EXTERNAL

CAROTID ARTERY

PRESENTED BY: DR.CHAITANYA AGGARWAL

PG RESIDENT 1ST YEAR
DEPT. OF ORAL AND MAXILLOFACIAL SURGERY
 STRUCTURE OF
1 ARTERIES

2 EMRYOLOGY

EXTERNAL CAROTID
3
ARTERY
Contents
4 A NOTE ON ANASTOMOSIS

5 CONCLUSION

6 REFERENCES
STRUCTURE OF ARTERIES
 HISTOLOGY
The outermost layer is known as the tunica externa also known as tunica adventitia

Inside this layer is the tunica media, or media

The innermost layer, which is in direct contact with the flow of blood is the tunica intima,

commonly called the intima.

Barakoti, Murari. (2018). Carotid intima-media thickness and coronary artery Disease. Nepalese Heart Journal. 15. 9. 10.3126/njh.v15i1.19705.
EMBRYOLOGY
 EMBRYOLOGY
The aortic arches are a series of six paired embryological vascular structures

which give rise to several major arteries.

Aortic arches are short vessels connecting ventral and dorsal aortae on each side

and are 6 in total, out of which The first, second and fifth pairs soon disappear.
 EMBRYOLOGY

The 1st aortic arch - disappears a small portion persists and forms maxillary artery

The 2nd aortic arch - disappears (small portion of this arch

contributes to the hyoid and stapedial arteries)

The 3rd aortic arch - has the same development on the right and left side it gives rise to

the initial portion of the internal carotid artery

The external carotid is derived from the cranial portion of the ventral aorta
 EMBRYOLOGY

The 4th aortic arch - has ultimate fate different on the right and left side

On the left - it forms a part of the arch of the aorta between left common carotid and

left subclavian artery

On the right - it forms the proximal segment of the right subclavian artery

The 5th aortic arch - is transient and soon obliterates

The 6th aortic arch - pulmonary arch - gives off a branch on each side that

grows toward the developing lung bud

Arterial Supply
Major Arteries of
Head and Neck
COMMON CAROTID ARTERY

INTERNAL CAROTID ARTERY

EXTERNAL CAROTID ARTERY

Common
Carotid Artery
Common Carotid Artery
Surface Marking
 CERVICAL PART OF COMMON CAROTID ARTERY

Carotid arteries are generally symmetric and approximately of same size unlike

vertebral arteries.

In 75% individuals , CCA bifurcates at the level of C3-C4, roughly at the upper

border of thyroid cartilage.

In children, the carotid bifurcates one vertebral level higher.

• Variation in the level of bifurcation

Highest seen in -C1 to C2
Lowest seen in -T1 to T2
 CAROTID SINUS( BARORECEPTORS )

Present at the bifurcation of common carotid artery

Responsive to changes in the arterial blood pressure. lt acts as a baroreceptor (pressure

receptor) and regulates blood pressure.

BLOOD SUPPLY-ICA

NERVE SUPPLY-carotid sinus nerve or nerve of hering.

 APPLIED ANATOMY OF CAROTID SINUS( BARORECEPTORS )

CAROTID SINUS SYNDROME

Loss of consciousness can occur due to simple head movements in patients having

hypersensitive carotid sinus due to an unknown etiology.

Impulses transmitted by the sinus reduce blood pressure and slow the pumping action of the

heart.

Decreasing blood supply to the brain and resulting in sudden loss of consciousness.

While supporting the mandible care should be taken not to apply pressure on the carotid

sinus.
Kharsa A, Wadhwa R. Carotid Sinus Hypersensitivity. [Updated 2022 Oct 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK559059/
 DIAGNOSTIC CRITERIA
Massage Technique: With the patient in the supine position, use the second and third fingers over the carotid
sinus, which is located anterior to the sternocleidomastoid muscle at the level of the upper border of the thyroid
cartilage.

First, massage the right carotid sinus as there are a bunch of receptors, and there is greater response than the
left, massage for 5 to 10 seconds with a circular motion.

If there is no response, switch to left carotid sinus unless it is contraindicated, and if there is asystole for 3 seconds
or more and/or a drop in systolic blood pressure 50 mmHg or more, the test is considered positive regardless of
symptoms evolution.

Image reference Kenny BJ, Bordoni B. Neuroanatomy, Cranial Nerve 10 (Vagus Nerve) [Updated 2022 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
External Carotid
Artery
 EXTERNAL CAROTID ARTERY

Generally,it lies anterior to the internal carotid artery.

It is the chief artery of supply to structures in the front of the neck and in the face
EXTERNAL CAROTID ARTERY SURFACE MARKING
BRANCHES OF EXTERNAL CAROTID ARTERY
 COURSE OF EXTERNAL CAROTID ARTERY

ECA begins in the carotid triangle at the level of upper border of thyroid

cartilage opposite the disc between the third and fourth cervical vertebrae.

In the carotid triangle, it lies under cover of the anterior border of the

sternocleidomastoid muscle

As the artery ascends,it passes deep to the posterior

belly of digastric and stylohyoid muscle and terminates behind the neck of the

mandible by dividing into the maxillary and superficial temporal arteries

Has slightly curved course,so that it is anteromedial to ICA in it lower part,and anterolateral to the ICA
in its upper part.
 SUPERIOR THYROID ARTERY

Arises from ECA immediately above the bifurcation of CCA Curves anteriorly and

downwards to give off anterior and posterior branch.

normal arterial supply of thyroid gland (A) anterior view (B) posterior view
SUPERIOR THYROID ARTERY
 APPLIED ANATOMY OF SUPERIOR THYROID ARTERY

The arch of superior thyroid artery is characteristic - diagnostic landmark for ECA

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.

 LINGUAL ARTERY

ORIGIN

Lingual Artery arises from the ECA opposite the tip of greater cornu of the hyoid bone

COURSE

First part of artery lies in the carotid triangle

Second part of artery lies deep to the hyoglossus muscle which separates it from the

hypoglossal nerve

Third Part or deep part runs horizontally upwards along the anterior margin of the

hyoglossus

In vertical course, it lies between the genioglossus medially & inferior longitudinal

muscle of tongue laterally. Horizontal part is accompanied by lingual nerve

 BRANCHES
SUPRAHYOID ARTERY
DORSAL LINGUAL ARTERY
SUBLINGUAL ARTERY
DEEP LINGUAL ARTERY

Course, branches, and surrounding structures of the Lingual Artery, Victoria Manon, DDS, MBA, MD.
 APPLIED ANATOMY OF LINGUAL ARTERY

In surgical removal of tongue, first part of artery is ligated before it gives any branches to

the tongue or tonsil.

LIGATION OF LINGUAL ARTERY :

Incision - circling the lower pole of submandibular gland.

Skin, platysma, deep fascia incised, submandibular gland exposed, lifted, tendon of

diagastric visible

Free border of mylohyoid muscle seen, hypoglossal nerve identified. Digastric tendon

pulled downwards -enlarges the lingual triangle, hyoglossus muscle visible.

Muscle divided bluntly, in the gap of its vertical fibers lingual artery found & ligated.
REFERENCE:SICHER ORL ANATOMY;3RD EDITION;PAGE 441
 FACIAL ARTERY

ORIGIN

Arises from the ECA just above the tip of greater cornua of hyoid bone.

COURSE

Runs upwards in 1.Neck as cervical part

2.Face as facial part.

Course, branches, and surrounding structures of the Facial Artery, Grays Anatomy
 FACIAL ARTERY

CERVICAL PART

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.
 FACIAL ARTERY

BRANCHES OF CERVICAL PART

1. Ascending palatine artery- it supplies to root of tongue & tonsil.

2. Tonsillar artery- supplies the palatine tonsil and the posterior tongue.

3. Submental artery- it is a large artery which accompanies the mylohyoid nerve,

and supplies the submental triangle and sub lingual salivary gland.

4. Glandular branches- that supplies submandibular salivary gland and submental

lymph nodes.
 FACIAL ARTERY

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
 FACIAL ARTERY

BRANCHES OF FACIAL PART

1. Superior labial- supplies to upper lip & antero-inferior part of nasal septum.

2. Inferior labial- supplies to lower lip.

3. Lateral nasal-to the ala & dorsum of nose.

4. Angular - supplies the lacrimal sac and orbicularis oculi

Lohn, Jonathan W. G. MRCS, Eng*; Penn, Jack W. BSc*; Norton, John†; Butler, Peter E. M. MD, FRCSI, FRCS(Eng), FRCS(Plast)*. The Course and Variation of the Facial Artery and Vein:
Implications for Facial Transplantation and Facial Surgery. Annals of Plastic Surgery 67(2):p 184-188, August 2011. |
Lohn, Jonathan W. G. MRCS, Eng*; Penn, Jack W. BSc*; Norton, John†; Butler, Peter E. M. MD, FRCSI, FRCS(Eng), FRCS(Plast)*. The Course and Variation of the Facial Artery and Vein:
Implications for Facial Transplantation and Facial Surgery. Annals of Plastic Surgery 67(2):p 184-188, August 2011. |
 APPLIED ANATOMY OF FACIAL ARTERY

The facial artery is sometimes referred to as the "anaesthetist's artery"

In mandibular 1st molar region care must be taken not to infure the facial artery while extending

the vertical incision down the vestibule during surgical extraction of mandibular impaction.

• So it is recommended that start vertical incision from the vestibule in upward direction.

• While excising the submandibular gland, the facial artery should be ligated at two points and

should be secured before dividing it, otherwise it may retract through stylomandibular ligament

causing serious bleeding.

 APPLIED ANATOMY OF FACIAL ARTERY

LIGATION OF FACIAL ARTERY.

• Exposed at the point crossing the lower border of mandible .

• Using contracted masseter as a landmark, pulse of facial artery felt at point situated

anterior to the attachment of masseter.

Incision - at least half inch below the border of mandible & parallel to it.
Sharp dissection through the platysma muscle that has been undermined with a hemostat.

Artery is accompanied by facial vein & crossed superficially by marginal

mandibular branch of facial nerve
Pulse of facial artery is felt.

Artery is isolated, tied & cut

 ASCENDING PHARYNGEAL ARTERY

• A small branch arises from medial side of ECA

Long, slender vessel, deeply seated in the neck

COURSE: Ascends vertically between the internal carotid and the side of the pharynx, to the

under surface of the base of the skull, lying on the Longus capitis.

Hacein-Bey, L. et al. “The ascending pharyngeal artery: branches, anastomoses, and clinical significance.” AJNR. American journal of neuroradiology 23 7 (2002): 1246-56 .
 POSTERIOR AURICULAR ARTERY

ORIGIN

Arises from the posterior aspect of the external carotid artery just above the posterior

belly of the digastric.

COURSE

It runs upwards and backwards deep to parotid gland, but superficial to the styloid process.It

crosses the base of the mastiod process and ascends behind the auricle.

BRANCHES

STYLOMASTOID

AURICULAR

OCCIPITAL
Gómez Díaz OJ, Cruz Sánchez MD. Anatomical and Clinical Study of the Posterior Auricular Artery Angiosome: In Search of a Rescue Tool for Ear Reconstruction. Plast Reconstr Surg
Glob Open. 2016;4(12):e1165. Published 2016 Dec 27. doi:10.1097/GOX.0000000000001165
 OCCIPITAL ARTERY

ORIGIN

Arises in carotid triangle from posterior aspect of ECA ,opposite the origin of facial artery. It is

crossed at its origin by hypoglossal nerve.

 OCCIPITAL ARTERY

COURSE

The occipital artery passes posteriorly, parallel and deep to the posterior belly of the digastric

muscle, and passes in a groove on the temporal bone medial to the mastoid process. It then

runs towards the external occipital protuberance where it ascends the scalp. It perforates the

trapezius muscle and the nuchal fascia between the cranial insertions of the trapezius and

sternocleidomastoid muscles.

BRANCHES

STERNOMASTOID BRANCHES
• AURICULAR BRANCH
• MASTOID BRANCH
• MENINGEAL BRANCH
• MUSCULAR BRANCH
 MAXILLARY ARTERY

ORIGIN

Larger of the two terminal branches

Arises behind the neck of the mandible, and is embedded in the substance of the parotid gland

It supplies the deep structures of the face

BRANCHES OF MAXILLARY ARTERY
 1ST PART (MANDIBULAR) OF MAXILLARY ARTERY

It passes horizontally forward, between the ramus of the mandible and the sphenomandibula

ligament, where it lies parallel to and a little below the auriculotemporal nerve; it crosses the

inferior alveolar nerve, and runs along the lower border of the lateral pterygiod.
 MIDDLE MENINGEAL ARTERY

ORIGIN

A branch of first part of maxillary artery given in the infratemporal fossa. It is the largest of

the arteries which supply the dura mater.

COURSE
It ascends between the sphenomandibular ligament and the lateral pterygiod muscle, and
between the two roots of the auriculotemporal nerve to the foramen spinosum
 MIDDLE MENINGEAL ARTERY

BRANCHES

ANTERIOR BRANCH OR FRONTAL BRANCH

Larger than the posterior branch.

Crosses the great wing of the sphenoid, reaches the groove, or canal, in the sphenoidal angle
of the parietal bone, and then spread out between the dura mater and internal surface of the
cranium.
After crossing the pterion, the artery is closely related to the motor area of the cerebral
cortex.

POSTERIOR BRANCH OR PARIETAL BRANCH

Curves backward on the squama of the temporal bone, and, reaching the parietal some
distance in front of its mastoid angle, divides into branches which supply the posterior
part of the dura mater and cranium.
 MIDDLE MENINGEAL ARTERY

CRANIAL BRANCHES

1. Numerous ganglionic branches

2. A superficial petrosal branch supplies the facial nerve

3. A superior tympanic artery supplies Tensor tympani

4. Orbital branches anastomose with the lacrimal or other branches of the ophthalmic artery.

5. Temporal branches anastomose in the temporal fossa with the deep temporal arteries.
APPLIED ANATOMY OF MIDDLE A ARTERYRTERY

EPIDURAL HEMATOMA
 EXTRADURAL HEMATOMA

Introduction
Incidence of epidural hematoma (EDH): 1% of head trauma admissions

(which is ≈ 50% the incidence of acute subdurals)

Ratio of male:female = 4:1.

Temporoparietal skull fracture disrupts the middle meningeal artery as it exits its bony

groove to enter the skull at the pterion, causing arterial bleeding that gradually dissects

the dura from the inner table resulting in a delayed deterioration.

70% occur laterally over the hemispheres with their epicenter at the pterion, the rest occur in

the frontal, occipital, and posterior fossa (5–10% each)

 Clinical
Presentation
Brief posttraumatic loss of consciousness (LOC): from initial impact

Then, obtundation, contralateral hemiparesis, ipsilateral pupillary dilatation as a result of mass

effect from hematoma

Deterioration usually occurs over a few hours, but may take days and rarely, weeks (longer

intervals)

Contralateral hemiparesis is not uniformly seen, especially with EDH in locations other than

laterally over the hemisphere.

Shift of the brainstem away from the mass may produce compression of the opposite cerebral

peduncle on tentorial notch which can produce ipsilateral hemiparesis (Kernohan’s phenomenon),
Evaluation

Fracture
EDH

NCCT BRAIN SHOWING EDH POST PARIETAL BONE FRACTURE

EDH
 Management
CT may detect small EDHs and can be used to follow them. However, in most cases, EDH
is a surgical condition
Nonsurgical management may be attempted in the following:

EDH volume of less than 30 ml

Clot diameter of less than 15 mm

Midline shift of less than 5 mm

GCS greater than 8 and on physical examination, shows no focal neurological symptoms.

Khairat A, Waseem M. Epidural Hematoma. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan
 2ND PART (PTERYGOID) OF MAXILLARY ARTERY

Artery runs forward &upward superficial to the lower head

of the lateral pterygoid muscle

 3RD PART (PTERYGOPALATINE) OF MAXILLARY ARTERY

Terminal portion of the artery passes between the two heads

of the lateral pterygoid muscle

 SPHENOPALATINE ARTERY

Passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior

meatus.Here it gives off its posterior lateral nasal branches which spread forward over the concha and

meatuses, anastomose with the ethmoidal arteries and the nasal branches of the descending palatine, and

assist in supplying the lateral wall of nose and frontal, maxillary, ethmoidal, and sphenoidal sinuses.
 APPLIED ANATOMY OF SPHENOPALATINE ARTERY

Kiesselbach’s plexus is an integral anastomosis of five branches converging in the anterior

inferior quadrant of the nasal septum (over the septal cartilage). The area has been referred

to as Little’s Area, Kiesselbach’s Triangle or Kiesselbach’s Area. Little’s area is a common site

of epistaxis in both paediatric and adult cases.

 ANTERIOR NASAL BLEED AND ITS MANAGEMENT
Anterior epistaxis is a benign self-limited event or resolves by applying direct pressure.
Pediatric and elderly populations are most commonly affected by epistaxis, frequently due
to direct trauma from nose picking or foreign body insertion, friable mucosa, or
anticoagulant use with or without hypertension.
The most commonly implicated arterial blood supply in anterior epistaxis is the Kiesselbach
plexus in Little’s area
 POSTERIOR NASAL BLEED AND ITS MANAGEMENT

Posterior epistaxis occurs at more posterior sites on the nasal septum or the lateral wall.
Bleeding usually comes from the sphenopalatine artery but can also involve terminal
branches of the maxillary artery, the descending palatine artery, the posterior ethmoidal
artery
 APPLIED ANATOMY OF MAXILLARY ARTERY

Surgeries involving condyle-Avoid injury to maxillary artery as it lies medial to condyle.

Ankylotic mass of TMJ may encircle the artery.So it is advisable to remove ankylotic mass

in pieces rather than in toto

The maxillary arteries (red arrow), can be seen. The maxillary artery courses anteriorly behind the subcondylar portion of the mandible.
Orbay, Hakan et al. “Maxillary artery: anatomical landmarks and relationship with the mandibular subcondyle.” Plastic and reconstructive surgery vol. 120,7 (2007): 1865-1870.
doi:10.1097/01.prs.0000287137.72674.3c
 APPLIED ANATOMY OF MAXILLARY ARTERY

During Le fort I osteotomy procedure-

Pterygopalatine portion of maxillary artery may be injured during fracturing the pterygoid

plates if Tessier's osteotome is directed backwards.

It should be should be directed downwards and medially

https://surgeryreference.aofoundation.org/sitecore/content/AO-JSS/AOSR/aosr/home/cmf/Orthognathic
 SUPERFICIAL TEMPORAL ARTERY

ORIGIN

The smaller of the two terminal branches of the external carotid, appears, to be the

continuation of ECA. It begins in the substance of the parotid gland, behind the neck of

the mandible.

COURSE

It runs vertically upwards crossing over

the root of the zygomatic process -about 5 cm. above this process it divides into two

branches, a frontal and a parietal.

 SUPERFICIAL TEMPORAL ARTERY

Besides some twigs to the parotid gland, to the temporomandibular joint, and to the

Masseter muscle

Branches of Superficial Temporal Artery

 APPLIED ANATOMY OF SUPERFICIAL TEMPORAL ARTERY

Anaesthetist's artery

In Gillies Approach : A temporal incision (2 cm in length), made 2.5 cm superior and anterior

to the helix, within the hairline is placed in the temporal region between two branches of the

superficial temporal artery.

Markose G, Graham RM. Gillies temporal incision: an alternate approach to superficial temporal artery
biopsy. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.05.002
 APPLIED ANATOMY OF MAXILLARY ARTERY

Transmaxillary IMA ligation via Caldwell-luc approach

Incision made at the canine mucobuccal fold

Following an incision into the soft tissue over the maxillary sinus,
the bony face of this sinus is exposed.

fenestration of the bony face of

maxillary sinus

Esther Kim, James Duncavage,Caldwell-Luc procedure,Operative Techniques in Otolaryngology-Head and Neck Surgery,Volume 21, Issue 3,2010,
Pages 163-165,ISSN 1043-1810,
 LIGATION OF EXTERNAL CAROTID ARTERY

INDICATIONS
Injuries causing carotid blow-outs

•Head and Neck Cancers

• Acute massive epistaxis

• Hereditary teliangectiasis

• Nasopharyngeal angiofibroma

• Aneurysms ( traumatic aneurysms of head and neck)

•Life threatening bleeding following severe maxillofacial trauma

 LIGATION OF EXTERNAL CAROTID ARTERY

ECA-LIGATION can be done in carotid triangle or in retromandibular fossa.

Injuries causing carotid blow-outs

INCISION- A horizontal skin incision is outlined at the level of hyoid bone and submandibular
gland, two to three fingerbreadths below the angle of the mandible.It is placed in a skin crease.
The posterior border of the incision is over the SCM.
 LIGATION OF EXTERNAL CAROTID ARTERY

Dissection is carried through skin,platysma, then anterior border of SCM is identified and
retracted posteriorly.

A clamp is used to dissect anterior to the muscle parallel to great vessels to identify carotid
sheath.

The CCA is carefully separated from other contents of sheath.

The IJV, vagus nerve and ansa hypoglossi are retracted posteriorly.

Usually at this place,a vesicular loop is placed loosely around CCA to obtain control.

Then dissection is carried up along the CCA to the bifurcation area.

 LIGATION OF EXTERNAL CAROTID ARTERY

At this point hypoglossal nerve is identified crossing the branches, it should be

preserved

A 2-0 silk tie is placed between the superior thyriod and lingual arteries
LIGATION OF EXTERNAL CAROTID ARTERY
 LIGATION OF EXTERNAL CAROTID ARTERY IN RETROMANDIBULAR FOSSA
Skin incision at line starting at the tip of mastoid process, circling the mandibular angle,
continuing forward below the mandible one inch

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

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

scalpel. Parotid gland retracted

Post. Belly of digastric ,stylohyoid muscle is visible. Above this stylomandibular ligament
can be palpated if mandible is pulled forward.

This movement widens the entrance into retromandibular fossa, tenses the stylomandibular
ligament.

Pulsations of ECA are felt, isolated & tied.

A NOTE ON ANASTOMOSIS
 CONCLUSION

After ligation of the external carotid artery the circulation is later re-established by the free

communication between most of the large branches of the arteries and its corresponding

artery in the opposite side and also anastomosing with the internal carotid

system
 References

GRAY'S ANATOMY- 39TH EDITION

NETTER'S- COLOUR ATLAS OF ANATOMY

SICHER 0RAL ANATOMY

SURGICAL ANATOMY OF OTOLARYNGOLOGY-JEFFREY J. BAILLEY

JOURNAL OF MAXILLOFACIAL AND ORAL SURGERY

AO SURGERY REFERENCE

RESEARCH ARTICLES AS MENTIONED