complete blood supply of head and neck along with the ligation of important arteries useful for oral and maxillofacial surgeon

1. Presented By:
Dr. Pratik Warade
MDS I7/03/2018

2. Contents
 Functional morphology
 Arterial supply of head and neck
 Veinous supply of head and neck
 Veinous sinuses
 Applied anatomy

3. Functional morphology
 Arteries:
1. Blood flows away from the heart.
2. Possess thick elastic walls.
3. Carry oxygenated blood except the
pulmonary artery.
4. Do not possess valve except in aorta.
5. Arteries are deeper in the flesh as veins.
6. Pulse is detectable.
7. Have narrower lumen.

4.  Veins
1. Blood flow towards the heart.
2. Possess thin walls.
3. Carry deoxygenated blood except the
pulmonary vein.
4. Have valves to prevent backflow of the blood.
5. Veins are nearer the surface of the skin.
6. Pulse is not detectable.
7. Have wider lumen.

5. Features Artery Vein
Tunica Intima-Endothelium Usually rippled due vessel
constriction
Often smooth
Internal elastic membrane Present Absent
Tunica media Thick, dominated by
smooth muscle cells and
elastic fibers
Thin, Dominated by smooth
muscle cells and collagen
fibers
External elastic membrane Present Absent
Tunica externa Collagen and elastic fibers Collagen, elastic fibers and
smooth muscle cells

7. Arteries of head and neck
 Common carotid artery
 External carotid artery
 Internal carotid artery
 Subclavian artery

8. Common carotid artery

9. Common carotid artery
 CCA runs lateral to trachea
and larynx to bifurcate at upper
border of thyroid cartilage i.e.,
at the level of the disc b/w 3rd
and 4th cervical vertebrae
 CCA gives rise to ICA
posteromedially and ECA
anterolaterally
 ICA is slightly widened at
division to formCAROTID
SINUS
Common
carotid
artery

10. Relations to common carotid
artery
Anterolaterally:
• Sternocleidomastoid
• Sternohyoid
•Sternothyroid
•Superior belly of omohyoid
Posteriorly:
• Prevertebral muscles
Medially:
• Larynx
• Pharynx
Laterally:
• Internal jugular vein

11. Applied anatomy of Common
carotid artery
 The CCA can be compressed against the
carotid tubercle i.e the anterior tubercle of
the transverse process of the vertebra C6
which lies at the level of cricoid cartilage
 Patency of the carotid system can be
investigated by angiography

12. Ligation of carotid arteries
 ECA can be ligated at 2 points:
 Origin from CCA
 Retromandibular fossa

13. 1. Origin from CCA
 Ligated usually above omohyoid muscle in carotid
triangle i.e., between superior thyroid and lingual
artery.
 Ligation can be used in bleeding from any one or more
arteries or in injuries of ECA itself.
Surgical procedure
 Incision over the skin starts at the level of angle of
mandible just behind anterior border of
Sternocleidomastoid muscle, downward and forward
till level of cricoid cartilage
 Skin, platysma, superficial sheath of SCM is incised
 Blunt dissection over the anterior border of muscle is
done to expose the deep layer of SCM and IJV
 Fascia in front of IJV is cut to expose arteries
 ECA is identified by it’s first ant. branch, sup. thyroid
artery
 Isolated and ligated few mm above the origin of
Superior thyroid artery.

14. 2) Retromandibular fossa
 Retromandibular fossa lies behind the angle of
mandible
 ECA crosses stylomandibular ligament on it’s
lateral side, therefore method known as “ligation
of ECA at stylomandibular ligament.”
 Recommended if one deals with hemorrhage
from one of the branches of maxillary artery
 As artery supplies both U/L jaws this should be
method of choice in injuries of jaws and
preparatory operations.

15.  Surgical procedure
1. Less dangerous procedure than exposure of artery
in neck
2. Incision placed over the skin at the tip of mastoid
process, circling the mandibular angle, about 1
inch below mandible
3. Blunt dissection to locate retromandibular vein or
EJV, tied and cut
4. Branches of greater auricular cut to permit
mobilization of cervical lobe of parotid
5. Parotid capsule detached from anterior border of
SCM
6. Helps skin retraction with parotid, anteriorly and
upward
7. Exposes posterior belly of digastric and stylohyoid
muscle above which lies stylomandibular ligament
8. Ligament can be palpated on mandibular
protrusion
9. Pulse of ECA can be felt, isolated and cut even
accompanied by larger vein.

16. Variations in branching of
External carotid artery
A. Most common arrangement
B. Superior thyroid arising from CC and lingual and facial having common stem
C. Posterior auricular artery branch of occipital and asc. pharyngeal arises higher
than normal

17. Branches of common carotid
artery
 External carotid artery
 Internal carotid artery

18. External carotid atery
•External carotid artery is the terminal branch
of common carotid artery.
•Chief artery of supply to structures in front of
the neck and face.
•Generally arises medial and anterior to
the ICA. Begins at the level of upper border of
thyroid cartilage.
•In 15% ECA originates lateral to the ICA,
this variation occurs more frequently on
the right (3:1)

19. Branches of external carotid
artery
 Anterior
1. Superior thyroid
2. Facial
3. Lingual
 Posterior
1. Posterior auricular
2. Occipital
 Medial
1. Ascending pharyngeal
 Terminal
1. Superficial temporal
2. Maxillary

20. Superior thyroid artery
 First branch from ECA
arises immediately above
the bifurcation of CC
 Arises just below the
greater cornu of hyoid
bone.
 A diagnostic landmark in
surgical exposure of EC
 Ends in thyroid gland.

21. Lingual artery
 Lingual Artery arises from the
ECA opposite the tip of
greater cornu of the hyoid
bone.
 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.

22.  Lingual artery gives 2 dorsal-lingual branches as it passes under cover of
hypoglossal muscle
 Sub-lingual artery is smaller branch, passes b/w genioglossus muscle and
sublingual gland and supplies them
 At ant. floor of mouth, this artery anastomizes with opposite side and gives off
artery to frenulum
Cutting of frenulum in tongue-tie needs ligation of sub-lingual artery.
 Deep lingual artery lies in the inferior surface of the tongue
 Excision Involving only portion of tongue, artery can be identified through
incision of mucous membrane in lateral part of floor of mouth and ligated

23. Ligation of lingual artery
 At origin stem from ECA gives good
collateral circulation (1/5th of the cases
have common stem for lingual and facial
art.)
 Usually above hyoid bone, if interruption
of entire vessel desired
 Hypoglossal n. identified after pushing
sub-mandibular gland upwards as it runs
across digastric
 LINGUAL OR LESSER’S triangle is formed
by pushing hypoglossal n. upwards
 Lingual art. lies deeply in the fibers of
hyoglossus muscle, posterior within the
triangle

24. Facial artery
 Arises opp. the great cornu of hyoid bone,
enters digastric triangle by passing deep to
tendon
 Lies deeply embedded in the substance of
submandibular salivary gland and then enters
it’s facial course by curling around the inferior
border of mandible immediately anterior to
masseter muscle, i.e. about 1½ inch in front
of angle of mandible
 At the anteroinferior angle of the masseter
muscle, it can be palpated here and is called
as an “anaesthetist’s artery”

25.  Branches of cervical part:
1. Ascending palatine – supplies tonsil, root of tongue,soft
palate and the pharyngotympanic tube
2. Tonsillar - mainly supplies the tonsils
3. Sub mental – large artery, accompanies mylohyoid
nerve, supplies sub mental triangle and sublingual
salivary gland.
4. Glandular branches – 3 or 4 large vessels ,supply the
submandibular salivary gland and the lymph node.

26.  Branches of facial part
1. Inferior labial
2. Superior labial
3. Lateral Nasal
4. Angular

27. Ligation of facial artery
 Easily exposed where it crosses the
lower border of mandible to pass
from submandibular region into face
i.e. anterior to attachment of
masseter muscle on mandible
 Care should be taken to prevent
marginal mandibular branch of facial
nerve.Therefore incision should be
taken 1-2 cm below the border of
mandible
 Skin, platysma muscle and deep
fascia are cut, soft tissue bluntly
retracted upwards until palpating
finger can feel pulse of facial art.
 Artery isolated, tied and cut

28. Occipital artery
 Arises from post. surface of ECA
about same level as facial
 Runs obliquely backwards,
upwards, crosses ICA and IJV
 At it’s origin, hypoglossal n. lies
b/w IC & IJ
 Branches – SCM (muscular)
– Auricular
– Mastoid
– Meningeal

29. Posterior auricular artery
 Arises from posterior surface of EC in retro-
mandibular fossa above stylohyoid muscle.
 Largely covered by parotid gland
 Ascends along the styloid process b/w
external ear and mastoid process
 May arise as a branch of occipital rather than
independent
 Supplies to outer ear and partly adjacent
area of scalp
 Anastomosis with branches of occipital art.
and auricular branch of superficial temporal

30. Ascending pharyngeal artery
• Smallest branch, arises from post. surface often close
to origin
• Ascends vertically, anteromedially to ICA and
pharynx
• Supplies – to pharynx (several branches)
– palate and tonsils
– inf. tympanic branch to tympanum and
– several meningeal branches
• Larger terminal br. usually post. meningeal enters
cranium through jugular foramen
 Approx. 14% of individuals asc. pharyngeal arises not
from ECA but from occipital art.

31. Applied anatomy
 The ascending pharyngeal artery plays an
important role in healing process of Le Fort I
osteotomies, because it supplies the attached
posterior palatal soft tissue pedicle.

32. Maxillary artery
 ECA artery gives 2 terminal branches
(maxillary & sup. temporal) at approx. ½ to
2/3rd distance between lower border of
angle andTMJ
 Leaves ECA at right angles passing almost
horizontally b/w ramus and
sphenomandibular ligament
 Acc. to Lasker et al maxillary artery may
have varying relations to lateral pterygoid
muscle in different individuals in slightly
more than 50% individuals the artery is
found on outer side of muscle,in remaining
artery lies at medial side.

33. 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

34. Middle maningeal artery
 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.

35. 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.Inferior
alveolar
artery

36.  2nd part (pterygoid part)
Artery runs forward & upward superficial to the
lower head of the lateral pterygoid muscle

37.  3rd part (pterygopalatine)
Terminal portion of the artery passes between
the two heads of the lateral pterygoid muscle

38. Superficial temporal artery
 Is 2nd terminal branch of ECA
ascending vertically it crosses the
posterior root of zygomatic arch
immediately in front of outer ear
 Pulse of this artery can be felt as is
covered by superficial fascia & skin
 Releases transverse facial artery
before it leaves parotid gland
 Transverse facial lies beween
zygomatic arch & parotid duct
 Sends branches to masseter muscle,
parotid and terminates below outer
corner of eye where anastomosis with
palpebral artery.

39.  ST divides above zygomatic arch into
2 main branches – parietal and
frontal
 Parietal continues vertically upwards
and supplies wide lateral area of scalp
 Frontal runs obliquely and forward, is
often tortuous
 Superficial branch – zygomatico-
orbital arises either from main stem
or anterior branch which runs
horizontally towards outer corner of
eye supplies orbicularis oculi &
anastomosis with lacrimal art.

40. Internal carotid artery
 Principal artery of brain and eye. 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.
 Divided into 4 parts:
1. Cervical part – in neck (Branchless)
2. Petrous part – within the petrous temporal bone
a. Caroticotympanic
b. Pterygoid
3. Cavernous part – within cavernous sinus
a. Branch to trigeminal ganglion
b. Sup. & inf. hypophyseal
4. Cerebral part – in relation to base of brain
a. Opthalmic c. Middle cerebral e. Ant. chorodial
b. Ant. cerebral d. Post. communicating

41. 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

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

43.  Cavernous part
Within the Cavernous Sinus
Branches
1) Artery to trigeminal ganglion
2) Superior & inferior Hypophyseal artery

44. 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

45. Subclavian artery
Right Subclavian Artery:
 Arises from brachiocephalic artery (Behind right
sternoclavicular joint)
 At outer border of 1st rib it becomes Axillary
Artery
Left Subclavian Artery:
 Arises from Arch of Aorta in the thorax
 Runs upwards to the root of the neck & arches
laterally
 At outer border of 1st rib it becomes Axillary
Artery

46. Subclavian artery
 Scalenus Anterior muscle passes anterior to
the artery on each side and divides it into 3
parts.
1. 1st part of subclavian artery
2. 2nd part of subclavian artery
3. 3rd part of subclavian artery

47. 1st part of Subclavian artery
 Extends from the origin of the subclavian
artery to the medial border of the Scalenus
anterior muscle.
 Branches:
1.Vertebral artery
2.ThyrocervicalTrunk
3. Internal thoracic artery

48. 2nd part of subclavian artery
Lies behind the Scalenus anterior muscle.
 Branches:
1. Costocervical trunk
2. Superior intercostal artery
3.Deep cervical artery

49. 3rd part of subclavian artery
Extends from the lateral border of the Scalenus
anterior muscle to the lateral border of 1st
rib.
 Branches: (Occasional)
1. Superficial cervical artery
2. Suprascapular artery

50. Veins of the head and neck

51.  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

52. Internal Jugular vein
 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

53.  Tributaries

54. Facial Vein
 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

55.  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:
1. Pterygoid plexus through deep facial
vein
2. Cavernous sinus through superior
ophthalmic vein

56. Retromandibular 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

57. 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

58. The maxillary 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

59. Pterygoid plexus
 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.

60.  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

61. External jugular vein
 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

62. Tributaries
 Posterior auricular vein
 Posterior division of retro mandibular vein
 Posterior external jugular vein
 Transverse cervical vein
 Suprascapular vein
 Anterior jugular vein

63. Venous sinuses
 The blood of the brain and the eye is collected by
a system of specialized veins in the dura matter
called sinuses.
 These sinuses are not collapsible, and their
lumen is unchangeable because their walls are
formed by the dense, rigid, and inelastic tissues
of the dura matter.
 They drain eventually into the internal jugular
vein, but there are numerous communications
between the sinuses and extracranial veins.

65. Superior saggital 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.

66. 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.

67. Inferior saggital 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

68. Cavernous sinus
 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.

69. Structure passing through
the sinus
 Internal carotid artery
 Abducent nerve
 Occulomotor nerve
 Trochlear nerve
 Ophthalmic nerve
 Maxillary nerve

70.  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

71. Dangerous area of face
The facial vein communicates
with the cavernous sinus through
superior opthalmic vein.
Infections from upper lip and
lower part of nose can spread in
a retrogade direction and cause
thrombosis of cavernous sinus.
So this area is known as
Dangerous area of Face.

72. References:
 Gray’s Anatomy 41st Edition
 Sicher and Dubrul’s Oral Anatomy 8th edition
 BD Chaurasia’s Human Anatomy 5th edition.

73. Thank you.