Detail description of supply,course,variations and clinical implications of arteries of head and neck

1. ARTERIAL SUPPLY OF HEAD
AND NECK
PRESENTED BY
DR PREETI SHARMA
DEPT. OF ORAL AND MAXILLOFACIAL
SURGERY

2. INTRODUCTION
 Arteries are the vessels which convey oxygenated blood away from the heart
to the tissues of the body, limbs and internal organs.

3. As they move away from heart diameter of vessels
get reduced
Branches off into arterioles
Arterioles become capillaries
Diameter increases when vessels bring deoxygenated
blood back to heart
Capillaries become venules
Venules join to become veins

4. ARTERIAL WALL STRUCTURE

5. • Arteries of head & neck regions are mainly the branches of external carotid
artery with a few exceptions
(ECA also known as facial carotid artery as it supplies superficial & deep
structures of face)
• Only parts of nasal cavity & upper parts of face receive branches of internal
carotid artery
( ICA also known as cerebral carotid artery as it supplies blood almost
exclusively to brain )

6. EMBRYOLOGY
• During 4th and 5th weeks of embryological
development pharyngeal arches form the aortic
sac which gives rise to the aortic arches.
• In the initial stage there are pairs of aortic arches
,which are numbered I,II,III,IV,V,VI

7. FATE OF AORTIC
ARCHES

8. Development of main arteries of head and neck
ARCH OF AORTA
1.Aortic sac
2.left horn
3.left 4th arch
BRACHIOCEPHALIC ARTERY
Right horn of aortic sac
SUBCLAVIAN ARTERY
RIGHT:
1.Right 4th arch artery
2.Right 7th cervical intersegmental
artery
LEFT: left 7th cervical intersegmental
artery

9. Development of main arteries of head and neck
COMMON CAROTID ARTERY
Each side from proximal part of 3rd
arch
INTERNAL CAROTID ARTERY
1.Distal part of 3rd arch
2.Dorsal aorta
EXTERNAL CAROTID ARTERY
Bud from 3rd arch

10. AORTIC ARCH
LEFT CC A
EXTERNAL
CAROTID
INTERNAL
CAROTID
Middle cerebral
Anterior
communicating
Posterior
communicating
Opthalemic
BRACHIOCPHALIC
RIGHT CCA
RIGHT
SUBCLAVIAN
VERTEBRAL
BASILAR
POSTERIOR
COMMUNICATING
CIRCLE OF WILLIS
Superior Thyroid
Posterior auricular
Lingual
Occipital
Maxillary
Facial
Superficial Temporal
Ascending
Pharyngeal

11. ARCH OF AORTA
• The aortic arch is a continuation of the
ascending aorta.
• Originates slightly to the right at the level of
2nd right sternocoastal joint ascends
diagonally back left side(in front of
bifurcation of trachea) ends at the level
with sternal end of 2nd left coastal
cartilage.(T4 VERTEBRA)
• Diameter :at origin is 28mm but reduces to
20mm at end.

12. VARIATIONS

13. VARIATIONS

15. BRACHIOCEPHALIC ARTERY
• Largest branch of aortic arch
• 4-5 cm in length
• Arises from arch’s convexity posterior to centre of
menubriumsterni ascends posterolaterally to right
and anterior to the trachea ends at the level of
upper part of rt. Sternoclavicular joint by dividing
into right subclavian artery and common carotid
artery

16. RELATIONS
• Anteriorly
Sternohyoid and sternothyroid,thymus,left
brachiocephalic vein and right inferior thyroid veins.
• Posteriorly
Trachea below ,Right pleura above
• Posterolaterally
Right vagus
• Right lateral –right brachiocephalic vein,upper part
of superior vena cava and pleura
• Left lateral-thymic remains,origin of left common
carotid artery,inferior thyroid veins and trachea at
higher level

17. BRANCHES
• Also sometimes gives a thymic or bronchial branch

18. COMMON CAROTID ARTERY
• It is the largest bilateral vessel.
• Right and left carotid arteries differ
in length and origin.
• RIGHT – Exclusively cervical
,originates from brachiocephalic
trunk behind the right
sternoclavicular joint
• LEFT – Directly from arch of aorta
immediately posterolateral to
brachiocephalic trunk and has both
thoracic and cervical part.

19. • Thoracic part of left CCA-Ascends
until level with the left
sternoclavicular joint ,it is 20-25 mm
long
• Cervical part of both CCA-Ascends
and diverge laterally from behind the
sternoclavicular joint upper border
of thyroid cartilage(where it divides
into internal and external carotid)

20. BIFURCATION OF COMMON CAROTID ARTERY
• CCA bifurcates at the level of superior
border of thyroid cartilage
• Two structure of importance at bifurcation
are
carotid body
carotid sinus
CAROTID SINUS
CAROTID BODY

21. • CAROTID SINUS
Dilation on the CCA at its bifurcation,then continues a little way up the
internal carotid branch
Tunica media is thinner and tunica adventitia is relatively thicker
Contains receptors(baroreceptors) ending of glossopharyngeal nerve .
Carotid sinus is responsive to changes in arterial BP,leading to
hemodynamic modification.
• CAROTID BODY
Small flattened structure situated behind the sinus or between internal
and external carotid arteries(2.5x5mm to 4x7mm)
Contains chemoreceptors responding to oxygen and CO2 levels in blood
It is also sensitive to changes in Ph and temperature.

22. CAROTID SHEATH
• The CCA ascends lateral to
the trachea and oesophagus within a deep
cervical fascia , ie the CAROTID SHEATH, with
the internal jugular vein and the vagus nerve
and the constituents of ansa cervicalis
• Internal carotid artery continues upwards
within the carotid sheath.
• External carotid artery leaves the sheath and
becomes external to it.

23. CAROTID TRIANGLE

24. RELATIONS OF COMMON CAROTID ARTERY
• Anterolateral
Skin,Fascia,SCM,Sternohyoid,superior
belly of omohyoid
• Posterior
Transverse process of lower 4 cervical
vertebrae ,Prevertebral
muscles,sympathetic trunk,vertebral
vessel in lower part of neck

25. • Medially
larynx,pharynx,trachea,esophagus,thyroid
gland
• Laterally
Internal jugular vein
• Posterolaterally
Vagus nerve

26. ANATOMICAL VARIATIONS
• The left CCA varies in its origin and can arise with the brachiocephalic artery.
• The right CCA arises above the level of the sternoclavicular joint in 12% of cases.
• Occasionally, the common carotid artery bifurcates at a higher level near the hyoid bone
• More rarely, it bifurcates lower than usual at the level of the larynx.
• In very rare cases, the CCA does not bifurcate, resulting in the absence of the external and
internal carotid arteries and may be replaced by arteries, which arise directly from
the aorta
• Apart from these two terminal branches, the CCA usually gives off no other branches but
may occasionally give rise to superior thyroid, inferior thyroid, vertebral, occipital,
ascending pharyngeal or superior laryngeal arteries.

27. EXTERNAL CAROTID ARTERY
• Begins lateral to the thyroid cartilage's upper
border level with the disc between 3rd and 4th
cervical vertebrae Passes midway between
mastoid tip and mandibular angle goes in parotid
gland behind mandible’s neck and divide into
superficial temporal and maxillary artery
• Arises under the cover of the anterior border of
sternocleidomastoid muscle.
• At its origin it is in carotid triangle and lies
anteromedial to the internal carotid artery but
becomes anterior then lateral to this as it
ascends.

29. SURFACE MARKING
External carotid artery is marked by making :
(a) A point on the anterior border of the
sternocleidomastoid muscle at the level of upper
border of thyroid cartilage.
(b) Posterior border of the neck of the mandible.
Artery is slightly convex forwards in its lower half and
slightly concave forwards in its upper half.

30. RELATIONS
IN THE CAROTID TRIANGLE
• Superficially—Skin, superficial fascia,deep
fascia and anterior margin of SCM ,cervical
branch of the Facial N. ,Hypoglossal N, and
facial ,lingual and superior thyroid veins.
• Deep:- Wall of pharynx, Superior laryngeal
nerve, Ascending pharyngeal artery

31. ABOVE THE CAROTID TRIANGLE
External carotid artery lies deep within the parotid
• Within the gland it related
Superficially -Retromandibular vein,Facial nerve
Deep to artery – ICA
Structures passing between ECA and ICA
Styloglossus,stylopharyngeus,Glossopharyngeal nerve,
pharyngeal branch of vagus nerve,styloid process.

32. • External carotid artery gives off eight branches
Anterior 1) Superior thyroid
2) Lingual
3) Facial
Medial Ascending pharyngeal artery
Posterior 1) Occipital
2) Posterior auricular
Terminal 1) Maxillary
2) Superficial temporal

33. ANTERIOR BRANCH

34. SUPERIOR THYROID ARTERY
Arises from the front of ECA below the level of
greater cornu of hyoid bone dividing into terminal
branches at the apex of the thyroid lobe.
Runs downwards ,forwards parallel and superficial
to the external laryngeal nerve in the carotid
triangle along the lateral border of thyrohyoid,
covered by skin, platysma and fascia and then runs
deep to the omohyoid, sternohyoid and
sternothyroid.(outwards to inwards)
Reaches the upper pole of lateral lobe of thyroid
gland

35. BRANCHES

36. VARIATIONS

37. APPLIED ANATOMY
 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.

39. LINGUAL ARTERY
• Arises anteromedially from ECA opposite to the
tip of the greater cornu of the hyoid bone
between the superior thyroid and facial artery.
• Cheifly supply tongue and floor of the mouth.
• Its Ascends medially , loops down and
forwards,then passes medial to the posterior
border of the hyoglossus and horizontally
forwards deep to it and ascending again almost
vertically till the tongue’s inferior surface as far as
tip.

40. Hyoglossus muscle divide the artery into 3 parts
• 1st part before Suprahyoid A
• 2nd part behind 2-3 Dorsal lingual A
• 3rd part after(arteria profunda linguae) Sublingual A and ends as Deep Artery of
Tongue

41. ANATOMICAL VARIATION

42. APPLIED ANATOMY
• In surgical removal of tongue , first part of artery is ligated before it gives any branches to
the tongue or tonsil.
• Injury occurs in premolar & molar region, when sharp instrument or rotating disks slips off
a lower molar & injure the floor of mouth.
• For implants,CBCT to localize the vascular canal ,injuries to arteries in vascular canal can
cause sublingual hematoma leading to blockage of airway.

44. FACIALARTERY
• It is the chief artery of the face.
• It is also known as EXTERNAL MAXILLARY
• Supplies muscles of face.
• Arises anteriorly from the ECA(in carotid triangle)above lingual A immediately above the tip
of greater cornua of hyoid bone
• Runs upwards in(tortuous course) –
neck as CERVICAL PART allows free movements of pharynx during deglutition
face as FACIAL PART free movements of mandible , lips, & cheek during mastication & facial
expressions, escapes traction & pressure during movements

45. 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.

46. 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

47. SURFACE MARKING OF FACIAL PART
By joining 3 points
1)A point on 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 between first two points.

48. BRANCHES
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 ARTERY:
• Passes between the styloglossus and medial pterygoid
muscles and pierces the superior pharyngeal constrictor
muscle to supply the palatine tonsil and the posterior
tongue.

49. GLANDULAR ARTERIES
• 2-3 vessels to the submandibular gland to supply it
and the adjacent area.
SUBMENTAL ARTERY
• Arises 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.
• Anastomoses with sublingual branch of lingual A. and
mylohyoid branch of inferior alveolar A

50. 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 and runs near
lower lip’s margin between muscle and mucous membrane
• Supplies inferior labial glands and mucous membrane and muscle
• an anastomosis with its counterpart of the other side and with branches
of the mental branch of inferior alveolar artery
SUPERIOR LABIAL ARTERY:
• Anastmoses with counterpart and supply upper lip,the SEPTAL BRANCH
to supply anteroinferior part of the nasal septum and an ALAR BRANCH

51. LATERAL NASAL ARTERY:
• Ascends the side of the nose.
• Supplies ala and dorsum of the nose.
• Anastomoses with septal and alar
branch,dorsal nasal ramus of opthalamic
and infraorbital branch of maxillary A.
ANGULAR ARTERY:
Is the terminal continuation of the facial
artery, supplying the tissues of medial corner
of the eye and anastomosing with dorsal
nasal branch of the ophthalmic artery.

52. VARIATIONS
• May arise in common with lingual artery constituting ―linguo-facial trunk. Occasionally
ends by forming submental artery and frequently extends only to the angle of mouth or
nose.
• Deficiency is compensated by enlargement of one of neighboring arteries.

54. 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
mucocele.
• In mand. 1st 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.
• 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 stylo mandibular
ligament causing serious bleeding.

55. • Anesthetist'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

56. MEDIAL BRANCH

57. ASCENDING PHARYNGEAL ARTERY
The smallest branch arising from the medial side of the external carotid artery.
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.

59. BRANCHES
PHARYNGEAL BRANCHES
 PALATINE BRANCHES
PREVERTEBRAL BRANCHES
INFERIOR TYMPANIC ARTERY
MENINGEAL BRANCHES

60. POSTERIOR BRANCH

61. OCCIPITAL ARTERY
• Arises from posterior aspect of ECA(2mm above),medial to
posterior belly of diagastric and ends posteriorly in scalp.
• It is crossed at its origin by hypoglossal nerve
• 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.
• Finally accompanied by greater occipital N it pierces the
trapezius muscle and ascends in a tortuous course in the
superficial fascia of the scalp.

62. BRANCHES
• STERNOCLEIDOMASTOID BRANCHES: 2 in no., upper branch
accompanies the accessory N and lower branch arises near
the origin of occipital artery and supplies SCM
• AURICULAR BRANCH: Passes superficial to the mastoid
process to reach and supply the back of the auricle.
• 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 diagastric,stylohyoid, , Splenius,
and Longissimus capitis.

63. • DESCENDING BRANCH :
Largest branch
Descends on the back of the neck, and divides into a superficial and deep portion.
Superficial portion runs beneath the splenius, to supply the trapezius and anastomose with
the ascending branch of the transverse cervical artery
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.

64. • OCCIPITAL BRANCH:
Tourtuous terminal branches
distributed to scalp as far as vertex
Runs between skin and occipital belly
of occipitofontalis
Anastomosing with opposite
occipital, posterior auricular and
temporal arteries.
Supply occipital belly of
occipitofrontalis , skin and
pericranium

65. POSTERIOR AURICULAR ARTERY
Arises from the posterior aspect of the external carotid artery just above the posterior belly
of the digastric.
It runs upwards and backwards deep to parotid gland, but superficial to the styloid process
crosses the base of the mastiod process and ascends behind the auricle.

66. BRANCHES
• STYLOMASTOID ARTERY :
Enters the stylomastoid foramen along with facial
nerve and supplies the tympanic cavity, the
tympanic antrum and mastoid cells, and the
semicircular canals.
• AURICULAR BRANCH:
Ascending deep to auricularis posterior branch out
on cranial aspect of auricle and also pierces to
supply lateral aspect.
• OCCIPITAL BRANCH:
Passes laterally across mastoid process ,turning
back over SCM to supply occipitofrontalis and
anastomoses with occipital artery.

67. TERMINAL BRANCH

68. SUPERFICIAL TEMPORAL ARTERY
• It is the continuation of ECA.
• It begins in the substance of the parotid gland,
behind the neck of the mandible.
• 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.
• 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

69. BRANCHES
• Supplies to parotid gland, to the temporomandibular joint, and to the Masseter muscle
1. Transverse Facial
2. Anterior Auricular
3. Zygomatico-orbital
4. Middle Temporal.
5. Frontal.
6. Parietal

70. TRANSVERSE FACIAL
Originates from STA before it leaves parotid gland.
Passes transversely 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: Parotid gland and duct, Masseter
ANASTOMOSE: External maxillary, Masseteric,
Buccinator, and Infraorbital arteries.

71. • ANTERIOR AURICULAR BRANCHES :
Distributed to the anterior portion of the auricle,
the lobule, and part of the external meatus,
anastomosing with the posterior auricular.
• ZYGOMATICO ORBITAL:
Sometimes from middle temporal it skirts the
upper border of zygomatic arch between 2 layer of
temporal fascia to lateral orbital angle.
Supplies orbicularis oculi and anastomoses with
lacrimal and palpebral branches of ophthalmic
artery.

72. • 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 maxillary
artery.
• 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.

73. APPLIED ANATOMY
• Crossing zygomatic process artery is palpable through
skin and fascia and easily compressed here to control
temporal hemorrhage.
• In craniotomy ,incision should be made convex
upwards to include the superficial temporal artery in
flap
• In carotid angiograms branches of the superficial
temporal artery and middle meningeal arteries are
superimposed ,but are distinguishable by the
straighter course.

74. REFERENCES
• GRAY‘S ANATOMY- 39TH EDITION
• HUMAN EMBRRYOLOGY INDRERBIR SINGH-9TH EDITION
• W.HENERY HOLLINSHEAD -2nd edition
• SICHER’S ORAL ANATOMY- 8TH EDITION
• B D CHAURASIA VOL 3- 6TH EDITION
• INTERNET SOURCES

75. MAXILLARY ARTERY
• Supplies deep structures of the face.
• Arises behind the neck of the mandible, and is at first imbedded in parotid gland; it passes
medial to mandibular neck and superficial or deep to lower head of lateral pterygoid to
reach pterygopalatine fossa passing between 2 heads of lateral pterygoid.

76. Maxillary artery is divided into 3 portions
MANDIBULAR:
Passes between the
mandibular neck and the
sphenomandibular
ligament, below
auriculotemporal
nerve,crosses inferior
alveolar.
PTERYGOID:
Ascends obliquely forwards medial
to temporalis and superficial to
lower head of lateral pterygoid
PTERYGOPALATINE:
Passes between the heads of pterygoid
and through pterygomaxillary fissure into
the pterygopalatine fossa
DEEP AURICULAR ARTERY DEEP TEMPORAL BRANCH POSTERIOR SUPERIOR ALVEOLAR ARTERY
ANTERIOR TYMPANIC ARTERY PTERYGOID BRANCH INFRA ORBITAL ARTERY
MIDDLE MENINGEAL ARTERY MASSETERIC ARTERY GREATER PALATINE ARTERY
ACCESSORY MENINGEAL
ARTERY
BUCCAL ARTERY PHARYNGEAL ARTERY
INFERIOR ALVEOLAR ARTERY ARTERY TO PTERYGOID CANAL
SPHENOPALATINE ARTERY

77. • IMAGES

78. FIRST OR MANDIBULAR PART
• DEEP AURICULAR ARTERY
It ascends in 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, the
temporomandibular joint

79. • ANTERIOR TYMPANIC ARTERY
Ascends behind the temporomandibular
articulation and enters the tympanic cavity through
the petrotympanic fissure.
Ramifies upon the tympanic membrane, it forms a
vascular circle around the membrane with the
stylomastoid branch of the posterior auricular, and
anastomose with the artery of the pterygoid canal
and with the caroticotympanic branch of internal
carotid in the mucosa of tympanic cavity
Supplies inner surface of tympanic membrane

80. MIDDLE MENINGEAL ARTERY
• A branch given in the infratemporal fossa.
• Largest artery which supply the dura mater.
• 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 and enters the middle cranial fossa.
• It then runs in anterolateral groove on squamous
part of temporal bone dividing into two
branches,frontal(anterior) and parietal(posterior)

81. FRONTAL (ANTERIOR )
• Larger than the posterior branch.
• Crosses the great wing of the sphenoid, and divides
into branches which spread out between the dura
mater and internal surface of the cranium.
• Some ascends to vertex and occipital region.
PARIETAL (POSTERIOR)
• Curves backward on the squamous of temporal
bone, and, reaching the lower border of parietal in
front of its mastoid angle, divides into branches which
supply the posterior part of the dura mater and
cranium.

82. • 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:
GANGLIONIC BRANCHES supply trigeminal ganglion and roots
PETROSAL BRANCH supplies the facial nerve and anastomoses with the stylomastoid artery
SUPERIOR TYMPANIC ARTERY runs in the canal for the Tensor tympani, and supplies this muscle and the lining
membrane of the canal.
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.
TEMPORAL BRANCHES pass through foramina in the great wing of the sphenoid, and anastomose in the
temporal fossa with the deep temporal arteries.

83. SURFACE MARKING
• 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.

84. 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.
PARIETAL OR POSTERIOR BRANCH
• contralateral deafness APPROACH
• hole is made 4cm above and 4cm behind the external acoustic meatus.

85. ACCESSORY MENINGEAL BRANCH
• It enters the skull through the foramen ovale, and supplies the semilunar ganglion, dura
mater and structures in infratemporal fossa.

86. INFERIOR ALVEOLAR ARTERY
• 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 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.

87. 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

88. SECOND OR PTERYGOID PART
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( branch of
superficial temporal artery)
• Anterior communicates with the lacrimal
artery( branch of opthlemic artery) by
means of small branches which perforate
the zygomatic bone and great wing of the
sphenoid.

89. 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(branch of superficial temporal
artery)

91. BUCCINATOR ARTERY
( BUCCAL ARTERY)
• Runs obliquely forward, between the
medial pterygoid and the insertion of
the Temporalis, to the outer surface of
the Buccinator
• Anastomosing with branches of the
external maxillary and with the
infraorbital.

92. THIRD OR PTERYGOPALATINE PART
BEFORE ENTERING PTERYGOMAXILLARY
FISSURE
POSTERIOR SUPERIOR ALVEOLAR ARTERY
• Descends upon the tuberosity of the maxilla, it divides
into numerous branches, some of which enter the
alveolar canals
• 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.

93. APPLIED ANATOMY
• 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.

94. INFRAORBITAL ARTERY
• Also arises just before maxillary
artery enters the pterygomaxillary
fissure.
• 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 levator labii
superioris .

95. BRANCHES
WITHIN THE CANAL ON THE FACE
ORBITAL BRANCHES
supply the inferior rectus and inferior oblique muscle
BRANCH TO THE LACRIMAL SAC
anastomosing with the angular branch of the
external maxillary artery
ANTERIOR SUPERIOR ALVEOLAR BRANCHES
supply the upper incisor and canine teeth and the
mucous membrane of the maxillary sinus
BRANCH TO NOSE: anastomosing with the dorsal
nasal branch of the ophthalmic.

96. BRANCHES WITHIN THE PTERYGOPALATINE FOSSA
GREATER PALATINE ARTERY OR DESCENDING PALATINE ARTERY
• Descends through the pterygopalatine canal and emerges 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.

98. 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.
• During lefort I osteotomy:
Greater palatine artery is easily injured during oteotomy of the medial or lateral maxillary
sinus walls, pterygomaxillary dysjunction or during fracturing of maxilla

99. ARTERY OF THE PTERYGOID CANAL (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
Passes through the sphenopalatine foramen into the cavity of the nose, at the back part of
the superior meatus.
Gives off its posterior lateral nasal branches which spread forward over the concha and
meatus, anastomose with the ethmoidal arteries and the nasal branches of the descending
palatine and assist in supplying the lateral wall of nose and paranasal sinuses.
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

101. • 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.

102. INTERNAL CAROTID ARTERY

103. INTERNAL CAROTID ARTERY
• Supplies most of the ipsilateral cerebral hemisphere accessory organs,forehead and in part
of the nose
• originate from their respective common carotid arteries at the carotid bifurcation situated
at a level between the third and fourth cervical vertebrae (C3-C4)
• It is divided into four parts
Cervical(neck)
Petrous(temporal)
Cavernous(cavernous sinus)
Cerebral(after piercing the dura mater)

104. Ascends in cranial base
enters
Cranial cavity thru carotid canal
turns anteriorly
Cavernous sinus
ends
Below anterior perforated
substance by division into anterior
and middle cerebral arteries

105. • Divided into
1. CERVICAL PART
Carotid bifurcation
front of cervical process
Through carotid triangle in carotid
sheath
Inferior aperture of carotid canal
in petrous temporal bone
Cervical part has no branches

106. The cervical part has no branch and slightly curved so that it can follow the
movements of neck without being stretched ,it increases with advancing age
due to loss of elasticity of arterial wall
In the upper part of its course ,a torturous ICA may bulge towards the lateral
wall of pharynx and pulse of ICA then can be seen through wide open mouth.

107. 2. PETROUS PART
Ascends through carotid canal of temporal bone.
foramen lacerum
Enters cranial cavity
Branches
CAROTICOTYMPANIC
ARTERY
Enters tympanic cavity by
foramen in carotid canal
ANASTOMESES
Anterior tympanic branch of
maxillary A and stylomastoid
A
PTERYGOID ARTERY
Enters pterygoid canal branch of greater palatine artery

108. 3. CAVERNOUS PART
Here artery is covered by
lining of endothelium of
veins
Ascends to posterior clinoid
process
Turns anterior
Side of sphenoid
Again curves
Medial to anterior clinoid
process emerging through
dural roof of sinus

109. • BRANCHES
CAVERNOUS
BRANCH
SUPPLY
Walls of cavernous and inferior petrosal
sinus and containing nerves
HYPOPHYSEAL
BRANCH Pitutary gland
MENINGEAL
BRANCH
Passes over lesser sphenoid and supply
dura mater and bone in anterior cranial
fossa and anastomoses with meningeal
branch of posterior ethmoidal artery

110. 4. CEREBRAL PART
Artery turns back below
between optic nerve and
oculomotor nerve
medial end of lateral cerebral
sulcus
divides into
Anterior and middle cerebral
arteries

111. BRANCHES
OPTHALMIC ARTERY
• It is the branch of internal carotid artery as it
leaves cavernous sinus
• Passes forward through optic canal , it is
inferolateral to optic nerve
• In the orbit it crosses above optic nerve
obliquely from lateral to medial
accompanied by nasocilliary nerve
• Runs in the medial wall of the orbit
• Ends at the upper eyelid by dividing into
supratrochlear and dorsal nasal arteries

112. BRANCHES
CENTRAL ARTERY OF THE RETINA
• Runs below optic nerve
• pierce the nerve inferomedially
1.25 cm behind the eye and runs
to the retina along the axis
• Divides into superior and inferior
branches each one divide into
temporal and nasal branches

113. LACRIMAL ARTERY
• Runs forward along upper border of lateral rectus to reach lacrimal gland
• Accompanied by lacrimal nerve and ends in eyelids and conjunctiva.
• Gives off :
SUPPLY ANASTOMOSE
Lateral palpebral
artery
Upper and lower
eyelid(runs medially)
Medial palpebral
arteries
Zygomatic branches Temporal fossa(via
zygomaticotemporal
foramen)
Deep temporal arteries
Cheek(via zygomatico-
orbital foramen)
Transverse facial and
zygomatico orbital
arteries
Recurrent meningeal
branch
Lateral part of superior
orbital fissure
Middle meningeal
branch

114. CILIARY ARTERIES
They are divided into three groups
Long posterior ciliary Short posterior ciliary Anterior ciliary
2 branches pierce the sclera on
either side of optic nerve They
form circulus arteriosus major
which supply the iris
15-20 branches pierce the sclera
around the optic Nerve Supply
choroid and cilliary process
Reaches eyeball forms
circumcorneal subconjunctival
vascular zone
Pierce the anterior part of sclera
near sclerocorneal junction and
end in the iris

115. SUPRAORBITAL
• Arise where the ophthalmic artery crosses the optic nerve
• Runs with corresponding nerves above levator palpebrea supirioris
• Leaves the orbit through supraorbital foramen to supply forehead and scalp

116. • ETHMOIDAL BRANCHES
Anterior ethmoidal Posterior ethmoidal
COURSE Enter through anterior
ethmoidal canal to
reach anterior cranial
fossa
Passes through
posterior ethmoidal
canal
BRANCH Meningeal branch
Branch to dura mater
Nasal branch
Meningeal branch
Branch to dura mater
Nasal branch
SUPPLY anterior, middle
ethmoidal air sinus
Lateral nasal wall
septum
Upper nasal cartilage
-posterior ethmoidal
air sinus
Nasal cavity

117. MENINGEAL BRANCH
• Passes backward to enter middle cranial fossa though superior orbital fissure
MUSULAR BRANCHES
• Accompany nerves to extraocular muscles
MEDIAL PALPEBRAL BRANCH
• Superior and inferior branches to medial part of both eyelid
2 TERMINAL BRANCH
SUPRATROCHLEAR
• Leave the orbit above the trochlea to supply the forehead and scalp
DORSAL NASAL
• Leaves the orbit below the trochlea to supply dorsum of the nose
• Anastomose with angular of facial

118. ANTERIOR CEREBRAL ARTERY
• Smaller terminal branches arises at medial end of cental sulcus
• Anteromedially above the optic nerve to the longitudinal fissure and connects with anterior
communicating artery
• BRANCHES
• Anterior communicating
• Supply optic chiasma,lamina terminalis,hypothalamus parafactory areas,fronix and
cingulate gyrus
• Cental branches
• Supply rostum of corpus callosum

119. MIDDLE CEREBRAL ARTERY
• Larger terminal branch
• Supplies most of the
temporal lobe, anterolateral
frontal lobe, and parietal
lobe.
BRANCHES
• CORTICAL BRANCH
• FRONTAL BRANCH
• PARIETAL BRANCH
• TEMPORAL BRANCH

120. POSTERIOR COMMUNICATING ARTERY
• Runs above oculomotor nerve and anastomoses with posterior cerebral artery (basilar
branch)
• Supplies medial thalamic surface and walls of 3rd ventricle.
ANTERIOR CHOROIDAL ARTERY
• Leaves ICA near posterior communicating branch
• Last branch to originate from Internal Carotid Artery.
• Cisternal segment: supplies optic tract, posterior limb of internal capsule, branches to
midbrain,and lateral geniculate nucleus.
• Plexal segment:Supplies choroid plexus of anterior portion of temporal horn of lateral
ventricles.

121. CIRCLE OF WILLIS
• The Circle of Willis is a ring-like arterial
structure located at the base of the brain
that supplies blood to the brain and
surrounding structures.
• It is a circulatory anastomosis that
encircles the stalk of the pituitary gland.
• Also referred to as the Loop of
Willis,Circulus arteriosus cerebri, the
cerebral arterial circle or the Willis
polygon

122. • Three main (paired) constituents of the Circle of
Willis:
1. Anterior cerebral arteries
2. Internal carotid arteries
3. Posterior cerebral arteries ( terminal branches of
the vertebral arteries)
To complete the circle, two ‘connecting vessels’ are
also present:
1. Anterior communicating artery ( connects the
two anterior cerebral arteries)
2. Posterior communicating artery (branch of the
internal carotid, which connects the ICA to the
posterior cerebral artery)

123. IMPORTANCE
• The circle serves as a back-up system or a bypass, allowing for an alternative
route if there is an occlusion in the normal route of supply to an area. For
example, if there is an obstruction of blood supply through the left internal
carotid artery, and blood cannot reach the front of the left side of the brain
through this artery, blood will be routed to this area, through the anterior
communication artery, from the right internal carotid artery.

124. CLINICAL ANATOMY OF INTERNAL CAROTID ARTERY
• INFARCTION
• CEREBROVASCULAR ACCIDENTS
The anterior circulation is the site of approximately 70% of cerebral infarcts, with the middle
cerebral artery being the offending artery in about 90% of these cases. Lesions of the anterior
communicating artery (which supplies the medial surface of the cerebrum) accounts for as
little as 2% of cases
• Atherosclerotic plaques can also build up earlier in the course of the internal carotid artery
or in its terminal branches ,the plaques from the artery artery can be eliminated by the
procedure carotid endarterectomy
• BASAL SKULL FRACTURES
Fractures of the base of the skull can easily tear the internal carotid artery resulting in
an arteriovenous fistula inside the cavernous sinus

125. LIGATION OF CAROTID ARTERIES
LIGATION
It is the act of binding or tying of blood vessels with sutures or wires.
PROCEDURE OF LIGATION
1.EXPOSE THE SHEATH OF VESSEL
2. ISOLATE THE VESSEL
3. PLACE THE LIGATURE

126. LIGATION OF EXTERNAL CAROTID ARTERY
• EXPOSED AT TWO SITES
• 1. 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 hemorrhage
from one of the branches of maxillary artery)

127. IN THE CAROTID TRIANGLE
INCISION
A submandibular skin crease incision is made approximately two finger breadth below the
angle of mandible extending from the inferior to the mastoid process to just short of midline
(behind the anterior border of sternocleidomastoid process)
• 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 jugular vein is exposed

128. 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
EXPOSURE OF CAROTID BULD 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 arrhythmia and anesthetist should be informed
• LIGATION
• External carotid artery is identified & ligated above the superior thyroid artery
• Closure of wound a vacuum drain is placed and wound is sutured in layers

129. COMPLICATION
• Hemorrhage 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

130. IN THE RETRO MANDIBULAR FOSSA
ADVANTAGES:
• Simpler
• Less dangrous procedure
• Artery is ligated in the retromandibular fossa behind the angle of mandible & here artery
crosses the stylomandibular ligament at lateral side so

131. LIGATION OF CAROTID ARTEY AT THE STYLOMANDIBULAR LIGAMENT
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
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

132. IDENTIFICATION
• Underneath the parotid gland & post. Belly of digastric, small thin part of st ylohyoid 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

133. 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
EXPOSURE OF ARTERY
After blunt dissection submandibular gland is exposed post belly of digastrics identified,
mylohyoid muscle reached, hypoglossal nerve and accompanying vein identified

134. 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)
INDICATIONS
Injury is observed when sharp instruments or rotating disc are skipped on floor of the
mouth
In various surgical procedure like ranula and tumors of salivary glands
DIFFICULT TO LIGATE SUBLINGUAL ARTREY MAY BE A BRANCH OF
1. LINGUAL ARTERY
2. SUBMENTAL ARTERY

135. LIGATION OF FACIAL ARTERY
INCISION
• ½ inch below & parallel to the lower border of mandible exposure the skin, platysma
muscle and deep fascia are cut, soft tissue is bluntly cut and retracted
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 1st mandibular
molar
• During buccal space infection the artery is dislocated
• Avoid deep incision, incision should be downwards & inwards instead of straight upwards

136. LIGATION OF MAXILLARY ARTERY
• Ligation causes decrease in intra vascular pressure gradient, resulting in homeostasis
approaches:
• Can be done by
• 1. Transantral approach
• 2. Intraoral approach
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

137. EXPOSURE & LIGATION
• Area is enlarged,artery is identified &ligated success rate
• 87% success rate
INTRA ORAL APPROACH
• This procedure is given in 1984 by maceri & makilski
• Ligate infratemporal portion of maxillary artery
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

138. PROCEDURE
• 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
LIGATION OF SPHENOPALANTINE ARTERY
Can be done by two methods
1. Transantral ligation
2. Endoscopic ligation

139. 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 artery is done
ENDOSCOPIC LIGATION
• Described by white (modification of simpsons tech)
• Approach through 1. Meatal antrostomy 2. Canine fossa
• Not using widely as costly
• Advantages 1. Reduce patient discomfort
• 2. Duration of hospitalization

140. LIGATION OF GREATER PALANTINE 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
ANTERIOR AND POSTERIOR ETHMOIDAL ARTERY
INDICATION
1. When local hemorrhage can’t be controlled by other measures
2. To decrease blood flow to upper nasal vault from the internal carotid system generally
performed in conjugation with maxillary artery or ECA

141. INCISION
• A circumlinear incision is normally made betweeen the inner canthus of eye and middle
of nose(lynch incision)
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

142. LIGATION OF INTERNAL CAROTID ARTERY
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.
EVEN AFTER LIGATION CAROTID ARTERY BLEEDING PERSIST
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

143. REFERENCES
• GRAY‘S ANATOMY- 39TH EDITION
• HUMAN EMBRRYOLOGY INDRERBIR SINGH-9TH EDITION
• W.HENERY HOLLINSHEAD -2nd edition
• SICHER’S ORAL ANATOMY- 8TH EDITION
• B D CHAURASIA VOL 3- 6TH EDITION
• INTERNET SOURCES

144. THANK
YOU