Seminar on Arterial Supply of Head and Neck

1. ARTERIAL SUPPLY OF
HEAD AND NECK

2. CONTENTS
ARTERIES OF HEAD AND NECK
 Common Carotid Artery
 Internal Carotid Artery
 External Carotid Artery
 Applied Anatomy

3. Common Carotid Artery
 The CCA is a large elastic artery,
which provides the main blood
supply to head and neck region.
• There is one common carotid
artery on either side of the body
and these arteries differ in their
origin.
• The left common carotid
artery arises from the aortic arch
directly, whereas the right
common carotid artery arises from
the brachiocephalic trunk posterior
to the right sterno-clavicular joint.

4. Course
• The CCA ascends lateral to the
trachea and esophagus,
lies within the deep cervical fascia
of the carotid sheath, along with
the IJV and vagus nerve.
• The left CCA is longer than the
right having cervical and thoracic
parts, whereas the right one has
only a cervical part.
• The cervical part of the common
carotid artery is symmetrical on
both sides.

5. • After separating from the aortic
arch, the left CCA ascends
through the superior
mediastinum up to the level of
the left sternoclavicular joint.
• Then it ascends from behind the
sternoclavicular joint up to the
level of the upper border of the
thyroid cartilage of the larynx,
where it bifurcates into the
internal and external carotid
arteries.
• Both the left and right CCA
terminates at the level of upper
border of thyroid cartilage.

6. Branches
 Internal carotid artery: It is one of the branches of CCA which is the
chief artery to supply blood to the brain.
 External carotid artery: It is one of the terminal branches of CCA.
• In general it lies anterior to ICA and is the chief artery to supply
structures in front of the neck.

7. Lo, A., Oehley, M., Bartlett, A., Adams, D., Blyth, P. and Al‐Ali, S. (2006), ANATOMICAL
VARIATIONS OF THE COMMON CAROTID ARTERY BIFURCATION. ANZ Journal of
Surgery, 76: 970-972. https://doi.org/10.1111/j.1445-2197.2006.03913.x

8. Carotid Sheath
Contents:
• CCA as well as the ICA (medial)
• IJV (lateral)
• Vagus nerve (posterior)
• Deep cervical lymph nodes

9. Carotid Sinus
• It is also called as Carotid Bulb.
• The carotid sinus is a dilation of the base of the ICA or the
termination of CCA, innervated by IX cranial nerve.

11. Carotid body
• It is also called as Carotid glomus (glomus caroticum).
• Most vacularised part in body.
• The carotid body is a small, flattened structure, located at the level of carotid
bifurcation, typically posteromedial to the common carotid artery; measuring
about 2.5 by 5mm to 4 by 7mm

12. • It is involved in relaying information about the arterial
chemical composition to respiratory centres in the
brainstem.
• Also innervated by IX nerve.
• The carotid body is surrounded by a fibrous capsule and
consists of multiple lobules divided by septa.

13. • Within each lobule, there are two types of cells: glomus (type I) cells
and sustenacular (type II) cells
• The glomus cells are involved in storing peptides, such as neurotensin,
adrenaline, noradrenaline and dopamine.
• The sustentacular cells separate and support the glomus cells by
forming an extensive network of fenestrated sinusoids.

14. • The carotid body is a chemoreceptor stimulated by
hypercapnia, hypoxia and low pH.
• Individuals with chronic hypoxia or who live at high altitudes
may have enlarged carotid bodies

15. Carotid Body Tumor
• Largely vascular or largely epithelial.
• Referred to as glomus tumor.
• A carotid body tumor that does not secrete cathecholamines is
symptomless.
• Only about 5% of tumors metastasize.
• May embarrass the circulation.
• Frequently found to surround the common or internal carotid
arteries.
Tumor

16. Applied Anatomy
 Carotid Pulse: is felt by palpating the CCA on either side of the
neck beneath the anterior border of the sternocleidomastoid
muscle by compressing the fingertips against the prominent
transverse process of the sixth cervical vertebra.
• During CPR this pulse is routinely checked and its absence
can indicate cardiac arrest.

17. • The CCA is often used for measuring pulse, especially the patients in
shock who lack detectable pulse in the more peripheral arteries of the
body.
• The carotid artery should be palpated gently because, stimulating its
baroreceptors may cause severe bradycardia or even stop the heart in
over sensitive persons.
• A person’s both the carotid arteries should not be palpated at the
same time. By doing so it may limit the blood flow to the brain and
may cause fainting or cerebral ischemia.

18.  Carotid Sinus Hypersensitivity:
• Carotid sinus hypersensitivity is an increased response to
carotid sinus stimulation, which can occur with advanced age,
coronary artery disease or hypertension.
• External pressure on the carotid sinus can cause bradycardia
and hypotension, which can lead to dizziness or syncope.
• Therefore, palpation of the carotid pulse is not recommended
in patients with this condition.

19.  Carotid sinus massage:
• Bedside maneuver performed to terminate some
supraventricular tachycardias, eg. AV reentry SVTs.
• This technique is performed with the patient's neck in an
extended position, the head turned away from the side being
massaged.
• Only one side should be massaged at a time.
• Pressure is applied underneath the angle of the jaw in a gentle
circular motion for about 10 seconds.

20.  Carotid Artery Stenosis:
• The common carotid artery is a common site
for atherosclerosis, a degenerative arterial disease resulting in
the formation of plaques.
• This can lead to carotid artery stenosis, narrowing of the CCA,
which increases the risk of a transient ischaemic attack or a
stroke.

21.  Treatment: Involves pharmacological management, such as
aspirin or warferin therapy or surgical management- Carotid
endarterectomy.
• This procedure is only indicated with a stenosis greater than
50%.

22. Carotid Blowout Syndrome
• CBS is classically defined as rupture of
the extracranial carotid artery or its
branches.
• It is one of the most devastating
complications associated with radical
head and neck surgery.
• Surgical management of carotid
blowout is usually technically difficult
for exploring and repairing the
previously radiated field.

23. • It is an uncommon but fatal
complication that occurs in patients
treated for head and neck cancer(3-
4%). It is the result of necrosis of the
arterial wall, which can occur following
resection, after irradiation for a
recurrent or primary tumor, by direct
tumor invasion of the carotid artery
wall or by a combination of these
factors.
• When associated with open surgical
treatment, high mortality (40%) and
neurologic morbidity (60%) have been
reported.

24. Grading System: CBS may be categorized into four types that may involve
CCA and ICA.
 Threatened: refers to a visibly exposed carotid artery secondary to wound
breakdown that will almost inevitably rupture if it is not promptly covered
with healthy tissue.
 Impending CBS: refers to transient carotid artery hemorrhage that resolves
either spontaneously or with simple surgical packing.
 However, complete rupture is a certainty and may occur at any time
because the carotid artery is devoid of supportive, surrounding structural
elements.
 Acute CBS: the most emergent subtype, refers to complete rupture of the
carotid artery and profuse hemorrhage that is not well controlled by
surgical packing.
 Recurrent CBS: refers to previously treated patients with CBS who develop
recurrent CBS episodes

25. Management
Historically CBS was associated with 40-60% moratality rate but
outcomes have improved with advent of various endovascular
techniques.
• Percutaneous Balloon Occlusion.
• Embolization with coils.
• Using overlapping or covered
stents.
• Direct carotid puncture.
Benjamin Zussman, L. Fernando Gonzalez, Aaron Dumont,
Stavropoula Tjoumakaris, Robert Rosenwasser, David Hasan, David
Cognetti, Rita Axelrod, Pascal Jabbour;Endovascular Management
of Carotid Blowout; World Neurosurgery, 2012; Volume 78, Issues
1–2,Pages 109-114

26. Clamping Of CCA
• Clamping of CCA reduces blood flow to
the brain by ICA by 50%.
• Clamping of the internal or common
carotid artery is followed by a high
mortality rate and a high percentage of
cerebral complications.
• Indications: Deep neck lacerations,
Carotid blowout syndrome, Carotid
endarterectomy.

27. Internal Carotid Artery
Introduction:
• The Internal Carotid Artery is one of the two terminal branches of the common
carotid artery.
• It is a principal artery of the brain and eye. It also supplies the related bones
and meninges.

28. Embryology
• Several main and terminal branches of the ICA start developing from the 4th
gestational week onwards when it bifurcates into anterior and posterior
components.
The anterior component will differentiate into the anterior cerebral, middle cerebral, and
anterior choroidal arteries.
The posterior component form the posterior cerebral and the posterior choroidal artery.

29. Course
• The ICA arises at the level of the upper border
of the thyroid cartilage opposite the disc
between the third and fourth cervical
vertebrae.
• From its origin, the vessel passes up the
neck travel through Carotid sheath in a
superior direction along the neck, and enter
the skull through carotid canal.

30. Segments & Branches.
There are two main ways to categorize
the segments of the internal carotid
artery.
The newest one (1998) which divides the
artery into four parts namely:
1. Cervical part (neck)
2. Petrous part (temporal bone)
3. Cavernous part (cavernous sinus)
4. Cerebral part (after piercing the dura
mater)

31. • According to this classification, there are seven segments:
C1 – Cervical Segment
C2 – Petrous Segment
C3 – Lacerum Segment
C4 – Cavernous Segment
C5 – Clinoid Segment
C6 – Ophthalmic (Supraclinoid) Segment
C7 – Communicating (Terminal) Segment
• An older method described in 1996, known as the Cincinnati Classification
(Bouthillier et. al., 1996).

32. CERVICAL PART:
• This part is branchless and slightly curved so
that the artery can follow the movements of
the neck without being stretched.
• It ascends vertically in the neck from its
origin to the base of the skull to reach the
lower end of the carotid canal. This part is
enclosed in the carotid sheath (with the
internal jugular vein and the vagus).
• Its initial part usually shows a dilatation, the
carotid sinus which acts as a baroreceptor.
• The lower part of the artery (in the carotid
triangle) is comparatively superficial.
• The upper part, above the posterior belly of
the digastric, is deep to the parotid gland,
the styloid apparatus, and many other

33. Relations:
• Anterior or Superficial
1. In the carotid triangle:
– Anterior border of
sternicleidomastoid
– The ECA is anteromedial to it.
2. Above the carotid triangle:
– Posterior belly of digastric
– Stylohyoid
– Stylopharyngeus
– Styloid process
– Parotid gland
• Posterior
1. Superior cervical ganglion
2. Carotid sheath
3. The glossopharyngeal, vagus,
accessory and hypoglossal nerves
at the base of the skull.
• Medial
1. Pharynx
2. The ECA is anteromedial below the
parotid.
• Lateral
1. Internal Jugular Vein
2. Temporomandibular Joint (at the
base of the skull)

34. PETROUS PART (C2):
This segment travels superiorly before
taking an anteromedial course, after which
it travels along a superomedial course
advancing towards foramen lacerum.
Relations:
• Surrounded by venousand sympathetic
plexus.
• Posterosuperiorly:
‒ The middle ear
‒ The cochlea
• Anterolaterally
‒ The auditory tube
‒ Tensor Tympani
‒ Superiorly: Trigeminal Ganglion

35. BRANCHES:
• Caroticotympanic artery :
It originates from the petrous part (C2) and travels through
the tympanic cavity via foramen within the carotid canal and
anastomose with the anterior tympanic branch of the internal
maxillary, and with the posterior tympanic branch of
the stylomastoid artery. It supplies the tympanic cavity.

36. Vidian artery:
• Also called as pterygoid artery.
• The Vidian artery courses through the pterygoid
canal together with the Vidian nerve, anastomoses with a
branch of the greater palatine artery.
• Supplies pharynx, pharyngo-tympanic tube.
• It may not be present in some individuals, and can originate
from ECA as well (branch of maxillary artery)

37. CAVERNOUS PART (C4):
• Begins at petrolingual ligament and
extends till proximal dural ring.
• Within the cavernous sinus it courses
superiorly along the posterior clinoid
process, making its way towards the
anterior clinoid process before finally
emerging through the roof of
the cavernous sinus.

38. Within the cavernous sinus, the internal carotid artery travels superomedially
to CN VI and gives rise to:
 Cavernous branches to Trigeminal ganglion
 Superior and Inferior hypophyseal branches to the hypophysis cerebri

39. Carotid Siphon
• The carotid siphon is a U or S-shaped part to the ICA that begins at the posterior
bend of the cavernous part and ends at the cerebral part, at ICA bifurcation.
Importance:
• Several factors are related to the formation, development, and rupture of intracranial
aneurysms. Hemodynamic contribution can be illustrated by the preferred location
of aneurysms at arterial bifurcations and curvatures.
• It is of particular importance because it is a tortuous vessel segment with sharp
bends through which blood enters the anterior cerebral circulation.

40. CEREBRAL PART (C7):
This part lies at the base of the
brain after emerging from the
cavernous sinus.
Branches:
• Ophthalmic
• Posterior Communicating
• Anterior Choroidal
• Anterior Cerebral
• Middle Cerebral

41. • Ophthalmic artery: passes through the optic
canal, ultimately entering the orbit and
supplies Frontal belly of the occipito-
frontalis, Lacrimal gland, Nasalis, Procerus,
Voluntary muscles of eye.
• Branches:
Central retinal artery
Lacrimal artery
Posterior ciliary arteries.
• Clinical significance: Severe occlusion of the
ophthalmic artery causes ocular ischemic
syndrome. As with central retinal
artery occlusions, ophthalmic artery
occlusion can lead to rapid death of retinal
cells, thereby resulting in severe loss of
vision.

42. Circle Of Willis
 It is an arterial circle, situated at the
base of the brain in the
interpenduncular fossa.
 It is a part of the cerebral
circulation and is formed by:
• Two anterior cerebral arteries
connected by anterior communicating
artery; the middle and posterior
cerebral arteries of the same side are
united by the posterior communicating
artery.
 It attempts to equalize the flow of blood
to different parts of brain and provides
a collateral circulation in the event of
obstruction to one of its components.

43. Clinical Aspects Of ICA
Basal skull fractures:
• As the ICA enters the skull via the carotid canal, fractures of the
base of the skull can easily tear the ICA at this particular point
resulting in an Carotico-Cavernous fistula.
• An abnormal communication is created between the ICA, and a vein
or venous system, this being the cavernous sinus.

44. • An engorged cavernous sinus can put pressure on the structures passing
through it, such as cranial nerves III, IV, V1, V2, and VI, ultimately
producing distinct clinical signs and symptoms.

45. External Carotid Artery.
• The external carotid artery arises
from the bifurcation of the
CCA when it divides into the
external and internal carotid
arteries.
• The carotid bifurcation occurs at
the level of the thyroid cartilage
opposite the disc between 3rd and
4th cervical vertebrae.
• It generally lies anterior to ICA and
is the chief artery of supply to
structures in the front of the neck
and in the face.

46. Course
• The ECA arises from CCA at the level of the superior border of the
thyroid cartilage opposite the disc between the 3rd and 4th
cervical vertebrae.
• On each side, the artery originates in the carotid triangle, lying
anteromedial to ICA.
• It runs upwards and slightly backwards and laterally, and terminates
behind the neck of the mandible by dividing into its terminal
branches - The Maxillary and The Superficial Temporal arteries.

47. • In the carotid triangle,
– Comparatively superficial
– Lies under cover of the anterior border
of the sternocleidomastoid muscle
– It is crossed superficially by
• The cervical branch of facial nerve
• the hypoglossal nerve
• the facial, lingual and superior thyroid
veins.
– Deep to the artery there are:
• The wall of the pharynx
• The superior laryngeal nerve which
divides into the external and internal
laryngeal nerves.
• The ascending pharyngeal artery
Relations:
The ECA has a slightly curved course.
It is anteromedial to ICA in its lower part and anterolateral to the ICA in its upper part.

48. • Above the carotid triangle, ECA lies deep in the substance of the
parotid gland.
• Within the gland, it is related superficially to the retromandibular
vein and the facial nerve.
• Deep to the ECA, there are:
– The ICA
– Styloglossus
– Stylopharyngeus
– Glossophayngeal nerve
– Pharyngeal branch of vagus
– Styloid process

49. Branches
 Anterior branches:
Superior thyroid artery
Lingual artery
Facial artery
 Posterior branches:
Occipital artery
Posterior auricular artery
 Medial branch:
Ascending pharyngeal artery
 Terminal branches:
Maxillary artery
Superficial temporal artery

50. Ligation Of External Carotid Artery
There are two surgical approaches to ligate the ECA
• In the carotid triangle
• In the retromandibular fossa
Landmarks:
• Upper border of thyroid cartilage
• Carotid bulb
• Internal Jugular Vein
• Lower border of the mandible
• Anterior border of sternocleidomastoid muscle.

51. Ligation in the Carotid Triangle
• Surgically the exposure and ligation of the
external carotid artery in the carotid triangle
can best be done in the following way.
• The incision of the skin starts at the level of
the angle of the mandible just behind the
anterior border of the sternocleidomastoid
muscle and is continued downward, parallel
to the border of the muscle, to the level of
cricoid cartilage.
• After penetrating through the skin and the
platysma muscle, the superficial sheath of
the sternocleidomastoid muscle is incised.

52. • Bluntly, the anterior border of the muscle is exposed and the muscle retracted;
thus the deep layer of the sterno- cleidomastoid sheath becomes visible and
through it the internal jugular vein.
• In front of this vein the fascia is cut to expose the arteries.
• The ECA is identified by its first anterior branch, the superior thyroid artery, and
then isolated and tied a few millimeters above the origin of the superior thyroid
artery.
• While the incision through the deep layer of the sternocleidomastoid sheath is
made, care has to be taken not to injure the hypoglossal nerve. It is suggested that
the incision through the fascia be started at the lowest point of the wound.

53. • The surgical exposure of the external carotid
artery at the stylomandibular ligament is a
procedure much simpler and much less
dangerous than the exposure of the artery in
the neck.
• The skin is incised in a line which starts at the
tip of the mastoid process and circles the
mandibular angle, continuing forward below
the mandible for about one inch.
• The incision is kept at an equal distance from
the posterior and inferior borders of the
mandible.
• After passing through the skin and some of the
posterior fibers of the platysma muscle, the
retromandibular vein or the external jugular
vein is located, tied, and cut.
• Branches of the great auricular nerve have also
to be cut in order to permit the mobilization of
the cervical lobe of the parotid gland.
Ligation in the Retromandibular Fossa

54. • To this end the attachment of the parotid capsule to the anterior border of the
sternocleidomastoid muscle has to be severed with the scalpel.
• If this is done, the flap of soft tissues, consisting of skin and parotid gland, is retracted
anteriorly and upward.
• Immediately underneath the parotid gland the posterior belly of the digastric muscle
becomes visible and slightly above it is the stylohyoid muscle. Above these muscles the
styloid process can be palpated and also the upper border of the stylomandibular
ligament, especially if at this moment the lower jaw of the patient is pulled forward.
• This movement of the mandible not only widens the entrance into the retromandibular
fossa, but also tenses the stylomandibular ligament.
• At the stylomandibular ligament the pulse of the external carotid artery can be felt, and it
is easy to isolate the artery and to tie it, even if it is accompanied by a larger vein.

55. Superior Thyroid Artery
• The superior thyroid artery is a
branch of the ECA arising from its
anterior surface.

56. Course
• The superior thyroid artery is the first branch of the ECA, arising just
below the level of the greater cornua of the hyoid bone.
• It runs downwards, forwards and parallel and superficial to external
laryngeal nerve.
• It passes deep to omohyoid, sternohyoidand sternothyroid to reach the
upper pole of the lateral lobe of the thyroid gland and divides into its
terminal branches.

57. Branches
The superior thyroid artery in its
course gives off the following
branches:
• Infrahyoid artery
• Superior laryngeal artery
• Sternocleidomastoid artery
• Cricothyroid artery
• The infrahyoid artery passes along
the lower border of the hyoid
bone below and anastomoses
with the same artery of the
contralateral side to supply the
infrahyoid muscles of the neck.

58. • The superior laryngeal artery supplies blood to the tissues of the upper
part of the larynx. It anastomoses with its fellow artery of the opposite
side and with the inferior laryngeal branch of the inferior thyroid artery.
• The sternocleidomastoid artery runs downward and laterally across the
carotid sheath to supply the middle region of the sternocleidomastoid.
• The cricothyroid artery crosses the anterior cricothyroid ligament to
supply the cricothyroid muscle.

59. Clinical Aspects
• Its relationship with external laryngeal nerve, which supplies
cricothyroid muscle is very important during thyroid surgery.
• The artery and nerve stays in close proximity to each other
near the thyroid gland higher up. To avoid injury to the nerve
the artery should be ligated as close as possible to the thyroid
gland.
• The thyroid has a rich blood supply; therefore, during
thyroidectomy, the superior thyroid artery requires ligation.

60. Lingual artery.
• The lingual artery is a branch of the ECA that supplies blood to
the tongue and floor of the mouth.

61. Course
• It arises medially from the ECA at the level of
the greater cornua of the hyoid bone.
• It may arise in common with the facial artery
then becoming the linguofacial trunk.
• The course is divided into three parts by
hyoglossus muscle.
• First part lies in carotid triangle where it forms
a characteristic upward loop which is crossed
by hypoglossal nerve.
• Second part lies deep to hyoglossus along
upper border of hyoid bone.
• Third part is called deep lingual artery. It runs
upwards along upper border of hyoglossus and
horizontally to undersurface of tongue as
fourth part. It is accompanied by lingual

62. Branches
• On its course, the lingual artery also gives off side branches, including:
• Suprahyoid branches which supplies to muscles attached to hyoid bone.
• Dorsal lingual branches that supply the dorsum of the tongue till the epiglottis.
• Sublingual artery supplying the sublingual gland.
• The branches of the lingual artery provide blood supply to the tongue, sublingual
gland, and the floor of the mouth.

63. LIGATION OF LINGUAL ARTERY
submandibular gland palpated through skin
incision circling the lower pole of the gland
skin, platysma, deep fascia incised
lower pole of the submandibular gland exposed
gland lifted from its bed by blunt dissection
flap retracted upward, tendon of the digastric exposed, mylohyoid is seen.
hypoglossal nerve identified and retracted to prevent injury
Digastric tendon pulled downward, Hyoglossus muscle dissected - Lingual
artery is found and ligated.

64. • During surgical removal of tongue the first part of lingual
artery is ligated before it gives off any branches to the tongue
or the tonsils.

65. Facial Artery
• The facial artery is the chief
artery of the face which arises
from the ECA in the carotid
triangle just above the greater
cornua of hyoid bone.

66. Course
• It runs upwards in the neck as cervical part and on the face as facial part.
• The course of the artery is tortuous.
• This allows free movements of the pharynx during deglutition.
• On the face, it allows free movements of mandible, lips and cheek during
mastication and facial expressions.
• The artery escapes traction and pressure during these movements.

67. Branches
 Cervical branches:
• Ascending Palatine
• Tonsilar
• Glandular
• Submental.
 Facial branches:
• Inferior labial
• Superior labial
• Lateral nasal
• Angular
 The facial artery with its branches
supplies the submandibular gland, lips,
chin, most of the facial muscles, tongue,
pharyngotympanic tube, soft palate,
and tonsils.

68. Variations of facial artery
• The facial artery may arise with the
lingual, as a liguo-facial trunk. It
varies in size and supply to the face: it
may end as submental artery and
often extends only to the buccal
angle. The deficiency is then filled by
branches of neighbouring arteries
• In human fetuses a common linguo-
facial trunk occurred in 43%; in 42%
the facial did not reach the medial
orbital angle, ending as a superior
(20%) or inferior (22%) labial artery
(Kozielec & Jozwa 1977)

70. Ligation of Facial Artery
• The facial artery can be easily exposed at the
point where it crosses the lower border of the
mandible to pass from the submandibular region
into the face.
• This point is situated anterior to the attachment
of the masseter muscle to the mandible.
• Here, the pulse of the facial artery can easily be
felt, especially if the contracted masseter muscle
is used as a landmark.
• The artery is accompanied by the facial vein,
which lies posterior to the artery.
• The artery and vein are crossed superficially by
the marginal mandibular branch of the facial
nerve.
• This rather small nerve runs approximately
parallel to the lower border of the mandible,
sometimes slightly above or below this border.

71. • The nerve and vessels are covered by the platysma muscle, the subcutaneous
tissue, and the skin.
• Since the mandibular branch of the facial nerve supplies the muscles of the
lower lip, it is necessary to plan the operation in such a way that this nerve is not
in danger of being cut.
• To achieve this end, the incision is made at least one centimeter below the
border of the mandible and parallel to it.
• The skin, platysma muscle, and deep fascia are cut and then the soft tissues are
bluntly retracted upward until the palpating finger can feel the pulse of the facial
artery.
• The artery then can be isolated, tied, and cut.

72. Occipital Artery.
• The occipital artery is one of the posterior branches of the
ECA that arises from the posterior aspect, opposite to the
origin of Facial artery, therefore below the level of disgastric
and stylohyoid.

73. Course

74. Branches
• Sternocleidomastoid branches: This branch supplies SCM and
hypoglossal nerve loops around this branch.
• Auricular branch supplies back of concha
• Mastoid branch arises along with auricular branch and supplies mastoid
cells, dura by entering skull through mastoid foramen.
• Meningeal branch enters skull though jugular foramen.
• Occipital artery anastomoses with transverse cervical, vertebral, deep
cevical artery at the base of skull which help to maintain collateral after
ligation of CCA or subclavian artery.
 The occipital artery supplies blood to the back of the
scalp, sternocleidomastoid, trapezius, deep muscles of the back, and
dura mater of the posterior cranial fossa.

75. Posterior Auricular Artery.
• The posterior auricular artery is a small branch of the
ECA which arises from the posterior aspect, just above the
posterior belly of digastric and stylohyoid muscle.

76. Course
• It is largely covered by parotid
gland and runs upwards and
backwards deep to the gland,
along the styloid process.
• It crosses the base of mastoid
process and ascends behind the
auricle to reach auricular
cartilage.
• Here it divides into mainly five
branches.
• It may arise as a branch of
occipital artery rather than an
independent branch.

77. Branches
• Stylomastoid branch
• Auricular
• Posterior tympanic
• Parotid
• Occipital branch
 The posterior auricular artery
with its branches supplies the
digastric, stylohyoid and
sternocleidomastoid muscles,
parotid gland, tympanic cavity,
facial nerve, and mastoid
antrum cells.

78. Ascending Pharyngeal Artery
• The ascending pharyngeal
artery is the smallest
branch of ECA that arises
from the medial side of
ECA.
• It arises very close to the
lower end of ECA.

79. Course
• The ascending pharyngeal artery
passes vertically upwards
between the lateral side of the
pharynx and tonsils, middle ear
and auditory tube to the base of
the skull.
• Further, it continues as
the meningeal artery, which is
the terminal branch of the
ascending pharyngeal artery.

80. Branches
• On its course, the ascending pharyngeal artery
gives rise to two side branches:
• Pharyngeal branches that supply the muscles
and mucosa of the pharynx, as well as the
pharyngotympanic tube;
• Inferior tympanic branch that supplies the
medial wall of the tympanic cavity.
• It sends meningeal branches into the cranial
cavity through foramen lacerum.
• The ascending pharyngeal artery with its
branches provides blood supply to the muscles
and mucosa of the pharynx, pharyngotympanic
tube, medial wall of the tympanic cavity, and
the middle cranial fossa.

81. Maxillary Artery
• The maxillary artery is the largest terminal branch of the ECA that arises at
the back of the neck of the mandible, within the substance of parotid gland.
• It supplies deep structures of the face, such as the
mandible, maxilla, teeth, muscles of mastication, palate, nose, and part of
the cranial dura mater.

82. Course.
 Topographically the maxillary artery can be divided into three
portions:
• Mandibular
• Pterygoid
• Pterygomandibular

83. • The first part runs horizontally forwards, between the neck of the mandible and
sphenomandibular ligament then along the lower border of lateral pterygoid.
• The second part runs upwards and forward superficial to lower head of lateral
pterygoid.
• The third part passes between two heads of lateral pterygoid and through
pterygomaxillary fissure to enter pterygopalatine fossa.

84. Branches
 From the mandibular part, the maxillary artery gives off five
branches that enter the skull to supply bones of the skull,
including:
I. Deep auricular artery,
II. Anterior tympanic artery,
III. Middle meningeal artery,
IV. Accessory meningeal artery,
V. Inferior alveolar artery.

85. Deep Auricular:
• Supplies : External acoustic
meatus, Tympanic
membrane, TMJ
Anterior tympanic:
• Supplies : Middle ear, Medial
surface of tympanic
membrane
Accessory meningeal: enters
the cranial cavity through
foramen ovale
• Supplies: Meninges,
Structures in infra temporal
fossa .

86.  Middle meningeal artery:
- Course : closely related to the
auriclotemporal nerve and enters the
cranial cavity through the foramen
spinosum running laterally over the floor
of middle cranial fossa giving 2 branches.
- Frontal & Parietal Supplies : Meninges,
Skull bones, Middle ear, Trigeminal
ganglion, Tensor tympani, Auditory tube.
- Great surgical importance as it can be
injured in head injuries-common source
of extradural haemorrhage.

87. Clinical significance
• An injured middle meningeal artery is
the most common cause of
an epidural hematoma.
• A head injury can rupture the artery.
Emergency treatment requires
decompression of the hematoma,
usually by craniotomy.
• Subdural bleeding is usually venous in
nature, rather than arterial.
• The anterior branch of the middle
meningeal artery runs beneath
the Pterion. It is vulnerable to injury
at this point, where the skull is thin.
Rupture of the artery may give rise to
an epidural hematoma.

88. Inferior alveolar artery:
Course : runs downwards and forwards medial to the ramus to reach
the mandibular foramen. Before entering the canal it gives lingual
branch & mylohyoid branch. It then passes through the mandibular
canal giving branches to the mandible and to the roots of each tooth
attached to the bone. Then it gives mental branch that passes through
the mental foramen to supply the chin.

89.  The Pterygoid part of the maxillary artery gives off the following
four branches:
I. Deep temporal artery
II. Pterygoid artery
III. Masseteric artery
IV. Buccal artery

90. • Deep temporal branches: supplies the temporalis muscle
• Pterygoid branches: supplies the pterigoid muscles
• Masseteric branches: supplies the masseter
• Buccal artery: supplies the buccinator.

91.  The Pterygopalatine part of the maxillary artery provides four
branches that accompany similarly named branches of
the maxillary nerve. These branches include:
I. Posterior superior alveolar artery
II. Infraorbital artery
III. Greater palatine
IV. Pharyngeal
V. Artery of pterygoid canal (Vidian artery)
VI. Sphenopalatine artery

92.  Posterior superior alveolar artery:
• Supplies : Maxillary Molars &
Maxillary air sinus
 Infraorbital artery:
• Supplies : Lacrimal sac, Lower
eyelid, lateral part of the nose,
Upper lip, Maxillary incisors,
canines premolars and MB root of
Maxillary 1st molar
 Pharyngeal:
• Supplies : Nasopharynx, Auditory
tube, and Sphenoidal air sinus.

93.  Greater palatine artery :
• Supplies : Palate, Gingiva
• Gives off lesser palatine arteries
Supplies : Soft palate, Tonsils
• Can be accidently severed
during minor procedures in the
posterior palatine region
 Artery of the pterygoid canal
(Vidian artery):
• Supplies: Pharynx, Auditory
tube, Tympanic cavity
 Sphenopalatine artery:
o Posterolateral nasal branch
• Supplies : Lateral wall of nose,
Para nasal sinus
o Posterior septal branch
• Supplies : Nasal septum

94. Maxillary Artery Ligation
1) Transantral approach:
• first described by Scifert in 1928, for the third division of maxillary artery.
• Popularised by Chandler and Serrins in 1965
• It is currently the most widely used arterial ligation procedure for
controlling posterior epistaxis.
• In some cases bilateral maxillary artery ligation is required to control
unilateral bleeding because of cross-anastomosis from adominant
maxillary artery.

95. Procedure:
Standard gingival incision
Anterior wall of the maxillary sinus is exposed and removed with special care not to
injure the infraorbital nerve.
The posterior wall of the sinus is identified and a laterally based U-shaped mucosal flap
elevated
Positions of the posterior wall removed to gain exposure to the pterygopalatine fossa
and the branches of the maxillary artery
Complications –
a) Hypoesthesia of the infraorbital nerve
b) Persistent pain in the maxillary dentition
c) Oro-antral fistula
d) Damage to sphenopaltine ganglion
e) Total opthalmoplegia

96. 2) Intraoral Approach:
• This approach is described by Maceri and Makielski for the
ligation of the infratemporal portion of the maxillary
artery.
• This approach provides access to the 1st and 2nd parts of
the maxillarybartery without opening the maxillary sinus.
• It doesn’t require any microscope to operate.

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

98. Clinical Significance.
• In 50% of all persons, maxillary artery is found lateral to lateral
ptergoid muscle and remaining 50% the artery lies medial to
lateral ptergoid muscle. –Lauber(US)
• The maxillary artery is at risk of injury during intraoral
 vertical or oblique ramus osteotomy
 During treatment of subcondylar fracture, salivary gland tumors.
 Spenopalatine artery is most commonly responsible for post-
operative bleeding.

99. Superficial Temporal Artery
• The superficial temporal artery is one of the smaller terminal
branches of the ECA which arises behind the neck of mandible under
the cover of parotid.

100. Course
• The superficial temporal artery separates from the ECA behind
the neck of the mandible.
• About 5cm above zygoma it divides into anterior and postrior
roots which supply temple and scalp.

101. Branches
• Above the zygomatic process, the superficial temporal artery divides into two
branches, the frontal and parietal branches.
• The frontal branch supplies the forehead area and anastomoses with
the ophthalmic artery.
• The parietal branch supplies the temporal and parietal regions of the scalp. It
may form anastomoses with the posterior auricular artery and the occipital
artery.
• The superficial temporal artery also gives off the following side branches that
supply the external ear, parotid gland, temporal muscle:
 transverse facial artery
 anterior auricular branches
 middle temporal artery

102. Clinical Aspects
 In reduction of zygomatic arch fractures : Gillie’s
temporal approach the artery is often encountered.
 The pulsations of the artery can be felt on the
zygomatic arch as it crosses the root of zygoma or
pre-auricular point.
 The superficial temporal artery is frequently involved
in a pathology called the giant-cell
arteritis or temporal arteritis, which is a form of
systemic inflammatory vasculitis. The temporal
arteritis damages blood vessels resulting in
subsequent distal ischemia.
– Clinical symptoms include headache, visual
disturbances, neck pain, and scalp tenderness.