APPLIED SURGICAL

ANATOMY
OF ARTERIES OF HEAD
AND NECK
DEEPTHA.J

Arteries of head and neck

Aorta

Common carotid artery

External carotid artery

Internal carotid artery

Subclavian artery

COMMON CAROTID
ARTERY
COURSE The right common

carotid artery arises from the

brachiocephalic artery behind the
sternoclavicular joint.

-- The left artery arises directly from

the arch of aorta behind the
manubrium sternum.
-- In the neck, each CCA extends
upwards & laterally with in the
carotid sheath to the level of upper
border of lamina of thyroid
cartilage.

-- The bifurcation takes place in

carotid triangle opposite the
disc between c3 & c4 vertebra.

VARIATIONS OF CCA :

In 12% subjects right CCA arises above the level of

upper border of sternoclavicular joint.
May arise as a separate branch from arch of aorta, or
in conjunction with left CCA.
In majority of abnormal cases left CCA arises in
common with brachiocephalic artery , if that artery is
absent , two carotids arise by single trunk.
Rarely artery ascends in the neck without undergoing
division, either ECA or ICA being absent.

CCA usually has no branches ,but may give

origin to vertebral, superior thyroid, ascending
pharyngeal, inferior thyroid or occipital artery.

APPLIED ANATOMY

CAROTID PULSE : CCA may be

compressed against the carotid
tubercle of transverse process of
C6 vertebra ( carotid tubercle of
chassaignac ) about 4cm above
the sternoclavicular joint.
Patency of carotid system can be
investigated by angiography by
injecting a contrast medium into
CCA.

EXTERNAL CAROTID
ARTERY

Anterior : Superior thyroid

Lingual
Facial

Posterior: Occipital
Posterior auricular

Medial:

Terminal: Maxillary
Superficial temporal

Ascending pharyngeal

EXTERNAL CAROTID ARTERY

Introduction:
It lies anterior to ICA
and is the chief
arterial supply to
structures in front of
neck and face.
Under cover of
anterior border of
sternocleidomastoid

Course :
At

the origin - Artery lies in the carotid triangle,

antero medial to ICA.

As the artery ascends ,it

passes deep to the post.
Belly of digastric and
stylohyoid muscle and
enters the parotid gland
where it inclines
somewhat backwards n
lies lateral to the ICA.

Italic f shaped course

from commencement to
termination.

APPLIED ANATOMY
LIGATION OF ECA :
Done at 2 points
Artery exposed at its origin &

ligature above superior thyroid artery

upper part of neck, superficial &
deep structures of neck
Ligation higher up, behind the angle
of lower jaw- maxillary artery injuries
UNILATERAL LIGATION will not
stop hemorrhage

A] LIGATION OF ECA IN
CAROTID TRIANGLE:Skin incision-- at the
level of angle of mandible
behind anterior border of
sternocleidomastoid
muscle ,continued
downward to the level of
cricoid cartilage.
-- Platysma,

superficial sheath of sternomastoid

incised, muscle exposed & retracted ,deep layer
of sternomastoid head is visible & IJV through it.
-- Fascia in front of vein is cut to expose the
arteries.

LIGATION IN
RETROMANDIBULA
R FOSSA :

Skin incision--- at line starting

at the tip of mastoid process ,
circling the mandibular angle,
continuing forward below the
mandible one inch.

Passing scalpel through skin

& posterior fibers of platysma ,
the retromandibular vein or
EJV is located, tied & cut.

Branches of great auricular

nerve cut -- permit
mobilization of cervical lobe of
parotid gland.

Attachment of parotid
capsule to the anterior
border of sternomastoid
severed with scalpel.

Parotid gland 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.

1. SUPERIOR THYROID ARTERY

COURSE: arises from the

front of ECA below the tip of

greater cornu of hyoid bone,
passes downward and
forward accompanied by the
laryngeal nerve.

Rests on the inferior

constrictor muscle, passes
deep to omohyoid
,sternohyoid, sternothyroid
and reaches the upper pole
of lateral lobe of thyroid.

APPLIED ANATOMY:

The arch of superior thyroid artery is

characteristic diagnostic landmark
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.

2. LINGUAL ARTERY

Introduction: Principal
artery of tongue. Arises
from front of ECA
opposite the tip of greater
cornu of hyoid bone.
Sometimes arises in
common with facial artery
as a linguo-facial trunk.
Divided into 3 parts by
hyoglossus muscle.

FIRST PART In carotid

triangle, extends from
origin to the posterior
border of hyoglossus.
Rests on the middle
constrictor, crossed by
hypoglossal nerve.
SECOND PART Deep to
hyoglossus, runs
horizontally forward along
the upper border of hyoid
bone between hyoglossus
laterally and middle
constrictor, stylohyoid
ligament medially.

THIRD PART [ arteria profunda linguae ],ascends

along the anterior Border of hyoglossus, then
horizontally forward on the undersurface of tongue on
each side of frenum linguae.
In vertical course, lies b/t the genioglossus medially &
inferior constrictor of tongue laterally. Horizontal part
is accompanied by lingual nerve.

Applied anatomy

In surgical removal of tongue , first part of

artery is ligatured before it gives any branches
to the tongue or tonsil.

2] sublingual artery -- injury occurs in premolar &

molar region, when sharp instrument or rotating
disks slips off a lower molar & injure the floor of
mouth.

LIGATION OF LINGUAL ARTERY :

Incision circling the lower

pole of submandibular gland.
Posterior part towards tip of
mastoid ; anterior part
towards chin.
Skin, platysma, deep fascia
incised, submandibular gland
exposed , lifted,tendon of
diagastric visible.
Free border of mylohyoid
muscle ascertained,
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.

3.Facial artery

Arises from the ECA just

above the tip of greater
cornu of hyoid bone

Runs upwards -- neck as

cervical part ; face -- facial
part.

Tortuous courseallows
free movements of
pharynx during deglutition,
on face -- free movements
of mandible , lips, & cheek
during mastication & facial
expressions, escapes
traction & pressure during
movements.

Course:
Cervical part

Runs upwards on superior

constrictor of pharynx deep to the,
posterior belly of digastric with
stylohyoid & to the ramus of
mandible
Grooves the posterior border of
submandibular gland
Makes S-bend [2 loops] 1st winding
down over submandibular gland &
then over the base of mandible.

VARIATIONS :

May arise in common with lingual artery

constituting linguo-facial trunk.
Occasionly ends by forming submental
artery& not infreqently extends only as high
as the angle of mouth or nose.
Deficiency is compensated by enlargement
of one of neighbouring arteries.

3] facial artery 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.

LIGATION OF FACIAL ARTERY.

Exposed --at the point crossing

the lower border of mandible .
Using contracted masseter as a
landmark, pulse of facial artery
felt at point situated anterior to
the attachment of masseter.
Artery is accompanied by facial
vein & crossed superficially by
marginal mandibular branch of
facial nerve.
Taking this into consideration,
incision -- at least half inch below
the border of mandible & parallel
to it.
Skin, platysma, deep fascia are
cut , soft tissues retracted, pulse
of facial artery felt.
Artery-- isolated, tied & cut.

OCCIPITAL ARTERY

Arises in carotid triangle

from posterior aspect of
ECA .
Passes backward,
upward along & under
cover of post. Belly of
diagastric , crossing
superficial to contents of
carotid sheath,
hypoglossal & accessory
nerve.
Appears

in the sub occipital region , rests on the rectus capitis ,obliqus

capitis superior &semispinalis capitis, crosses the apex of post. triangle of
neck, finally piercing trapezius.

BRANCHES:

1]Sternomastoid branch two in no.,

supply sternomastoid m.
2]mastoid branch enters cranial cavity
through mastoid foramen, supplies
mastoid air cells in the dura.
3]meningeal branch enters the skull
through jugular foramen & condylar
canal, supplies dura of posterior cranial
fossa.

4] muscular branch- supply adj. muscles.

5]occasional auricular branch supplies cranial
surface of auricle.
6]descending branch- superficial
--anastamoses with sup.br. Of transverse
cervical art.; deep br.anastamoses with deep
cervical art.
7]occipital br. supply the scalp upto vertex.

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 ( costo-cervical trunk )
ECA * SCA
Important for neurosurgeons

ASCENDING PHARYNGEAL
ARTERY:

First, smallest,
medial br. Of ECA.
Ascends to base of
skull between wall
of pharynx & ICA.
Branches
pharyngeal,
tympanic,
meningeal.

Pharyngeal br.
supply wall of
pharynx,tonsil,part
of auditory tube,&
soft palate.
Inferior tympanic
branch supply
medial wall of
tympanic cavity.
Meningeal br.
supply dura matter
& adj. bones.

Maxillary artery
Origin larger terminal branch of external
carotid, arises behind and below the
mandibular neck, in substance of parotid gland
Course
Mandibular part
Pterygoid part
Pterygopalatine part
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Mandibular part ( first part)

Passes between the mandibular neck and the
sphenomandibular ligament, below auriculotemporal
nerve
Branches:
Deep auricular artery
Anterior tympanic branch
Middle meningeal artery
Frontal & Parietal
Accessory meningeal artery
Inferior alveolar artery

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Pterygoid part (Second part)

Ascends obliquely forwards medial to temporalis and
superficial to lower head of lateral pterygoid
Branches:
Deep temporal branches
Pterygoid branches
Massetric artery
Buccal artery

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Pterygopalatine part
Passes between the heads of lateral pterygoid, through
pterygomaxillary fissure into the pterygopalatine fossa
Branches:
- PSA Artery
- Infraorbital
- Greater palatine
- Pharyngeal branch
- Artery of pterygoid canal
- Sphenopalatine artery

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APPLIED SURGICAL
ANATOMY
MIDDLE MENINGEAL ARTERY ( 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
MMA ( parietal or posterior branch )contralateral deafness
APPROACH- hole is made 4cm above and 4cm
behind the external acoustic meatus.

POSTERIOR SUPERIOR ALVEOLAR

ARTERY- site of hematoma during PSA block.
- prevented by aspirating before giving LA in the
site.

GREATER PALATINE AND ANTERIOR

PALATINE ARTERY.
case of abscess from palatal root of first
molar,incision should be made in a anteroposterior direction ,then transversly.
Incision made near free margin of gingiva.
Edge of knife directed outward, upward.

Superficial temporal artery

Origin: smaller of the two
terminal branches, begins in
the parotid gland behind
mandibles neck

Course: crosses the posterior

root of zygomatic process of
temporal bone, divides into
anterior and posterior branches
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APPLIED

ANATOMY

Control of temporal haemorrhage

Anastomose freely; partially detached with scalp

also heal with reasonable hope even if one vessel
is intact

Placement of incisions in craniotomy

In reduction of zygomatic arch fractures Gillis

approach

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COLLATERAL CIRCULATION

In occlusion of CCA -- anastamoses between

branches of SCA & ECA.
Achieved through :1] Br. Of Right & left ECAs.,
2] between left & right ICA via circle of willis.
3] superior thyroid A. with inferior thyroid A.
4] descending branch of occipital A. with deep
cervical & asc. Branch of transverse cervical A.
5] vertebral A. may take over entire supply of
carotids with in skull.

APPLIED ASPECT OF
ARTERIES
:
A] Arteries
endangered during
minor surgical
procedures or dental
treatment :

1] anterior palatine artery :

2. sublingual artery
3. facial artery

B] ARTERIES ENDANGERED DURING ORTHOGNATHIC

SURGERIES :

Pterygopalatine portion of maxillary artery

during Le fort I osteotomy procedure
In mandibular orthognathic surgery,
collateral blood supply is central to
preservation of osteotomised segments.
Carotid A. may be susceptible to damage
during orthognathic surgery.
Thrombosis of ICA can occur after surgery
due to excessive extension of head & neck.

PROTECTION OF MAJOR BLOOD

VESSELS:

Vessels requiring special protection during &

following neck dissection are carotids, common &
internal.

Rupture of carotid system is reffered as carotid

blow-out.

Common adverse circumstance previous

exposure to ionising radiation.

Vessel damaged by radiotherapy is

subjected to added insult of wound
breakdown & exposure, & liable to
rupture.

Two methods of protecting:

Modified skin incisions
Covering of vessels using muscle flaps
or graft of dermis.

MODIFICATIONS OF SKIN INCISIONS

:

MacFee INCISION Most

widely used. The sites where
hazard remains are points at
which the transverse suture
lines ,upper & lower ,cross the
line of artery.
Upper more vulnerable, as
likely to be site of salivary
fistula or wound breakdown .
CONLEY INCISION also
provides excellent protection
for vessels below level of
hyoid.
HAYES MARTIN INCISION.

VESSEL COVERING :
1]MUSCLE FLAPS They carry their blood supply with
them in transfer.
- the group of muscles behind the carotids , scalenes &
levator scapulae are used for cover.
Most effective flap levator scapulae.
Transected at a suitable
level above the clavicle ,
mobilised & swung
anteriorly to cover the
area of carotid bulb.
-- myocutaneous flaps --standard techniques in
intraoral reconstruction.

--

DERMAL GRAFTS :

Alternative method of protection.

Standard split skin graft used,removing
a strip of underlying dermis & replacing
the skin graft in its original site.
Dermal strip along entire length of
carotid provide extra layer of protective
collagen.

END OF PART 1

THE SUBCLAVIAN SYSTEM OF

ARTERIES :

ORIGIN - Arises from the brachiocephalic trunk.

Left subclavian art.arises from the arch of
aorta.

BRANCHES OF SUBCLAVIAN
a) vertebral,
b) internal
thoracic
c) thyrocervical
trunk.
d) costo
cervical trunk.
e)Dorsal
scapular artery.

Course:

Cervical part -- curved course with

upward convexity.
extends from the sternoclavicular
joint to the outer border of first rib,
enters through the apex of axilla &
continued as axillary artery.
Each art. Arches over the cervical
pleura n apex of the lung,
subdivided into 3 parts by scalenus
anterior muscle
,1st part -- upto medial border of
muscle, 2nd part--- behind the
muscle, 3rd---- lateral border of
muscle to the outer border of 1st rib.

VARIATIONS :

Right SCA may arise from brachiocephalic artery

above or below the level of sternoclavicular joint.
May be a separate trunk from arch of aorta, & then
be either first or last branch.
When first branch occupies ordinary position of
brachiocephalic trunk.
When last branch arises from left extremity of
arch , ascends obliquely at right side behind
trachea , esophagus, & right CCA to inner border
of first rib.

Occasionly it perforates scalenus anterior, rarely

passing in front of muscle.
May ascend as high as 4cm above the clavicle or
only reach the upper border of bone.
Left SCA is occasionly joined at its origin with left
CCA.

APPLIED ANATOMY

Subclavian steal syndrome -takes place in obstruction of

SCA proximal to the origin of
vertebral artery. Some amount
of blood is stolen from the
brain through the vertebral
artery of the opposite side in
order to provide collateral
circulation to the affected arm.
This may result in ischemic
neurological symptoms.
Effective compression of SCA can be attained only where it
passes across the upper surface of 1st rib. To compress the
vessel here, the shoulder should be depressed & pressure
exercised downwards, backwards &medially in the angle
formed by the posterior border of the sternocleidomastoid with
the upper border of clavicle.

A cervical rib may compress the SCA,

diminishing the radial pulse.
An aneurysm may form in the 3rd part of SCA.its
pressure on the brachial plexus causes pain,
weakness,& numbness in the upper limb.
The rt. SCA may arise from the descending
thorasic aorta. In that case , it passes posterior
to oesophagus which may be compressed,
condition known as dysphagia lusoria.
Cervical rib may compress the subclavian artery.
Here the radial pulse is diminished or obliterated
on turning the patients head upwards and to
affected side after deep breath- ADSONS TEST.

BLALOCK S operation for fallots

tetrology right subclavian artery is
anastomosed end to side to short circuit
to pulmonary stenosis

VERTEBRAL ARTERY :

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.

BRANCHES:

A]Cervical branches
1] spinal branches enter the vertebral canal
through intervertebral foramina ; supplies spinal
cord,meninges, vertebra.
2] muscular branches from 3rd part ; supply
sub-occipital muscles.
B] cranial branches a) meningeal branches
b)posterior spinal artery,
c)ant. Spinal artery.,d) post. Inferior cerebellar
artery, e)medullary arteries.

Parts

First part:- extends from the origin of the

artery to the transverse process of c6.

Runs upwards and backwards in the

triangular space b/w scalenus anterior and
longus colli muscles called vertebral triangle
Second part runs through the foramina
transverseria of upper C6.it course is vertical
upto the axis vertebrae

Third part :Lies in the sub-occipital triangle emerging

from foramen tranversarium of atlas.
Enters the vertebral canal by passing deep to the
lower arched marginof the posterior atlanto-occipital
membrane .
Fourth part :Pierces the dura & arachnoid maters,&
passes upward & medially through the foramen
magnum in front of first tooth of ligamentum
denticulum.
At lower border of pons ,it unites with the fellow of
opp. Side to form basilar art.

INTERNAL THORACIC ARTERY

Arises from the inferior surface of 1st part of SCA,
opposite the origin of thyrocervical trunk.,2cm above
the sternal end of clavicle.
BRANCHES --1. Pericardico-phrenic artery.
2. Mediastinal branches.
3. Pericardial branches
4. Sternal branches
5. Ant. Inter-costal artery.
6. Perforating artery.
7. Musculo-phrenic artery.
8. Superior epigastric artery.

THYRO CERVICAL TRUNK

Arises from the upper surface of 1st part of

SCA,just distal to the origin of vertebral art.
3 branches : 1]inferior thyroid art.
-a]asc. Cervical art.
-b]inf laryngeal art.
-c]tracheal, oesophageal,
laryngeal br.
2]superficial cervical art.
3]suprascapular art.

COSTO-CERVICAL TRUNK

Arises from the back of 1st part of SCA on left

side2nd part of same art. On rt. Side.
Branches 1]deep cervical artery
--2] superior intercostal art.

DORSAL SCAPULAR ARTERY

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.

BRANCHES OF ICA
From petrous part
1]carotico-tympanic branches.
2] branches to pterygoid canal.
From cavernous part
3] inferior hypophysial artery.
4] meningeal branch.
From cerebral part
5]superior hypophyseal artery.
6]opthalmic artery.
7] posterior communicating artery.
8] anterior choriod artery.
9] anterior cerebral artery.

10] middle cerebral artery.

Internal carotid artery

Origin - similar to that of ECA
Course- broadest outline
Vertically upwards neck
Horizontally forwards and medially- petrous carotid canal
Upwards foramen lacerum
Horizontally forwards cavernous sinus
Vertically upwards medial- anterior clinoid process
Backwards and upwards to its terminal branches

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Internal carotid artery

Divided into

Cervical

Petrous

Cavernous

Cerebral

67

Internal carotid artery

Cervical part
Relations

Posteriorly -sup cervical

ganglion,sup laryngeal nerve
Medially - ascending pharyngeal
artery
Anterolaterally - sternocleidomastoid
muscle
Inferiorly-digastric, hypoglossal nerve
At the level of digastric - stylohyoid
muscle, posterior branches of
ECA
Above the digastric - styloid
process,deeper part of parotid gland

68

Internal carotid artery

Petrous part
Relations
Surounded by venous and
sympathetic plexuses
Posterolaterally-middle ear and
cochlea
Anterolaterally- auditory tube
and tensor
tympani
Superiorly-

trigeminal
ganglion

69

Internal carotid artery

Branches
Caroticotympanic branch or
artery
Pterygoid artery

70

Internal carotid artery

Cavernous part
Ascends to the posterior clinoid
process
Emerges through the dorsal
roof of the cavernous sinus
Branches
Cavernous branches
Hypophyseal branches
Meningeal branches

71

Internal carotid artery

Cerebral part
Lies at base of the brain.Divides into
Anterior and Middle cerebral
arteries.
Gives off 5 branches:
Ophthalmic artery
Anterior cerebral artery
Middle cerebral artery
Posterior communicating artery
Anterior choroid artery

72

Internal carotid artery

Ophthalmic artery
Artery enters the orbit
through optic canal.

Terminates near the

medial angle of the eye,
dividing into
supratrochlear and dorsal
nasal branches

73

Ophthalmic artery

Branches
Central artery of retina
Lacrimal branch
Muscular branch
Ciliary arteries
Supraorbital artery
Posterior ethmoidal artery
Anterior ethmoidal artery
Meningeal artery
Medial palpebral artery
Supratrochlear artery

74

end

Circle of Willis
Circulus arteriosus polygonal
Anterior cerebral arteries through
anterior communicating arteries
Basilar artery

Posterior cerebral arteries each joins the ipsilateral internal carotid

artery by a posterior communicating artery

76