleeding
• The subclavian arteries have little clinical significance. However, its third part can serve as a useful site
for locating arterial pulsations as it lies superficially and can be compressed against the first rib. Also,
because of its close relation to the first rib, compression of the subclavian artery against the rib can be
used to control bleeding in the upper limb.
• Obstruction
• Furthermore, like most major arteries, obstruction of the subclavian artery can lead to thrombosis and
this can occur following trauma. A syndrome known as Subclavian Steal Syndrome occurs when the
blood from the vertebral artery is shunted to the subclavian artery distal to the obstruction in the lumen,
depriving the circle of Willis of its posterior input, resulting in specific clinical features. These are:
• dizziness
• vertigo
• imbalance
• visual disturbances
• hemisensory dysfunction
• However, this condition is usually asymptomatic and affects less than 9% of people suffering from
occlusion of the subclavian artery.

100. SUBCLAVIAN STEAL
 Occlusion of SCA proximal to
origin of vertebral artery
results in vertebral acting as
collateral to the other arm&
stealing flow from the basilar
artery.

101. COLLATERAL CIRCULATION
Definition: It is an accessory circuit
which consist of preexisting
anastomoses between branches of
arteries,when one occludes then these
channels become patent above or below
the site of occlusion.

102. FACTORS AFFECTING COLLATEARAL
FLOW
 Pressure gradient across the site of occlusion
 Anatomic site of block
 Rate of occlusion
 Extent of occlusion
 Sympathetic activity

103. COLLATERALS AFTER LIGATION OF CCA
 Through subclavian artery, inferior thyroid  superior thyroid arteries.
 Either side of face – ECA.
 Deep cervical, transverse cervical and occipital arteries anastomoses.
 Circle of Willis

104. REFERENCES
• GRAY’S ANATOMY- 39TH EDITION
• NETTER’S- COLOUR ATLAS OF ANATOMY
• HEAD AND NECK ANATOMY- W.H HOLLINGSHEAD
• SICHER’S AND DUBRUL’S ORAL ANATOMY
• JOURNAL OF HEAD NECK PATHOLOGY 2009
• INDIAN JOURNAL RADIOLOGY AND IMAGING 2014
• HANDBOOK OF OPERATIVE SURGERY AND SURGICAL
ANATOMY- KARUNA K CHATTERJI
• PETERSON’S PRINCIPLES OF ORAL AND MAXILLOFACIAL
SURGERY

105. Thank
you