Arterial supply of head and neck with ligation of ECA and MA

Arterial supply of head and neck

1. Arterial supply of head and neck (ECA and MA )

2. CONTENTS : Introduction The Blood Vessels Embryology The Common Carotid Artery The External Carotid Artery The Internal Carotid Artery Applied Anatomy Diagnostic Aids In Arterial System Ligation Of Artery Conclusion References

3. INTRODUCTION T he major source of blood to the head and neck is provided by common carotid, internal carotid and external carotid arteries. Additional arteries arise from branches of the subclavian artery, particularly the vertebral artery. The common, internal and external carotid arteries and accompanying veins and nerves all lie in a cleft that is bound posteriorly by the transverse processes of cervical vertebrae and attached muscles, medially by the trachea, oesophagus , thyroid gland, larynx and pharyngeal constrictors, and anterolaterally by sternocleidomastoid and, at different levels, omohyoid, sternothyroid, digastric and stylohyoid muscles. The common and internal carotid arteries lie within the carotid sheath, accompanied by the internal jugular vein and the vagus nerve.

4. EMBRYOLOGY : Aortic Arches are also known as pharyngeal arch arteries or branchial arches. Formed sequentially within pharyngeal arches. Present during 4 th and 5 th week of IU life. 6 pairs in total 1 st , 2 nd and 5 th pair soon disappear.

5. COMMON CAROTID ARTERY :

6. COMMON CAROTID ARTERY : The  right common  carotid artery arises from a  bifurcation  of the  brachiocephalic trunk  (the right subclavian artery is the other branch). This bifurcation occurs roughly at the level of the right sternoclavicular joint. The left common carotid artery branches directly from the  arch of aorta . The left and right common carotid arteries ascend up the neck,  lateral  to the trachea and the esophagus . They do not give off any branches in the neck. At the level of the superior margin of the  thyroid cartilage (C4),  the carotid arteries split into the   external and internal  carotid arteries. This bifurcation occurs in an anatomical area known as the carotid triangle. The termination of the common carotid artery, or the beginning of the internal carotid artery shows a slight dilatation, known as the carotid sinus. Carotid sinus acts as baroreceptor or pressure receptor and regulates blood pressure. The carotid body is  a chemoreceptor located in the bifurcation of the common carotid artery .  Chemoreceptor function Carotid body monitors the blood's pH, pCO2, and pO2.

7. ORIGIN OF COMMON CAROTID ARTERY:

8. INTERNAL CAROTID ARTERY : It is a terminal branch of common carotid artery. It first runs through the neck (cervical part), then passes through the petrous bone (petrous part), then courses through the sinus (cavernous part) and lastly lies in relation to the brain (cerebral part) Area of distribution : Cervical part of the artery does not give any branch. Petrous part gives branches for the middle ear; C avernous part supplies hypophysis cerebri. The cerebral part gives ophthalmic artery for orbit, anterior cerebral, middle cerebral, anterior choroidal and posterior communicating for the brain.

9. Cervical part: Enclosed in sheath No branches Initial part shows dilation Lower part is superficial Upper part above post belly of digastric is deep to parotid gland Petrous part: Emerges at petrous temporal bone in posterior wall of foramen lacerum Branches: CAROTICOTYMPANIC BRANCHES- Enter middle ear and anastomoses with ant & post tympanic artery PTERYGOID BRANCH- Enters pterygoid canal & anastomoses with greater palatine artery

10. Cavernous part: Covered by lining endothelium of veins Surrounded by sympathetic plexus: occulomotor , trochlear, opthalmic & abducent Cerebral part: Divided into Opthalmic artery Anterior cerebral Middle cerebral artery Posterior communicating Anterior choroidal artery

11. EXTERNAL CAROTID ARTERY : It is one of the terminal branches of common carotid artery and lies anterior to internal carotid artery. External carotid artery starts at the level of upper border of thyroid cartilage,runs upwards and laterally to terminate behind the neck of mandible by dividing into larger maxillary and smaller superficial temporal branches. It supplies structures in the front of neck, i.e. thyroid gland, larynx, muscles of tongue, face, scalp, and ear

12. ANTERIOR BRANCHES OF THE EXTERNAL CAROTID ARTERY : Three arteries arise from the anterior wall of the external carotid artery: superior thyroid artery lingual artery facial artery.

13. SUPERIOR THYROID ARTERY: The superior thyroid artery is the first branch of the external carotid artery, and arises from the anterior surface of the external carotid just below the level of the greater cornu of the hyoid bone . It descends along the lateral border of thyrohyoid to reach the apex of the lobe of the thyroid gland. Lying medially are the inferior constrictor muscle and the external laryngeal nerve; the nerve is often posteromedial, and therefore at risk when the artery is being ligated. Occasionally, it may issue directly from the common carotid.

14. LINGUAL ARTERY : It arises from anterior aspect of external carotid artery forms a typical loop which is crossed by XII nerve. Its 2nd part lies deep to the hyoglossus. The 3rd part runs along the anterior border of hyoglossus and 4th part runs forwards on the under surface of tongue It supplies various muscles,papillae and taste buds of the tongue. It also gives branches to the tonsil.

15. COURSE OF LINGUAL ARTERY : The lingual artery arises from the anterior surface of the external carotid artery in the neck. It emerges close to the tip of the greater horn/ cornu of the hyoid bone, and lies on the middle pharyngeal constrictor muscle. From its origin, the artery arches upwards and anteriorly, giving off its first branch, the suprahyoid artery. The lingual artery then travels deep to the hyoglossus muscle, where it gives off the dorsal lingual arteries. The artery then continues into the floor of the mouth, passing lateral to the genioglossus muscle. At the anterior border of the hyoglossus muscle, the lingual artery takes an upward turn and bifurcates into the deep lingual and sublingual arteries. Along its path, the lingual artery is accompanied by the lingual veins and the glossopharyngeal nerve (cranial nerve IX).

16. Lingual ARTERY:

17. FACIAL ARTERY: This tortuous artery from anterior side also arises a little higher than lingual artery. It runs in the neck as cervical part and in the face as facial artery. arises from the external carotid just below the posterior belly of the digastric muscle. Cervical part gives off ascending palatine, tonsillar, glandular branches for the submandibular and sublingual salivary glands. The facial part lies on the face giving branches to muscles of face and its skin

18. CERVICAL PART: Cervical part runs upwards on superior constrictor of pharynx deep to the posterior belly of digastric. It grooves the posterior border of submandibular gland, makes S bend { 2 loops } . 1 st winding down over submandibular gland and then up over the base of mandible Ascending palatine artery Tonsillar artery Glandular artery Submental artery

19. FACIAL PART: The vessel enters the face by winding around the base of the mandible, and by piercing the deep cervical fascia at the anteroinferior angle of the masseter muscle. It runs upwards and forwards deep to the risorus to a point 1.25cm lateral to the angle of the mouth. Then it ascends by the side of the nose upto the medial angle of the eye where it terminates by anastomosing with the dorsal nasal branch of the of the ophthalmic artery. Branches : Inferior labial artery Superior labial artery Lateral nasal artery Angular artery

20. Posterior branches : At The Posterior Circumference Of The External Carotid Artery Arise Two Branches : Occipital Artery Posterior Auricular Artery.

21. OCCIPITAL ARTERY: It arises form the posterior aspect of external carotid artery and runs upwards along the lower border of posterior belly of digastric muscle. Then it runs deep to mastoid process and the muscles attached to it. The artery then crosses the apex of suboccipital triangle and then it pierces trapezius 2.5 cm from midline to supply the layers of scalp It gives two branches to sternocleidomastoid muscle, and branches to neighbouring muscles. It also gives a meningeal and mastoid branch

22. POSTERIOR AURICULAR: It arises from posterior aspect of external carotid artery, it runs along the upper border of posterior belly of digastric muscle to reach the back of auricle It gives branches to scalp. Its stylomastoid branch enters the foramen of the same name to supply mastoid antrum, nerve air cells and the facial

23. ASCENDING PHARYNGEAL: It is the medial branch of external carotid artery. It arises from the medial side of external carotid artery, close to its origin. It runs upwards and between pharynx and tonsil on medial side and medial wall of middle ear on the lateral side. It gives branches to tonsil, pharynx and a few meningeal branches

24. THE TERMINAL BRANCHES: Superficial Temporal Artery Maxillary Artery

25. SUPERFICIAL TEMPORAL: It is the smaller terminal branch of external carotid artery. It begins behind the neck of the mandible, runs upwards and crosses the preauricular point, where its pulsations can be felt. 5 cm above the preauricular point it ends by dividing into anterior and posterior branches. Its two terminal branches supply layers of scalp and superficial temporal region. It also supplies parotid gland, facial muscles and temporalis muscle

26. MAXILLARY ARTERY : It is the larger terminal branch of external carotid artery. It is given off behind the neck of the mandible. Its course is divided into 1st, 2nd and 3rd parts according to its relations with lateral pterygoid muscle. 1st part lies below the lateral pterygoid, 2nd part lies on the lower head of lateral pterygoid and 3rd part lies between the two heads

27. Second / pterygoid part: MASSETRIC DEEP TEMPORAL PTERYGOID BUCCALIS PTERYGOPALATINE PART DESCENDING PALATINE ARTERY OF PTERYGOID CANAL SPHENOPALATINE First mandibular part: DEEP AURICULAR ANTERIOR TYMPANIC MIDDLE MENINGEAL ACCESSORY MENINGEAL INFERIOR ALVEOLAR THIRD / MAXILLARY PART POSTERIOR SUPERIOR ALVEOLAR INFRAORBITAL

28. LIGATION OF ARTERIES : 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. This point is situated anterior to the attachment of the masseter muscle to the mandible Here, the pulse of the facial artery can easily be felt. The artery is accompanied by the facial vein, which lies posterior to the artery. The artery and vein are crossed superficially by the marginal mandibular branch of the facial nerve. the mandibular branch of the facial nerve supplies the muscles of the lower lip, it is necessary to plan the operation in such a way that this nerve is not in danger of being cut.

29. LIGATION OF FACIAL ARTERY: I ncision is made at least one centimeter 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.

30. LIGATION OF THE LINGUAL ARTERY: The exposure of the lingual artery is done in the submandibular triangle. This region of the neck is bounded by the lower border of the mandible and the two bellies of the digastric muscle. The posterior corner of this triangle behind the angle of the mandible is in open communication with the retromandibular fossa.

31. LIGATION OF LINGUAL ARTERY: Surgically, the procedure for exposing the lingual artery is as follows: The submandibular gland is palpated through the skin and an incision is made which circles the lower pole of this gland. The posterior part of the incision should point toward the tip of the mastoid process; the anterior part of the incision should point toward the chin. If the skin, platysma, and deep fascia are incised, the lower pole of the submandibular gland is exposed. If the gland is lifted from its bed by blunt dissection and the entire flap is retracted upward, the tendon of the digastric muscle becomes visible. Following the tendon anteriorly, the free border of the mylohyoid muscle is easily ascertained where it is crossed by the tendon not far above the hyoid bone. If one follows now the free border of the mylohyoid muscle upward and backward, the hypoglossal nerve can be identified by the accompanying vein and by the fact that nerve and vein disappear at the posterior border of the mylohyoid muscle. Thus the lingual triangle between the digastric tendon, the posterior mylohyoid border, and the hypoglossal nerve has been circumscribed. Pulling the digastric tendon downward helps to enlarge this triangle, at the floor of which the finely bundled hyoglossus muscle with its vertical fibers becomes visible. This muscle is divided bluntly, and, in the gap between its vertical fibers, the lingual artery is found.

32. LIGATION OF CAROTID ARTERY : Injuries of the upper part of the neck or of the superficial and deep structures of the face may make ligation of the external carotid artery or arteries necessary. There are two points at which the external carotid artery can be exposed and tied.

33. EXPOSURE IN CAROTID TRIANGLE: Incision of skin starts at level of mandible just behind the anterior border of the sternocleidomastoid muscle. Continued downwards , parallel to the border of the muscle to the level of the cricoid cartilage after penetrating skin & platysma muscle. S uperficial sheath of the sternocleidomastoid muscle is incised. Bluntly the anterior border of muscle is exposed & the muscle is retracted.

34. Thus the deep layer of sternocleidomastoid sheath becomes visible and through it internal jugular vein Infront of this vein the fascia is cut to expose the arteries The ECA is identified by its first ant branch , superior thyroid artery Isolated & tied few millimeters above origin of superior thyroid artery Care should be taken not to injure hypoglossal nerve

35. EXPOSURE IN RETROMANDIBULAR REGION : ECA is ligated in the retromandibular fossa behind the angle of mandible ECA crosses stylomandibular ligament on its lateral side Also called “ ligation of ECA at stylomandibular ligament” Simple and less dangerous than exposure of ECA in neck The skin is incised in a line starting at a tip of mastoid process encircling the mandibular angle

36. Continuing forward below the mandible for about 1 inch Incision is kept at an equal distance from the posterior and inferior borders at the mandible Scalpel has passed through the skin and some of the posterior fibres of platysma muscle , External jugular vein or retromandibular vein is located ,tied & cut To this end the attachment of parotid capsule to the anterior border of the sternocleidomastoid muscle has to be severed with scalpel

37. The flap of soft tissue consisting of skin & parotid gland is retracted anteriorly & upward Immediately underneath the parotid gland the post belly of digastric muscle becomes visible Slightly above it the thin round flesh of styloid muscle becomes visible Above muscle styloid process and stylomandibular ligamet can be palpated At this line pulse of ECA can be felt & it is easy to isolate the artery & tie it

38. LIGATION OF MAXILLARY ARTERY : Two approaches : Transantral Intraoral

39. TRANSANTRAL APPROACH: Gingival incision Anterior wall of the maxillary sinus is opened and removed with special care not to injure the infraorbital nerve. The posterior wall of the sinus is identified and a laterally based U – shaped mucosal flap elevated . Positions of the posterior wall removed to gain exposure to the pterygopalatine fossa and the branches of the maxillary artery.

40. INTRAORAL APPROACH : Incision at upper gingivobuccal sulcus at the level 2 nd and 3 rd molar and continued inferiorly along the ramus of the mandible. The buccal fat pad is retracted medially or removed and thr attachments of the temporalis muscle to the coronoid process of the mandible are identified. The temporalis muscle belly may need to be split and partially dissected from the mandible to gain access to the artery. Blunt dissection reveals the maxillary artery which is clipped or ligated.

41. APPLIED ANATOMY : Anterior palatine artery: Major palatine foramen- situated at palatal to last molar of maxilla & at the border between the inner plate of alveolar process the & roof of oral cavity PRECAUTIONS: Incision of palatine abscess should be given in antero posterior line , never in tranverse direction Incision – given near free gingival margin without missing abscess Edge of knife should be directed outward & upward & not straight upwards

42. SUBLINGUAL ARTERY: Injury due to sharp instruments / rotating discs slips off a lower tooth & injure floor of mouth Injury in region of premolar / first molar , sublingual artery may be severed where it is in considerable volume The hemorrhage from this artery may then be serious incident MANAGEMENT: Local clamping of artery attempted ( difficult) If to stop bleeding at place of injury fails , lingual artery must be ligated

43. FACIAL ARTERY: Performing operative procedures on lower premolar & molars the facial artery can be severed accidentally if an instrument enters the buccal region Deep incisions may endanger the facial artery PRECAUTIONS : The incision should be made downward & outward instead of straight downward Knife should not be allowed to penetrate the lateral or inferior wall of abscess

44. DIAGNOSTIC AIDS IN ARTERIAL SYSTEM : MAGNETIC RESONANCE ANGIOGRAPHY (MRA): MRI examination of blood vessels Detection of heart disorders , stroke & blood vessel abnormalities CT ANGIOGRAPHY (CTA): Less invasive , more patient friendly Uses x-rays to visualise blood flow in arterial and venous vessels Contrast material injected into small peripheral vein using small needle / catheter

45. SONOGRAPHIC VASCULAR IMAGING : Imaging extracranial carotid vessels. Used to measure blood velocity in the middle cerebral & other intracranial arteries. Grey scale imaging used to visualise the vessels & to document state of vessel wall. Doppler spectral analysis – determine blood flow velocity.

46. DIRECT INTRA –ARTERIAL ANGIOGRAPHY: Originally performed by percutaneous puncture of CCA in neck Nowadays performed by transfemoral approach CAUTION – In middle – elder patients , in passing catheters into the ICA , Particularly if there is any suspicion of atheromatous internal carotid artery stenosis

47. CONCLUSION : The arterial supply of the head and neck is a complex network of blood vessels crucial for providing oxygenated blood to these regions. It involves multiple arteries originating from different parts of the body and plays a vital role in sustaining various structures, including the brain, face, and neck.

48. REFERENCE : Gray’s Anatomy B. D. Chaurasia 3 RD volume Inderbir singh’s Human Embroylogy Sicher’s Anatomy Anatomy of surgeons Henry Hollinshead