2. External
carotid artery is the chief artery which
supplies to structures in the front of the neck and
in the face.
Description
of branches of it with their applied
anatomy .
ECA -ligation
3.
During the fourth and
fifth weeks of embryological
development, when the
pharyngeal arches form, the
aortic sac gives rise to arteries
– the aortic arches.
The aortic sac is the
endothelial lined dilation, it is
the primordial vascular channel
from which the aortic arches
arise.
In the initial stage there are
pairs of aortic arches, which
are numbered I, II, III, IV,
and V. This system becomes
altered in further development.
4.
3rd Arch : forms common
carotid
artery, first (cervical) part
of internal carotid
artery (rest of internal
carotid arises from dorsal
aorta), and external carotid
artery.
5. Right common carotid
artery is a branch of the
brachiocephalic artery.It
begins in the neck behind
the right sternoclavicular
joint.
Left common carotid artery
is a branch of the arch of
aorta.It ascends to the back
of the left sternoclavicular
joint and enters the neck.
In the neck,each artery runs
upwards within the carotid
sheath,under cover of the
anterior border of the
sternocleidomastoid muscle.
6. Carotid sheath is
condensation of the
fibroareolar tissue around
the main vessels of the
neck.
CONTENTS:It contains
the common and internal
carotid arteries,internal
jugular vein and the vagus
nerve.
In the sheath,common
carotid artery is medially
placed.Vagus nerve lies in
between.
7. RELATIONS
The ansa
cervicalis lies
embedded in the
anterior wall of
the carotid
sheath.
The cervical
sympathetic
chain lies behind
the sheath.
8. Common carotid artery
bifurcates into external and
internal carotid arteries at the
level of upper border of the
thyroid cartilage.
Two structures of importance
at the bifurcation are
Carotid sinus
Carotid body
9. Carotid
sinus is slight dilatation at the termination
of the common carotid artery or the beginning of
the internal carotid artery.
It receives a rich innervation from the
glossopharyngeal and sympathetic nerves.
FUNCTION:
Carotid sinus acts as a baroreceptor or pressure
receptor and regulates pressure.
10. 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.
11. Carotid
body is a small,oval reddish-brown
structure situated behind the bifurcation.
It receives nerve supply mainly from the
glossopharyngeal nerve, but also from the vagus
and sympathetic nerves.
FUNCTION:
Carotid body acts as a chemoreceptor and
responds to changes in the oxygen and carbon
dioxide and Ph content of the blood.
12. 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.
13.
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
14.
ECA begins in the carotid
triangle at the level of upper
border of thyriod cartilage
opposite the disc between
the third and fourth cervical
vertibrae.
In the carotid triangle,it lies
under cover of the anterior
border of the
sternocleidomastiod 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.
15. Has slightly curved course,so that it is anteromedial
to ICA in it lower part,and anterolateral to the ICA
in its upper part.
16. IN THE CAROTID TRIANGLE
Superficially—Cervical branch of facial nerve
Hypoglossal nerve
Facial,lingual,and superior
thyriod veins
Deep to the artery— Wall of pharynx
Superior laryngeal nerve
Ascending pharyngeal artery
17. ABOVE THE CAROTID
TRIANGLE
Lies deep in the substance of the
parotid triangle.
Within the gland, it is related
Superficially—Retromandibular vein
Facial nerve
Deep to the artery—ICA
Structures passing between ECA
and ICA
Styloglossus
Stylopharyngeus
IXth nerve
Pharyngeal branch of
Xth nerve
Styloid process
18. Total of 8 branches
ANTERIOR— Superior thyroid
Lingual
Facial
POSTERIOR-- Occipital
Posterior auricular
MEDIAL—
Ascending
pharyngeal
TERMINAL— Maxillary
Superficial temporal
Mn:Sister Lucy's Powdered Face
Often Attracts Silly Medicos"
19.
20.
21. ORIGIN:Arises from the front of
ECA below the tip of greater
cornua of hyoid bone.
COURSE: Runs downwards and
forwards parallel and just
superficial to the extenal laryngeal
nerve.
- It passes deep to omohyoid
,sternohyoid, sternothyroid and
reaches the upper pole of lateral
lobe of thyroid and divides into its
terminal branches.
It is accompanied by same-named
vein.
22. BRANCHES:
INFRAHYOID ARTERY :A small vessel, passing
inferior to the hyoid bone to anastomose with its
counterpart on the other side.
-Supplies infrahyiod muscles.
STERNOCLEIDOMASTOID ARTERY :Passes
ventral to the carotid sheath, suppling SCM on its deep
surface.
SUPERIOR LARYNGEAL ARTERY :Passes
superficial to the inferior pharyngeal constrictor muscle
and pierces the thyrohyoid membrane, accompanied by
the internal laryngeal nerve.
-Within the larynx, it serves its muscles, glands, and
mucosa.
23. CRICOTHYROID
ARTERY: Supplies
cricothyriod muscle and
anastomoses with the artery
of the opposite side.
GLANDULAR BRANCHES
Supplies the upper one third
of the lobe and the upper
half of the isthmus.
Anterior branch
Posterior branch
Lateral branches(occasionally).
The anterior branch
descends on the anterior
border of the lobe and
continues along the upper
border of the isthmus to
anastomose with its fellow
of the opposite side.
24. The posterior branch descends on the posterior
border of the lobe and anastomoses with the
ascending branch of the inferior thyriod artery.
Occasionally, a lateral branch is present, which
supplies the lateral aspect of the lateral lobe.
25. 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 cricothyriod on the vocal cord.
Intra-arterial infusion chemotherapy for laryngeal and
hypopharyngeal cancers.
The
26. ORIGIN:Arises from ECA opposite
the tip of the greater cornua of
hyoid bone.
-It may arise in common with the
facial artery, then becoming the
linguofacial trunk.
COURSE:Divided into three parts
by hypoglossus muscle.
FIRST PART – In carotid
triangle, extends from origin to the
posterior border of hyoglossus.
- Rests on the middle
constrictor,forms a upward loop
which is crossed by hypoglossal
nerve. This loop permits the free
movements of the hyiod bone.
27. 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‘ ]—Also called as deep
lingual artery.
-It runs upwards along the anterior
Border of hyoglossus, then
horizontally forwards on the
undersurface of tongue on each
side of frenum linguae.
-In vertical course,it lies b/t the
genioglossus medially & inferior
longitudinal muscle of tongue
laterally. Horizontal part is
accompanied by lingual nerve.
28. Has four branches:
SUPRAHYOID ARTERY :Courses along the superior
border of the hyoid bone, serving the muscles in its
vicinity, and anastomosing with its counterpart on the
other side.
DORSAL LINGUAL ARTERY: Arises deep to the
hyoglossus muscle. It ascends to the posterior dorsum
of the tongue to supply the palatoglossal arch,
mucous membrane of the tongue, palatine tonsil,
and some of the soft palate, freely anastomosing with
other arteries in its vicinity.
29. SUBLINGUAL ARTERY :Arises at the border of the
hyoglossus muscle to course between the genioglossus
and mylohyoid muscles on its way to the sublingual
gland, which it supplies along with adjacent muscles in
addition to the mucous membrane of the floor of the
mouth and gingiva.
-Branches of this artery anastomose with the submental
branch of the facial artery.
DEEP LINGUAL ARTERY:Terminus of the lingual
artery.
-Passes along the ventral aspect of the tongue,
immediately deep to the mucous membrane,
accompanied by the lingual nerve, to its apex, where it
will anastomose with its counterpart of the other side.
30.
31.
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 diagastric visible.
32. -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.
33. 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.
34. ORIGIN: Arises from the ECA just above the tip of
greater cornua of hyoid bone.
COURSE: Runs upwards in -- neck as cervical part ;
face -- facial part.
Tortuous course—In neck allows free
movements of pharynx during deglutition,
on face -- free movements of mandible , lips, &
cheek during mastication & facial expressions,
escapes traction & pressure during movements.
.
35. 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] 1st winding down
over submandibular
gland & then up over the
base of mandible.
36. 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
ophthalmic artery.
37. SURFACE MARKING
OF FACIAL PART
By joining the following 3
points.
1)A point o the base of the
mandible at the
anteriorinferior border
of the masseter muscle.
2)A second point 1.2cm
lateral to the angle of
the mouth.
3)A point at the medial
angle of the eye.
More tortuous b/n first
two points.
3
1
2
38. VARIATIONS : May arise in common with lingual
artery constituting ―linguo-facial trunk‖.
-Occasionly ends by forming submental artery and
freqently extends only as high as the angle of
mouth or nose.
-Deficiency is compensated by enlargement of one
of neighbouring arteries.
39. CERVICAL PART:
ASCENDING PALATINE ARTERY:
Originates near the origin of facial
artery.
-It passes upwards between the
stylopharyngeus and styloglossus
muscles, to supply the levator veli
palatini, superior pharyngeal
constrictor and neighboring muscles,
soft palate, tonsils, and auditory
tube.
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.
40. GLANDULAR ARTERIES:
Distribute as three or four vessels
to the submandibular gland to
supply it and the adjacent area.
SUBMENTAL ARTERY: Arises
from the facial artery near the
anterior border of the masseter
muscle.
-It follows the base of the mandible
in an anterior direction and turns
onto the chin at the anterior border
of the depressor anguli oris muscle
and accompanies with the
mylohyiod nerve.
-It supplies the submental triangle
and sublingual salivary gland and
forms anastomoses with several
arteries in its vicinity, including the
mental and sublingual arteries.
41. 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.
42. 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.
43. 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.
44.
o
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.
45. In mand. 1st molar region
care must be takent 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
sbmandibular gland,the facial
artery should be ligated at two
points and should be scured
before dividing it, otherwise it
may retract through
stylomandibular ligament
causing serious bleeding.
46. 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.
,
47. Incision
- at least half inch below the border of
mandible & parallel to it.
53. Anaesthetist’s
arteries:
Rather than using the radial artery for determining
pulse rate, anesthesiologists use either the
superficial temporal artery, accessed anterior to the
ear just superior to the zygomatic arch, or the
facial artery just as it crosses the mandible anterior
to the masseter muscle.
54.
55. 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 diagastric , crossing
carotid sheath, hypoglossal &
accessory nerves.
Then it runs deep to the mastiod
process and muscles attached
to it i.e.,sternocleidomastiod,
digastric etc.
56. 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.
57. 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.
58. 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 Digastricus,
Stylohyoideus, Splenius, and Longissimus capitis.
59. 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.
60.
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
61. Superficial branch anastomosis with ascending
branch of transverse cervical artery. Deep branch
of descending br of occipital artery anastomosis
with deep cervical artery.
Important for neurosuegeons.
62. ORIGIN: Arises from the
posterior aspect of the
external carotid artery just
above the posterior belly
of the digastric.
COURSE:It runs upwards
and backwards deep to
parotid gland, but
superficial to the styloid
process.It crosses the base
of the mastiod process and
ascends behind the auricle.
63.
Besides several small branches to the Digastricus,
Stylohyoideus, and Sternocleidomastoideus, and to the
parotid gland, this vessel gives off three branches:
Stylomastoid.
Auricular
Occipital.
Stylomastoid Artery (a. stylomastoidea) :Enters the
stylomastoid foramen along with facial nerve and
supplies the tympanic cavity, the tympanic antrum
and mastoid cells, and the semicircular canals. In
the young subject a branch from this vessel forms, with
the anterior tympanic artery from the internal
maxillary, a vascular circle, which surrounds the
tympanic membrane.
64.
Auricular Branch (ramus
auricularis): Ascends
behind the ear, beneath the
Auricularis posterior, and is
distributed to the back of
the auricle, upon which it
ramifies minutely, some
branches curving around the
margin of the cartilage,
others perforating it, to
supply the anterior surface.
-It anastomoses with the
parietal and anterior
auricular branches of the
superficial temporal.
65. Occipital
Branch (ramus occipitalis): Passes
backward, over the Sternocleidomastoideus, to the
scalp above and behind the ear. It supplies the
Occipitalis and the scalp in this situation and
anastomoses with the occipital artery.
66.
67. ORIGIN:The smallest branch
arising from the medial side
of the external carotid
artery, near its
commencement.
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.
68. PHARYNGEAL BRANCHES :Are three or four in
number. Descend to supply the medial and inferior
constrictors of pharynx and the Stylopharyngeus.
PALATINE BRANCH: It passes inward upon the
superior constrictor of pharynx, sends ramifications to
the soft palate and tonsil, and supplies a branch to the
auditory tube.
PREVERTEBRAL BRANCHES: Are numerous small
vessels, which supply the Longi capitis and colli, the
sympathetic trunk, the hypoglossal and vagus
nerves, and the lymph glands; they anastomose with
the ascending cervical artery.
69. INFERIOR TYMPANIC ARTERY : Passes
through a minute foramen in the petrous portion of
the temporal bone, in company with the tympanic
branch of the glossopharyngeal nerve, to supply
the medial wall of the tympanic cavity and
anastomose with the other tympanic arteries.
MENINGEAL BRANCHES: Are several small
vessels, which supply the dura mater. One, the
posterior meningeal, enters the cranium through
the jugular foramen; a second passes through the
foramen lacerum; and occasionally a third through
the canal for the hypoglossal nerve.
70.
71. ORIGIN:Large terminal branch
given off behind the neck of the
mandible.
COURSE: Divided into three
parts by lateral pterygiod muscle.
The first or mandibular
portion passes horizontally
forward, between the ramus of
the mandible and the
sphenomandibular
ligament, where it lies parallel to
and a little below the
auriculotemporal nerve; it
crosses the inferior alveolar
nerve, and runs along the lower
border of the lateral pterygiod.
72. The
second or pterygoid portion runs obliquely
forward and upward superficial to the lower head
of the lateral pterygiod.
The third or pterygopalatine portion passes
between the two heads of the lateral pterygiod and
pterygomaxillary fissure,to enter into the
pterygopalatine fossa where it lies in front of the
sphenopalatine ganglion.
73. First or Mandibular
Portion
Deep Auricular.
Anterior Tympanic.
Middle Meningeal
Accessory Meningeal
Inferior Alveolar.
Second or Pterygoid
Portion
Deep Temporal.
Masseteric.
Pterygoid.
Buccinator.
Third or Pterygopalatine
Portion
•Posterior Superior
Alveolar.
•Infraorbital.
•Greater palatine artery
•Pharyngeal.
•Aretry of pterygiod canal
•Sphenopalatine.
74.
75. Deep Auricular Artery (a. auricularis profunda):
-It ascends in the substance of the parotid
gland, behind the temporomandibular
articulation, pierces the cartilaginous or bony wall
of the external acoustic meatus.
-supplies its cuticular lining and the outer
surface of the tympanic membrane.
-It gives a branch to the temporomandibular joint.
76. Anterior Tympanic Artery :
Passes upward behind the temporomandibular
articulation, enters the tympanic cavity through the
petrotympanic fissure.
- Ramifies upon the tympanic membrane, forming a
vascular circle around the membrane with the
stylomastoid branch of the posterior auricular, and
anastomosing with the artery of the pterygoid
canal and with the caroticotympanic branch from
the internal carotid.
-Supplies inner surface of tympanic membrane.
77. MIDDLE MENINGEAL
ARTERY (medidural artery):
ORIGIN:A branch of first part
of maxillary artery given in the
infratemporal fossa. It is the
largest of the arteries which
supply the dura mater.
COURSE:It ascends between the
sphenomandibular ligament
and the lateral pterygiod
muscle, and between the two
roots of the auriculotemporal
nerve to the foramen spinosum
of the sphenoid bone, through
which it enters the middle
cranial fossa.
78. It
then runs forward in a groove on the great wing
of the sphenoid bone, and divides into two
branches, anterior and posterior.
79. a)Artery enters the skull
opposite to-A point immediately
above the middle of the zygoma
b)Artery divides deep to-2cm
above the first point
The anterior division can be
approached –By making a hole
in the skull over pterion, 4cm
above the midpoint of
zygomatic arch.
The posterior division can be
approached –By making a hole
at a point 4cm above and 4cm
behind the external acoustic
meatus.
80. ANTERIOR BRANCH OR FRONTAL BRANCH:
Larger than the posterior branch. Crosses the great wing
of the sphenoid, reaches the groove, or canal, in the
sphenoidal angle of the parietal bone, and then divides
into branches which spread out between the dura
mater and internal surface of the cranium.
-After crossing the pterion, the aretry is closely related
to the motor area of the cerebral cortex.
POSTERIOR BRANCH OR PARIETAL BRANCH:
Curves backward on the squama of the temporal
bone, and, reaching the parietal some distance in front
of its mastoid angle, divides into branches which
supply the posterior part of the dura mater and
cranium.
81.
The branches of the middle meningeal artery are
distributed partly to the dura mater, but chiefly to
the bones; they anastomose with the arteries of the
opposite side, and with the anterior and posterior
meningeal.
BRANCHES AFTER ENTERING CRANIUM:
(1) Numerous ganglionic branches supply the
semilunar ganglion and the dura mater in this
situation.
(2) A superficial petrosal branch enters the hiatus
of the facial canal, supplies the facial nerve, and
anastomoses with the stylomastoid branch of the
posterior auricular artery.
82. (3) A superior tympanic artery runs in the canal for
the Tensor tympani, and supplies this muscle and
the lining membrane of the canal.
(4) Orbital branches or anastomotic branches pass
through the superior orbital fissure or through
separate canals in the great wing of the sphenoid,
to anastomose with the lacrimal or other branches
of the ophthalmic artery.
(5) Temporal branches pass through foramina in
the great wing of the sphenoid, and anastomose in
the temporal fossa with the deep temporal arteries.
83.
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.
PARIETAL OR
POSTERIOR BRANCH contralateral deafness
APPROACH- hole is made 4cm above and 4cm
behind the external acoustic meatus.
86. Accessory Meningeal Branch (ramus meningeus
accessorius; small meningeal or parvidural
branch):
It enters the skull through the foramen ovale, and
supplies the semilunar ganglion, dura mater and
structures in infratemporal fossa.
87. Inferior Alveolar Artery ( inferior dental artery):
COUSE: Descends with the inferior alveolar nerve to the
mandibular foramen on the medial surface of the ramus
of the mandible.
It runs along the mandibular canal in the substance of the
bone, accompanied by the nerve, and opposite the first
premolar tooth divides into two branches, incisor and
mental.
The incisor branch is continued forward beneath the
incisor teeth as far as the middle line, where it
anastomoses with the artery of the opposite side;
The mental branch escapes with the nerve at the mental
foramen, supplies the chin, and anastomoses with the
submental and inferior labial arteries.
88. 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
89.
Deep Temporal Branches: two in
number, anterior and posterior, ascend on the
lateral aspect of the skull between the Temporalis
and the pericranium;
- Supply the muscle, and anastomose with the
middle temporal artery;
- Anterior communicates with the lacrimal artery
by means of small branches which perforate the
zygomatic bone and great wing of the sphenoid.
Pterygoid Branches: Irregular in their number
and origin, supplies the medial and lateral
pterygiod.
90. Masseteric Artery:
- Is small and passes lateralward through the
mandibular notch to the deep surface of the
Masseter.
-It supplies the muscle, and anastomoses with the
masseteric branches of the external maxillary and
with the transverse facial artery.
Buccinator Artery ( buccal artery) :
-Is small and runs obliquely forward, between the
Pterygoideus internus and the insertion of the
Temporalis, to the outer surface of the
Buccinator, to which it is distributed,
anastomosing with branches of the external
maxillary and with the infraorbital.
91. BEFORE ENTERING PTERYGOMAXILLARY
FISSURE:
Posterior Superior Alveolar Artery ( alveolar or
posterior dental artery):
-Is given off, frequently in conjunction with the
infraorbital just as the trunk of the vessel is passing
into the pterygopalatine fossa.
-Descending upon the tuberosity of the maxilla, it
divides into numerous branches, some of which
enter the alveolar canals, to supply the molar and
premolar teeth and the lining of the maxillary
sinus, while others are continued forward on the
alveolar process to supply the gums.
92. Site
of hematoma during PSA block.
Produces largest and most esthetically unappealing
hematoma.
Blood effuses until extravascular 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.
93.
Infraorbital Artery :
ORIGIN:Arises just before maxillary artery enters
the pterygomaxillary fissure.
COURSE;It runs along the infraorbital groove and
canal with the infraorbital nerve, and emerges on
the face through the infraorbital foramen, beneath
the infraorbital head of the Quadratus labii
superioris.
94. BRANCHES:
WITHIN THE CANAL
(a) orbital branches which assist in supplying the
Rectus inferior and Obliquus inferior.
(b) anterior superior alveolar branches which
descend through the anterior alveolar canals to
supply the upper incisor and canine teeth and the
mucous membrane of the maxillary sinus.
ON THE FACE
a) Branch to the lacrimal sac: some branches pass
upward to the medial angle of the orbit and the
lacrimal sac, anastomosing with the angular branch
of the external maxillary artery.
b) Branch to nose: anastomosing with the dorsal nasal
branch of the ophthalmic.
95. BRANCHES WITHIN THE
PTERYGOPALATINE FOSSA:
GREATER PALATINE ARTERY OR
DESCENDING PALATINE ARTERY:
Descends through the pterygopalatine canal with
the anterior palatine branch of the
sphenopalatine ganglion, emerging from the
greater palatine foramen, runs forward in a
groove on the medial side of the alveolar
border of the hard palate to the incisive canal.
The terminal branch of the artery passes
upward through incisive canal to anastomose
with the sphenopalatine artery. Branches are
distributed to the gums, the palatine
glands, and the mucous membrane of the
roof of the mouth;
While in the pterygopalatine canal it gives off
lesser palatine arteries which descend in the
lesser palatine canals to supply the soft palate
and palatine tonsil, anastomosing with the
ascending palatine artery.
96. In
case of abscess from
palatal root of first
molar,incision should be
made in a antero-posterior
direction parallel to the
artery.
97. During
lefort I osteotomy:
Greater palatine artery is easily injured during
oteotomy of the medial or lateral maxillary sinus
walls, pterygomaxillary dysjunction or during
dwnfracturing of maxilla
The average distance from the piriform rim to the
descending palatine artery was 35.4 mm, range is
31 to 42 mm.
The average length of the greater palatine canal
above the nasal floor was 10mm, range is 6 to 15
mm.
The average distance between the
pterygomaxillary fissure and the greater palatine
foramen was 6.6mm
98. GUIDELINES TO AVOID INJURY:
Oteotomy 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 anteriorinferior 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.
99. Artery
of the Pterygoid Canal (a. canalis
pterygoidei; Vidian artery):
- Passes backward along the pterygoid canal with
the corresponding nerve.
- It is distributed to the upper part of the pharynx
and to the auditory tube, sending into the
tympanic cavity a small branch which
anastomoses with the other tympanic arteries.
Pharyngeal Branch:
It runs backward through the pharyngeal canal
with the pharyngeal nerve, and is distributed to the
nasopharynx, the auditory tube and sphenoidal air
cells.
100. Sphenopalatine Artery (a. sphenopalatina;
nasopalatine artery):
Passes through the sphenopalatine foramen into the
cavity of the nose, at the back part of the superior
meatus.
-Here it gives off its posterior lateral nasal
branches which spread forward over the conchæ
and meatuses, anastomose with the ethmoidal
arteries and the nasal branches of the descending
palatine, and assist in supplying the lateral wall of
nose and frontal, maxillary, ethmoidal, and
sphenoidal sinuses.
101. -Crossing the under surface of the sphenoid the
sphenopalatine artery ends on the nasal septum as
the posterior septal branches;supplies to the
nasal septum.
-These anastomose with the ethmoidal arteries and
the septal branch of the superior labial; one branch
descends in a groove on the vomer to the incisive
canal and anastomoses with the descending
palatine artery.
102. 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.
103.
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
pterygiod comprises blood
supply to the nose.
104. During
Le fort I
osteotomy procedurePterygopalatine
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.
105. 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.
106. Indications for surgery for control of epistaxis
Continued
Nasal
bleeding despite nasal packing
anomaly precluding packing
Patient
refusal/intolerance of packing
112. ORIGIN: The smaller of the two terminal branches
of the external carotid, appears, to be the
continuation of ECA. It begins in the substance of
the parotid gland, behind the neck of the
mandible.
COURSE: It runs vertically upwards crossing over
the root of the zygomatic process
-about 5 cm. above this process it divides into two
branches, a frontal and a parietal.
113. Relations.—As
it
crosses the zygomatic
process, it is covered by
the Auricularis anterior
muscle, and by a dense
fascia; it is crossed by
the temporal and
zygomatic branches of
the facial nerve and one
or two veins, and is
accompanied by the
auriculotemporal
nerve, which lies
immediately behind it.
114.
115. Besides some twigs to the parotid gland, to the
temporomandibular joint, and to the Masseter muscle,
its branches are:
Transverse Facial.
Anterior Auricular.
Middle Temporal.
Frontal.
Parietal
117. 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.
118. 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.
119. Anterior Auricular
Branches :
Distributed to the
anterior portion of
the auricle, the
lobule, and part of
the external
meatus, anastomosin
g with the posterior
auricular.
120. 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.
121. 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.
122. 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)
123. Can be done in carotid triangle or in retromandibular
fossa.
INDICATION:
Bleeding from oral malignancies
Diminishment of blood supply to the area of the
tumour bed as adjunctive procedure prior to the
tumour resection.
Involvement of vesssel or major branch in tumour
Slipping of superior pedicle of thyriod gland
Injuries causing carotid blow-outs
SPECIAL INSTRUMENTS:
Vascular loops and sutures
Vascular clamps
124. PATIENT POSITION:
Supine position with shoulder on roll, neck extended
and turned to opposite side.
ANAESTHESIA:
GA(local when necessary)
125. LANDMARKS
1)Upper border of
thyriod cartilage
2)Carotid bulb
3)Internal jugular vein
4)Anterior jugular vein
-lower border of
mandible
-Anterior border of
sternocleidomastiod
muscle
126. Ligation in carotid triangle:
KEY POINTS:
-ICA doesn‘t branch in the neck,except for rare
exceptions.
-ECA is usually anterior and superficial to ICA but
not always.
-Follow the ECA to its 2nd branch,atleast.
127. -Obtain control of CCA below bifurcation before
ligation.
-Be certain that vagus nerve, IJV, hypoglossal nerve
and superior laryngeal nerve are identified .
-Bradycardia is common with carotid bulb
manipulation.1% lidocaine without epinephrine
may be injected into the areolar tissue around bulb.
128. INCISION:A horizontal
skin incision is outlined
and crosshatched at the
level of hyiod bone and
submandibular
gland,two to three
fingerbreadths below the
angle of the mandible.It
is placed in a skin
crease.The posterior
border of the incision is
over the SCM.
129. Dissection
is carried through skin,platysma,then
anterior border of SCM is identified and retracted
posteriorly.
A clamp
is used to dissect anterior to the muscle
parallel to great vessels ,to identify carotid sheath.
The
CCA is carefully separated from other
contents of sheath.
The
IJV, vagus nerve and ansa hypoglossi are
retracted posteriorly.
130.
Usually at this place,a
vesicular loop is placed
loosely around CCA to
obtain control.
Then dissection is
carried up along the
CCA to the bifurcation
area.
At this point
hypoglossal nerve is
identified crossing the
branches,it should be
preserved.
131.
132. -ICA doesn‘t branch in the
neck,except for rare
exceptions.
-ECA is usually anterior and
superficial to ICA but not
always.
-Follow the ECA to its 2nd
branch,atleast
-A 2-0 silk tie is placed
between the superior
thyriod and lingual arteries.
-The wound is closed in
layers after the removal of
vesicular loop from CCA .
133. COMPLICATIONS:
-Damage to vital structures.
-Retrograde thrombus formation.
-Persistence of bleeding due to collateral flow.
-Rarely blindness may occur if ophthalmic artery
arises from middle meningeal artery of ECA.
134.
135. LIGATION IN RETROMANDIBULAR FOSSA:
Done when there are maxillary artery injuries.
Skin
incision--- at line starting at the tip of
mastoid process , circling the mandibular angle,
continuing forward below the mandible one inch.
Skin & posterior fibers of platysma are cut, the
retromandibular vein or EJV is located, tied & cut.
Branches of great auricular nerve cut -- permit
mobilization of cervical lobe of parotid gland.
136. 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.
137. Elongation of styloid process or
ossification of stylohyoid ligament.
Mostly arises after tonsillectomy.
SYMPTOMS:
Sorethroat,otalgia, glossodynia and
pain along distribution of ICA and
ECA.
CAROTID ARTERY SYNDROME
Deviated styloid process or ossified
stylohyoid ligament causing
impingement on either ECA or ICA
These syndromes cited as DD for
atypical facial pain
138.
GRAY‘S ANATOMY- 39TH EDITION
NETTER‘S- COLOUR ATLAS OF ANATOMY
B.D.CHAURASIA‘S HUMAN ANATOMYVOL 3
SURGICAL ANATOMY OF OTOLARYNGOLOGY-JEFFREY
J. BAILLEY
JOURNAL OF MAXILLOFACIAL AND ORAL SURGERYLOCATION OF DESCENDING PALATINE ARTERY DURING
LEFORT I OSTEOTOMY
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