Arterial supply of head and neck

avinash rathore

1. 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

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

3. DEVELOPMENT

4. Aortic arches The  aortic arches are a series of six paired embryological vascular structures which give rise to several major arteries. A ortic arches are short vessels connecting ventral and dorsal aortae on each side, t hey run within branchial (pharyngeal) arches are based gradually in the 4th and 5th week, in 6 pairs in total. T he first, second and fifth pairs soon disappear.

5. T he 1st aortic arch – disappears ( a small portion persists and forms a piece of the maxillary artery ) T he 2nd aortic arch – disappears ( small portion of this arch contributes to the hyoid and stapedial arteries ) T he 3rd aortic arch - has the same development on the right and left side i t gives rise to the initial portion of the internal carotid artery T he external carotid is derived from the cranial portion of the ventral aorta T he common carotid corresponds to a p ortion of the ventral aorta between exits of the third and fourth arches

6. T he 4th aortic arch - has ultimate fate different on the right and left side O n the left - it forms a part of the arch of the aorta between left common carotid and left subclavian artery O n the right - it forms the proximal segment of the right subclavian arter y T he 5th aortic arch - is transient and soon obliterates

7. T he 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 O 2 concentration

8. The outermost layer is known as the  tunica externa  also known as  tunica adventitia  and is composed of  connective tissue  made up of collagen   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 the intima . 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.

9. The Structure of Blood Vessels A Comparison of a Artery and a Vein- Figure 13-1

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

11. COMMON CAROTID ARTERY

12. 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

13. 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-9 TH 10 TH 12 TH CN

14. 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 .

15. RELATION OF COMMON CAROTID ARTERY LATERA L-IJV ANTEROLATERALLY SKIN,FASCIA,SCM,STERNOHYOID,STERNOTHYROID,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

16. 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.

17. 20 Applied anatomy Carotid pulse Carotid palpation

18. 21 External carotid artery (Facial carotid)

19. 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.

20. 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

21. 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.

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

23. 28 External carotid artery Superficial temporal Maxillary Facial Lingual Superior thyroid Posterior auricular

24. 29 Superior thyroid artery

25. 30 Origin and course: Arises from ECA immediately above the bifurcation of CCA Curves anteriorly and downwards to enter Thyroid gland

26. 31 Branches Anterior Posterior Superior thyroid artery

27. 32

28. RELATION WITH EXTERNAL LARYNGEAL NERVE

29. 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.

30. 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

31. Branches of Lingual Artery Suprahyoid Br Dorsal Lingual Br Deep Lingual Artery Sublingual Artery

32. 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 LINGUAL ARTERY : Incision – circling the lower pole of submandibular gland. - Skin, platysma, deep fascia incised, submandibular gland exposed , lifted, tendon of digastric visible.

33. - 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.

34. SUBLINGUAL ARTERY 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.

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

36. FACIAL ARTERY

37. 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”

38. 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

39. Branches of Cervical part Ascending palatine artery- it supplies to root of tongue & tonsil. Tonsillar artery Submental artery- it is a large artery which accompanies the mylohyoid nerve, and supplies the submental triangle and sub lingual salivary gland. Glandular branches that supplies submandibular salivary gland and submental lymph nodes.

40. 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.

41. 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

42. Branches of facial part Superior labial - supplies to upper lip & antero -inferior part of nasal septum. Inferior labial - supplies to lower lip. Lateral nasal - to the ala & dorsum of nose. Angular – supplies the lacrimal sac and orbicularis oculi .

43. 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.

44. SUPERIOR LABIAL ARTERY: 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.

45. LATERAL NASAL ARTERY: 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.

46. VARIATIONS

47. 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. 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 .

48. In mand . 1 st 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.

49. MEDIAL BRANCH

50. 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 .

51. BRANCHES PHARYNGEAL BRANCHES PALATINE BRANCH PREVERTEBRAL BRANCH INFERIOR TYMPANIC ARTERY MENINGEAL BRANCHES

52. POSTERIOR BRANCHES

53. 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

54. 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.

55. 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.  

56. 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.

57. 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 .

58. 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.

59. 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

60. 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.

61. TERMINAL BRANCHES

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

63. 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

64. 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 5 th and 7 th nerve, middle ear, tensor tympani Meninges , Structures in the infra temporal fossa Lower teeth and mylohyoid muscle

65. 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

66. 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.

67. 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.

68. 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

69. 2nd part (pterygoid part) : Artery runs forward &upward superficial to the lower head of the lateral pterygoid muscle

70. B. Second part Branches 1.Deep temporal 2.Pterygoid 3.Masseteric 4.Buccal Distribution Temporalis Lateral and medial pterygoid Masseter Buccinator

71. 3rd part ( pterygopalatine ): Terminal portion of the artery passes between the two heads of the lateral pterygoid muscle

72. 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.

73. 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 .

74. 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.

75. 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.

76. 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.

77. 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.

78. 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.

79. 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.

80. 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 .

81. 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

82. Parietal branch Frontal branch Middle temporal artery Transverse facial artery

83. Transverse facial branch Anterior auricular branch Frontal branch Parietal branch Zygomatico - orbital branch Branches

84. 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.

85. 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.

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

87. 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.

88. 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.

89. 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.

90. 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.

91. 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

92. 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.

93. 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

94. CAVERNOUS PART Within the Cavernous Sinus Branches 1) Artery to trigeminal ganglion 2) Superior & inferior Hypophyseal artery

95. 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 )

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

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

98. Circle of Willis The  circle of Willis   is a c irculatory 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 .

99. 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)

100. CARATIDO-JUGULAR REFLEX

101. 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.

102. 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

103. Carotid body situated behind the bifurcation of CCA Act as a chemoreceptor & respond to change in the O 2, C O2 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

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

105. 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.

106. 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.

107. 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 .

108. PROCEDURE FOR LIGATION EXPOSE THE SHEATH OF VESSEL ISOLATE THE VESSEL PLACE THE LIGATURE

109. LIGATION OF EXTERNAL CAROTID ARTERY

110. EXPOSED AT TWO SITES 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)

111. 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

112. 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

113. 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

114. 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

115. 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

116. IN RETROMANDIBULAR FOSSA

117. 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

118. 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

119. 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

120. LIGATION OF LINGUAL ARTERY

121. 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

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

123. 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 )

124. 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

125. DIFFICULT TO LIGATE SUBLINGUAL ARTREY MAY BE A BRANCH OF LINGUAL ARTERY SUBMENTAL ARTERY

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

127. LIGATION OF FACIAL ARTERY

128. 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

129. 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 1 ST MANDIBULAR MOLAR. DURING BUCCAL SPACE INFECTION THE ARTERY IS DISLOCATED AVOID DEEP INCISION, INCISION SHOULD BE DOWNWARDS & INWARDS INSTEAD OF STRAIGHT UPWARDS.

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

131. Skin,platysma and deep cervical fascia cut

132. Skin,platysma and deep cervical fascia cut

133. Artery is accompanied by facial vein & crossed superficially by marginal mandibular branch of facial nerve

134. Pulse of facial artery felt. Artery- isolated, tied & cut

135. LIGATION OF MAXILLARY ARTERY

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

137. 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

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

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

140. 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

141. 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

142. LIGATION OF SPHENOPALANTINE ARTERY

143. LIGATION OF SPEHNOPALATINE ARTERY CAN BE DONE BY TWO METHODS TRANSANTRAL LIGATION ENDOSCOPIC LIGATION

144. 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

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

146. LIGATION OF GREATER PALANTINE ARTERY

147. 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

148. ANTERIOR AND POSTERIOR ETHMOIDAL ARTERY

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

150. 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)

151. 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

152. LIGATION OF INTERNAL CAROTID ARTERY

153. 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.

154. 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

155. REFERENCES: SICHER’S ORAL ANATOMY- 8 TH EDITION LORE AND MEDINA-6 TH EDITION PRINCIPLES OF SURGERY BY EDWARD WARN HEAD AND NECK SURGERY- OTOLARYNGOLOGY BY BYRON. J. BAILEY- 2 ND EDITION Human Anatomy by B.D. Chaurasia , 6 th 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,