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SEMINAR ONSEMINAR ONTHE EXTERNAL CAROTID ARTERY THE EXTERNAL CAROTID ARTERY

AND ITS APPLIED ANATOMYAND ITS APPLIED ANATOMY

Date:16/01/10Date:16/01/10 Presented by:Presented by:

Dr. PAVAN TENGLIKARDr. PAVAN TENGLIKAR

PG OMFS 1PG OMFS 1STST YEAR YEAR

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

MODERATOR: DR.SYED AHMED MOHIUDDIN Proff & H.O.D

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CONTENTSCONTENTS

1.1. INTRODUCTION.INTRODUCTION.2.2. HISTOLOGY OF ARTERIES.HISTOLOGY OF ARTERIES.3.3. COMMON CAROTID ARTERY.COMMON CAROTID ARTERY.4.4. EXTERNAL CAROTID ARTERY.EXTERNAL CAROTID ARTERY.5.5. COURSE AND RELATIONS.COURSE AND RELATIONS.6.6. BRANCHES BRANCHES 7.7. APPLIED ANATOMYAPPLIED ANATOMY8.8. REFERENCES.REFERENCES.

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INTRODUCTIONINTRODUCTION

►ECA is one of the terminal branches of ECA is one of the terminal branches of the CCA.the CCA.

►Lies anterior to the ICALies anterior to the ICA►Chief artery of supply to structures in Chief artery of supply to structures in

front of the neck and in the face.front of the neck and in the face.

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HISTOLOGY OF ARTERIESHISTOLOGY OF ARTERIES

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General structureGeneral structure

►Three layersThree layers Tunica intimaTunica intima Tunic mediaTunic media Tunic externaTunic externa

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Tunica intimaTunica intima

► INNERMOST LAYERINNERMOST LAYER Endothelial liningEndothelial lining Basal laminaBasal lamina Sub endothelial Sub endothelial

connective tissueconnective tissue Elastic fibers –elastic Elastic fibers –elastic

laminalamina

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Tunica mediaTunica media

►MIDDLE LAYERMIDDLE LAYER►Elastic Elastic

fibers/Smooth fibers/Smooth musclemuscle Circularly arranged Circularly arranged

fibers.fibers.

► Thickest layer in Thickest layer in arteriesarteries

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Tunica externaTunica externa

►Adventitia Adventitia ►Loose connective Loose connective

tissue/collagen fibers tissue/collagen fibers predominant.predominant.

►Thickest layer in veinsThickest layer in veins►Merges with Merges with

surrounding tissuesurrounding tissue►Prevents Prevents

Stretching/distensionStretching/distension

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COMMON CAROTID ARTERIESCOMMON CAROTID ARTERIES

►Rt CCA is branch of brachiocephalic Rt CCA is branch of brachiocephalic trunk, begins in neck behind rt trunk, begins in neck behind rt sternoclavicular joint.sternoclavicular joint.

►Lt CCA branch of arch of aorta, begins Lt CCA branch of arch of aorta, begins in thorax in front of trachea opposite in thorax in front of trachea opposite to a point a little left to the centre of to a point a little left to the centre of manubrium.manubrium.

►At the level of upper border of thyroid At the level of upper border of thyroid cartilage it divides into ECA & ICA.cartilage it divides into ECA & ICA.

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EXTERNAL CAROTID ARTERYEXTERNAL CAROTID ARTERY

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Course & relations:Course & relations:

►Begins –in carotid triangle.Begins –in carotid triangle.►Terminates –behind the neck of the Terminates –behind the neck of the

mandible.mandible.►Slightly curved course Slightly curved course ►Anteromedially -ICA-lower part of its Anteromedially -ICA-lower part of its

coursecourse►Anterolaterally –ICA-upper partAnterolaterally –ICA-upper part

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IN CAROTID TRIANGLEIN CAROTID TRIANGLE

► Lies under the cover of Lies under the cover of sternomastoid.sternomastoid.

► Crossed superficially:Crossed superficially:

1.1. Cervical branch of facial nerveCervical branch of facial nerve

2.2. Hypoglossal nerve.Hypoglossal nerve.

3.3. Facial nerve Facial nerve

4.4. Lingual nerveLingual nerve

5.5. Superficial thyroid veinsSuperficial thyroid veins

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Above carotid triangleAbove carotid triangle

►Lies deep to substance of parotid glandLies deep to substance of parotid gland►Within gland lies superficial to Within gland lies superficial to

retromandibular vein & facial nerve.retromandibular vein & facial nerve.►Deep to ECA Deep to ECA

– –ICAICA

-Superior laryngeal nerve-Superior laryngeal nerve

-supr cervical sympathetic -supr cervical sympathetic

ganglion ganglion

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►Between ICA & ECABetween ICA & ECA

- styloglossus, stylopharyngeus - styloglossus, stylopharyngeus

musclesmuscles

- glossopharyngeal &pharyngeal - glossopharyngeal &pharyngeal

branch of vagus nervesbranch of vagus nerves

- styloid process & part of - styloid process & part of

parotid glandparotid gland

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Branches of ECABranches of ECA

►There are 8 branchesThere are 8 branches 1.Anterior: a) Superior thyroid1.Anterior: a) Superior thyroid b) Lingualb) Lingual c) Facialc) Facial 2.Posterior:2.Posterior: a) Posterior auricular a) Posterior auricular b) Occipitalb) Occipital 3.Medial: Ascending pharyngeal3.Medial: Ascending pharyngeal 4.Terminal: a) Superficial temporal4.Terminal: a) Superficial temporal b) Maxillaryb) Maxillary

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SUPERIOR THYROID ARTERYSUPERIOR THYROID ARTERY

►Arises from the ECA just below the Arises from the ECA just below the greater cornu of the hyoid bone.greater cornu of the hyoid bone.

►Runs downwards, forwards parallel to Runs downwards, forwards parallel to external laryngeal nerve.external laryngeal nerve.

►Passes deep to the infrahyoid muscles Passes deep to the infrahyoid muscles to reach lateral lobe of thyroid gland.to reach lateral lobe of thyroid gland.

►Branches: superior laryngeal artery, Branches: superior laryngeal artery, sternomastoid branch, cricothyroid sternomastoid branch, cricothyroid branch,& terminal branches to the branch,& terminal branches to the thyroid glandthyroid gland

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LINGUAL ARTERYLINGUAL ARTERY

►Arises from the ECA opposite of the Arises from the ECA opposite of the greater cornu of the hyoid bone.greater cornu of the hyoid bone.

►Course: divided in to 3 partsCourse: divided in to 3 parts►11stst :lies in carotid triangle, forms :lies in carotid triangle, forms

characteristic loop, crossed by characteristic loop, crossed by hypoglossal nerve.hypoglossal nerve.

►22ndnd :lies deep to hypoglossus along the :lies deep to hypoglossus along the upper border of hyoid bone, superficial upper border of hyoid bone, superficial to middle constrictor of the pharynx.to middle constrictor of the pharynx.

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►33rdrd :called arteria profunda linguae, or :called arteria profunda linguae, or deep lingual artery, deep lingual artery,

►Runs upwards along the border of Runs upwards along the border of hypoglossus, and then forwards on the hypoglossus, and then forwards on the undersurface of the tongue.undersurface of the tongue.

►During surgical removal of tongue, the During surgical removal of tongue, the first part is ligated before it gives any first part is ligated before it gives any branch to tongue or tonsilbranch to tongue or tonsil

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FACIAL ARTERYFACIAL ARTERY

►Arises just above tip of greater cornu Arises just above tip of greater cornu of hyoid bone.of hyoid bone.

►Studied under 2 parts.Studied under 2 parts.►Cervical partCervical part►Facial part.Facial part.

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CERVICAL PART CERVICAL PART

► Runs upward on the pharynx deep to Runs upward on the pharynx deep to posterior belly of Digastric & to ramus of posterior belly of Digastric & to ramus of Mandible.Mandible.

►Grooves posterior border of Submandibular Grooves posterior border of Submandibular gland.gland.

►Makes an S bend.Makes an S bend.► Branches.Branches.

a. Ascending palatine.a. Ascending palatine.

b. Tonsillar.b. Tonsillar.

c. Submental.c. Submental.

d. Glandulard. Glandular

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FACIAL PARTFACIAL PART

► Enters by winding around base of mandible. Enters by winding around base of mandible. & by piercing antero-inferior angle of & by piercing antero-inferior angle of masseter.masseter.

► Course is very tortuous which prevents artery Course is very tortuous which prevents artery from being stretched during movements of from being stretched during movements of pharynx during deglutition. On face allow free pharynx during deglutition. On face allow free movements of mandible, lips & cheek during movements of mandible, lips & cheek during mastication & various facial movements.mastication & various facial movements.

► Branches: Branches: ► Inferior labialInferior labial► Superior labial Superior labial ► Lateral nasalLateral nasal

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POSTERIOR AURICULAR ARTERYPOSTERIOR AURICULAR ARTERY

► Arises from the posterior aspect of the ECA Arises from the posterior aspect of the ECA just above the posterior belly of Digastric.just above the posterior belly of Digastric.

► Runs upwards , backwards deep to the parotid Runs upwards , backwards deep to the parotid gland, but superficial to the styloid process.gland, but superficial to the styloid process.

► Crosses the base of the mastoid process, and Crosses the base of the mastoid process, and ascends behind the auricle.ascends behind the auricle.

► Supplies: back of auricle, skin over mastoid Supplies: back of auricle, skin over mastoid process, back of the scalp.process, back of the scalp.

► Branch: stylomastoid branch-supplies middle Branch: stylomastoid branch-supplies middle earear

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OCCIPITAL ARTERYOCCIPITAL ARTERY

► Arises from the posterior aspect of ECA, Arises from the posterior aspect of ECA, opposite the origin of facial artery.opposite the origin of facial artery.

► Runs backwards and upwards deep to the Runs backwards and upwards deep to the lower border of the posterior belly of lower border of the posterior belly of Digastric, crossing carotid sheath, and the Digastric, crossing carotid sheath, and the accessory and hypoglossal nerves.accessory and hypoglossal nerves.

►Next it runs deep to mastoid process and Next it runs deep to mastoid process and muscles attached to it, finally pierces muscles attached to it, finally pierces trapezius 2.5cm from midline.trapezius 2.5cm from midline.

► Branches : Mastoid, Meningeal, MuscularBranches : Mastoid, Meningeal, Muscular

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MAXILLARY ARTERYMAXILLARY ARTERY

► This is the larger terminal branch of ECA, This is the larger terminal branch of ECA, given off behind the neck of mandible.given off behind the neck of mandible.

► Supplies:Supplies:1.1. External & middle ear, Auditory tube.External & middle ear, Auditory tube.2.2. Dura matterDura matter3.3. Upper and lower jaw.Upper and lower jaw.4.4. Muscles of temporal infratemporal regionMuscles of temporal infratemporal region5.5. Nose and Para nasal sinuses.Nose and Para nasal sinuses.6.6. PalatePalate7.7. Root of the pharynxRoot of the pharynx

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Course and RelationCourse and Relation

► Divided in to 3 parts:Divided in to 3 parts:1.1. First- Mandibular part: runs horizontally First- Mandibular part: runs horizontally

forwards, between the neck of mandible forwards, between the neck of mandible and the sphenomandibular ligament, and the sphenomandibular ligament, below the Auriculotemporal nerve , then below the Auriculotemporal nerve , then along the lower border of the lateral along the lower border of the lateral pterygoidpterygoid

2.2. Second-pterygoid part: runs upwards and Second-pterygoid part: runs upwards and forwards either superficially or deep to the forwards either superficially or deep to the lower head of the lateral pterygoid.lower head of the lateral pterygoid.

3.3. Third – Pterygoplatine part: passes Third – Pterygoplatine part: passes between two heads of lat pterygoid and between two heads of lat pterygoid and through Pterygomaxillary fissure, to enter through Pterygomaxillary fissure, to enter Pterygopalatine fossaPterygopalatine fossa

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Branches Branches

► First part –First part –1.1. Deep auricular Deep auricular

arteryartery2.2. Anterior tynphanic Anterior tynphanic

arteryartery3.3. Middle meningeal Middle meningeal

arteryartery4.4. Accesory Accesory

meningeal arterymeningeal artery5.5. Inferiopr alveolar Inferiopr alveolar

arteryartery

► Second part-Second part-1.1. Deep temporal Deep temporal

branchesbranches2.2. Br to pterygoid and Br to pterygoid and

massetermasseter3.3. Buccal branchBuccal branch

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► Third part-Third part-

1.1. Posterior superior alveolar arteryPosterior superior alveolar artery

2.2. Infraorbital arteryInfraorbital artery

3.3. Greater palatine arteryGreater palatine artery

4.4. Pharyngeal branchPharyngeal branch

5.5. Artery to the pterygoid canalArtery to the pterygoid canal

6.6. Sphenopalatine arterySphenopalatine artery

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SUPERFICIAL TEMPORAL ARTERYSUPERFICIAL TEMPORAL ARTERY

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► It is the smaller terminal branch of ECA, It is the smaller terminal branch of ECA, ► Begins behind the neck of the mandible Begins behind the neck of the mandible

under cover of the parotid gland.under cover of the parotid gland.► Runs vertically upwards, crossing the root of Runs vertically upwards, crossing the root of

the zygoma (pre-auricular point), where its the zygoma (pre-auricular point), where its pulsation can be easily felt.pulsation can be easily felt.

► 5cm above zygoma it divides in to anterior 5cm above zygoma it divides in to anterior and posterior branches which supply temple and posterior branches which supply temple and scalpand scalp

►Other branches: Transverse facial artery and Other branches: Transverse facial artery and middle temporal artery.middle temporal artery.

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APPLIED ANATOMYAPPLIED ANATOMY

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CAROTID SINUSCAROTID SINUS

►Present at the termination of CCA. (or Present at the termination of CCA. (or beginning of ICA.)beginning of ICA.)

►Tunica media is thin, tunica adventia is Tunica media is thin, tunica adventia is thickthick

►Acts as BARORECEPTOR/PRESSURE Acts as BARORECEPTOR/PRESSURE RECEPTOR.RECEPTOR.

►Regulates Blood Pressure.Regulates Blood Pressure.

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LIGATION OF ECALIGATION OF ECA

►Arterial hemorrhages during major Arterial hemorrhages during major operations can be prevented.operations can be prevented.

►Due to wide anatomoses, and contra Due to wide anatomoses, and contra lateral arteries , bilateral ligation is lateral arteries , bilateral ligation is necessary.necessary.

►Abscess drainage, routine extraction of Abscess drainage, routine extraction of teeth, external force.teeth, external force.

►Consideration to be given to Consideration to be given to topographic relation of incision to topographic relation of incision to neighboring blood vessels. neighboring blood vessels.

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SURFACE MARKINGSURFACE MARKING

EXTERNAL CAROTID ARTERYEXTERNAL CAROTID ARTERY

The artery is marked by joining the The artery is marked by joining the following points.following points.

a.a. A point on the anterior border of A point on the anterior border of sternomastoid muscle at the upper sternomastoid muscle at the upper border of the thyroid cartilage.border of the thyroid cartilage.

b.b. A second point on the posterior A second point on the posterior border of the neck of the mandible.border of the neck of the mandible.

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► There are two points at which the There are two points at which the ECA can be exposed and tied.ECA can be exposed and tied.

1.1. EXPOSURE IN THE CAROTID EXPOSURE IN THE CAROTID TRIANGLETRIANGLE

2.2. EXPOSURE IN THE EXPOSURE IN THE RETROMANDIBULAR FOSSA.RETROMANDIBULAR FOSSA.

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EXPOSURE IN CAROTID TRIANGLEEXPOSURE IN CAROTID TRIANGLE

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TRIANGLES OF NECK

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Surgical procedure:Surgical procedure:

► Incision –level of the angle of mandible Incision –level of the angle of mandible just behind the SCM, continued just behind the SCM, continued downward parallel to lower border of downward parallel to lower border of mandible.mandible.

►Penetrating through skin, platysma, Penetrating through skin, platysma, superficial layer of SCM.superficial layer of SCM.

►Muscle is retracted to expose IJV & deep Muscle is retracted to expose IJV & deep layer of SCM.layer of SCM.

► In front of IJV, fascia is cut to expose In front of IJV, fascia is cut to expose Superior thyroid artery.Superior thyroid artery.

►ECA is identified by its first anterior ECA is identified by its first anterior branch, the superior thyroid artery, branch, the superior thyroid artery, and then isolated and tied a few and then isolated and tied a few millimeters above the origin of the millimeters above the origin of the superior thyroid artery.superior thyroid artery.

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EXPOSURE IN THE RETROMANDIBULAR EXPOSURE IN THE RETROMANDIBULAR FOSSAFOSSA

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►Behind the angle of the mandible.Behind the angle of the mandible.

►This method is also called “ligation of This method is also called “ligation of ECA at the stylomandibular ligament”.ECA at the stylomandibular ligament”.

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Surgical procedureSurgical procedure

►The skin is incised in a line starting at The skin is incised in a line starting at the tip of the mastoid process and the tip of the mastoid process and circling the mandibular angle, circling the mandibular angle, continuing below the mandible for continuing below the mandible for about 1 inch.about 1 inch.

►After scapel has pased through the After scapel has pased through the skin and posterior fibres of platysma skin and posterior fibres of platysma muscle,the EJV and great auricular muscle,the EJV and great auricular nerve is located,tied,and cut.nerve is located,tied,and cut.

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►Attachment of parotid capsule with Attachment of parotid capsule with SCM must be severed with scapel.SCM must be severed with scapel.

►Parotid gland is retracted anteriorly Parotid gland is retracted anteriorly and upward.and upward.

►Underneath the parotid gland, the Underneath the parotid gland, the posterior belly of Digastric , stylohyoid posterior belly of Digastric , stylohyoid muscle becomes visible.muscle becomes visible.

►Above these muscles the upper border Above these muscles the upper border of stylomandibular ligament can be of stylomandibular ligament can be palpated.palpated.

►Pulse is felt, artery is isolated, and tied.Pulse is felt, artery is isolated, and tied.

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LIGATION OF THE FACIAL ARTERYLIGATION OF THE FACIAL ARTERY

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►Can be easily exposed at the point Can be easily exposed at the point where it crosses the lower border of where it crosses the lower border of the mandible to pass from the mandible to pass from submandibular region into the face.submandibular region into the face.

►This point is situated anterior the This point is situated anterior the attachment to the masseter muscle to attachment to the masseter muscle to the mandible.the mandible.

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► Incision is made ½ inch below the Incision is made ½ inch below the border of the mandible and parallel to border of the mandible and parallel to it.it.

►The skin, platysma muscle, and deep The skin, platysma muscle, and deep fascia are cut and then the soft tissue fascia are cut and then the soft tissue are bluntly retracted until the palpating are bluntly retracted until the palpating finger can feel pulse.finger can feel pulse.

►Artery then can be isolated, tied, and Artery then can be isolated, tied, and cut.cut.

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LIGATION OF LINGUAL ARTERYLIGATION OF LINGUAL ARTERY

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►Exposure of lingual artery is done in Exposure of lingual artery is done in the submandibular digastric trianglethe submandibular digastric triangle

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►Submandibular gland is palpated, and Submandibular gland is palpated, and an incision is made that circles the an incision is made that circles the lower pole of this gland.lower pole of this gland.

►Posterior part of incision should point Posterior part of incision should point toward the tip of the mastoid process; toward the tip of the mastoid process; and anterior part points the chin .and anterior part points the chin .

►Skin, platysma and deep fascia is Skin, platysma and deep fascia is incised; the lower pole of gland is incised; the lower pole of gland is exposed.exposed.

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►Gland is lifted exposing tendon of Gland is lifted exposing tendon of digastric muscle.digastric muscle.

►Following the tendon anteriorly Following the tendon anteriorly mylohyoid muscle and hypoglossal mylohyoid muscle and hypoglossal nerve can be seen.nerve can be seen.

►By pulling digastric tendon downward, By pulling digastric tendon downward, hypoglossal muscle with its vertical hypoglossal muscle with its vertical fibers becomes visible.fibers becomes visible.

►Muscle is divided bluntly, and in the Muscle is divided bluntly, and in the gap between vertical fibers the lingual gap between vertical fibers the lingual artery is foundartery is found

CONCLUSIONCONCLUSION

►Severe arterial hemorrhages during Severe arterial hemorrhages during major operation can be prevented by a major operation can be prevented by a preparatory ligation of the respective preparatory ligation of the respective artery.artery.

►One has to consider , first, the areas in One has to consider , first, the areas in which an accident severing of the which an accident severing of the artery is possible and means to avoid artery is possible and means to avoid such an occurrence, and , second, the such an occurrence, and , second, the anatomic basis for ligating the afferent anatomic basis for ligating the afferent arteries of the facial regionarteries of the facial region 74

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REFERENCESREFERENCES

►HUMAN ANATOMY-GRAY’SHUMAN ANATOMY-GRAY’S►HUMAN ANATOMY-B.D.CHAURASIAHUMAN ANATOMY-B.D.CHAURASIA►ANATOMY FOR SURGEON’S- ANATOMY FOR SURGEON’S-

HOLLENSHEADHOLLENSHEAD►ORAL ANATOMY-SICHERORAL ANATOMY-SICHER►SURGICAL ANATOMY-SKANDALAKIS, 2004SURGICAL ANATOMY-SKANDALAKIS, 2004►CLINICAL ANATOMY-HAROLD ELLIS, 11CLINICAL ANATOMY-HAROLD ELLIS, 11THTH

EDITIONEDITION

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