CHPTER 4 THE FACE Vascular System of Head & Neck Dr. Motaz Shieban , PhD , MD Surgical Oncologist , Austria

Common Carotid Artery The right common carotid artery arises from the brachiocephalic artery behind the right sternoclavicular joint The left artery arises from the arch of aorta in the superior mediastenum Runs upward through the neck Divides into external and internal carotid arteries

Carotid Sinus At its point of division, the common carotid artery shows a localized dilatation, called carotid sinus It serves as a reflex pressoreceptor mechanism A rise in blood pressure causes a slowing of the heart rate and vasodilatation of the arterioles Carotid Body It is a small structure lies posterior to the point of bifurcation of the common carotid artery It is innervated by glossopharyngeal nerve It serves as a chemoreceptor Sensitive to excess carbon dioxide and reduced oxygen tension in the blood Stimulus reflexly produces a rise in blood pressure and heart rate and increase in respiratory movements

Common Carotid Artery Relations It is embedded in the carotid sheath throughout its course Closely related with the internal jugular vein and vagus nerve Apart from the two terminal branches, the common carotid artery gives off no branch in the neck Relations Anterolaterally: The skin, fascia, sternocleidomastoid, sternohyoid, sternothyroid, and posterior belly of omohyoid Posteriorly: The transverse processes of lower four cervical vertebrae, the prevertebral muscles, sympathetic trunk, vertebral vessels in the lower part of the neck Medially: The larynx, pharynx, and below these, the trachea and esophagus, the lobe of thyroid gland Laterally: The internal jugular vein, and posterolaterally, the vagus nerve

External Carotid Artery It is one of the terminal branches of the common carotid artery It supplies the structures in the neck, face, scalp, tongue and maxilla Begins at the level of the upper border of the thyroid cartilage Terminates in the substance of the parotid gland by dividing into superficial temporal and maxillary arteries At its origin, where its pulsation can be felt, the artery lies within the carotid triangle At first, it lies medial to the internal carotid artery It is crossed by the posterior belly of the digastric and the stylohyoid

Relations Anterolaterally: overlapped by sternocleidomastoid muscle, fascia and skin, it is crossed by the hypoglossal nerve the posterior belly of the digastric muscle and the stylohyoid, crossed by the facial nerve within the parotid gland The internal jugular vein first lie anterior to the artery then posterior to it Medially: the wall of the pharynx, internal carotid artery The stylopharyngeus muscle, the glossopharyngeal nerve, and pharyngeal branch of the vagus pass between the external and internal carotid arteries

Branches Superior thyroid artery Ascending pharyngeal artery Lingual artery Facial artery Occipital artery Posterior auricular artery Superficial temporal artery Maxillary artery

1. Superior Thyroid Artery Arises from the external carotid artery near its origin Passes almost vertically downward Reach the upper pole of thyroid gland It gives off a branch to the sternocleidomastoid The superior laryngeal artery pierces the thyrohyoid membrane with the internal laryngeal nerve

2. Ascending Pharyngeal Artery It’s a long slender vessel that ascends on the wall of the pharynx, which it supplies 3. Lingual Artery It arises from the external carotid artery, opposite the tip of the greater cornu of hyoid bone It loops upward to enter the submandibular region The loop of the artery is crossed superficially by the hypoglossal nerve It supplies the tongue

4. Facial Artery It arises in the carotid triangle from the external carotid artery a little above the lingual artery and, sheltered by the ramus of the mandible, passes obliquely up beneath the digastric and stylohyoid muscles, over which it arches to enter a groove on the posterior surface of the submandibular gland. It then curves upward over the body of the mandible at the antero-inferior angle of the masseter; passes forward and upward across the cheek to the angle of the mouth, then ascends along the side of the nose, and ends at the medial commissure of the eye, under the name of the angular artery. The facial artery is remarkably tortuous. This is to accommodate itself to neck movements such as those of the pharynx in deglutition; and facial movements such as those of the mandible, lips, and cheeks.

Branches of Facial Artery Cervical Ascending palatine artery Tonsillar branch Submental artery Glandular branches Facial Inferior labial artery Superior labial artery Lateral nasal branch to nasalis muscle Angular artery - the terminal branch

5. Occipital Artery It arises from the external carotid artery, opposite the facial artery It passes upward and reaches the back of the scalp Its terminal part accompanies branches of the greater occipital nerve to supply the back of scalp Its path is below the posterior belly of digastric to the occipital region. This artery supplies blood to the back of the scalp and sterno- mastoid muscles, and deep muscles in the back and neck.

6. Posterior Auricular Artery It arises from the external carotid artery, at the level of the upper border of the posterior belly of the digastric muscle It passes backward to reach the auricle 7. Superficial Temporal Artery It is the smaller terminal branch of the external carotid artery Ascends in front of the auricle in company with auriculotemporal nerve It divides into anterior and posterior branches, which supply the skin over the frontal and temporal regions

8. Maxillary Artery It is the larger terminal branch of the external carotid artery in the parotid gland ,It arises behind the neck of the mandible .It runs upward and forward, leaves the infratemporal fossa by entering the pterygopalatine fossa

Branches of Maxillary Artery First portion The first or mandibular portion passes horizontally forward, between the neck of the mandible and the sphenomandibular ligament, where it lies parallel to and a little below the auriculotemporal nerve; it crosses the inferior alveolar nerve, and runs along the lower border of the lateral pterygoid muscle. Branches include: Deep auricular artery Anterior tympanic artery Middle meningeal artery Inferior alveolar artery which gives off its mylohyoid branch just prior to entering the mandibular foramen Accessory meningeal artery

Second portion: The second or pterygoid portion runs obliquely forward and upward under cover of the ramus of the mandible and insertion of the temporalis, on the superficial (very frequently on the deep) surface of the lateral pterygoid muscle; it then passes between the two heads of origin of this muscle and enters the fossa. Branches include: Masseteric artery Pterygoid branches Deep temporal arteries (anterior and posterior) Buccal artery Third portion The third or pterygomaxillary portion lies in the pterygopalatine fossa in relation with the pterygopalatine ganglion. This is considered the terminal branch of the maxillary artery. Sphenopalatine artery (Nasopalatine artery is the terminal branch of the Maxillary artery) Descending palatine artery Infraorbital artery Posterior superior alveolar artery Artery of pterygoid canal Pharyngeal artery Middle superior alveolar artery (a branch of the infraorbital artery) Anterior superior alveolar arteries (a branch of the infraorbital artery) Greater palatine artery

Internal Carotid artery It is one of the terminal branches of the common carotid artery It supplies the brain, the eye, the forehead, and the part of nose It begins at the level of the upper border of the thyroid cartilage Ascends in the neck to the base of the skull

Internal Carotid artery It enters the cranial cavity through the carotid canal in the petrous part of the temporal bone It lies embedded in the carotid sheath with the internal jugular vein and vagus nerve It gives off no branches in the neck

Relations Anterolaterally: Below the digastric lie the skin, the fascia, anterior border of sternocleidomastoid and the hypoglossal nerve Above the digastric lie the stylohyoid and the stylopharyngeus muscles, the glossopharyngeal nerve, the pharyngeal branch of vagus nerve, the parotid gland and the external carotid artery

Relations Posteriorly: The sympathetic trunk, longus capitis muscle, and the transverse processes of the upper three cervical vertebrae Medially: The pharyngeal wall and the superior laryngeal nerve Laterally: The internal jugular vein and the vagus nerve

Veins of the Head and neck Venous drainage from the face is entirely superficial All the venous drainage from the head and neck terminate in the internal jugular vein which join the subclavian vein to form the brachiocephalic vein behind the medial end of the clavicle

Internal jugular vein: It receive blood from the brain, face and the neck. It emerges through the jugular foramen,as a continuation of the sigmoid sinus descend down in the neck, first behind then lateral to the internal carotid artery inside the carotid sheath

The deep cervical lymph nodes are adjacent to the vein Terminate beneath the triangular interval between the sternal and the clavicular head of the sternocleidomastoid muscle joining the subclavian vein to form the brachiocephalic vein

The superior and inferior bulbs: are dilatation near the origin and the termination of the vein. Above the inferior bulb is a bicuspid valve Skin, superficial fascia, platysma, deep cervical fascia and parotid lies lateral and anteriorly

Veins of the Head and neck Tributaries: Inferior petrosal sinus: assist in draining the cavernous sinus leaves through anterior part of jugular foramen join the vein below the superior bulb

Facial vein: is formed by the union of the supraorbital and supratrochlear veins the medial canthus to form the angular vein Communicate with the cavernous sinus through the ophthalmic vein via the supraorbital

Facial vein: Joins the: descend on the face behind the facial artery to the lower border of the mandible to be joined by the anterior division of the retomandibular vein Joins the: pterygoid plexus through deep facial vein Cavernous sinus through superior ophthalmic vein

Retromandibular vein: formed by the union of superficial temporal and maxillary vein from the pterygoid plexus passes downwards in the substance of the parotid gland emerging from its lower border & divide into two divisions

Retromandibular vein: Anterior division: joins the facial vein Posterior division: pierces the deep fascia and join the posterior auricular to form the external jugular. It empty into the subclavian vein

The maxillary vein: A short trunk accompany the first part of the artery. Formed by confluence of the veins of the pterygoid plexus. It passes backward between the sphenomandibular ligament and the neck of the mandible Unite with the superficial temporal vein to form the retromadibular vein.

Pterygoid plexus: A network of very small veins, lie around and within the lateral pterygoid muscle in the infratemporal region receive some of the veins that correspond to the maxillary artery, inferior ophthalmic vein (internal carotid blood) and the deep facial vein.

Pterygoid plexus: Drain into a pair of large, short maxillary veins which join the superficial temporal vein to form the retromandibular. Deep facial vein drain the plexus into the facial vein if the maxillary is occluded

Pterygoid plexus: Act as peripheral pump, to aid venous return by the pumping action of the muscle every time the mouth is opened. Yawing, a prolonged and forcible contraction of the lateral pterygoid to open the mouth, is accompanied by contraction of the diaphragm and stretching of limbs, is a reflex triggered by venous stagnation

Pharyngeal veins: drain the pharyngeal plexus on the outer surface of the pharynx. End in the internal jugular vein , the facial the lingual or the superior thyroid veins

Lingual vein: the tip drain into the deep lingual vein, visible on the under surface near the midline run back superficial to the hypoglossus and is joined by the sublingual vein from the gland to form vena comtians join the internal jugular near the greater horn of the hyoid bone

Veins of the Head and neck Superior thyroid vein: leaves the superior pole of the thyroid gland and empty in the facial or the internal jugular Middle thyroid vein: short and wide, pass from the middle of the pole directly into the internal jugular Occipital vein: join the internal jugular but more often join the vertebral or the posterior auricular

Anterior jugular vein: start below the chin, pass beneath the platysma to the suprasternal notch. Pierce the deep fascia and is connected to the other side by an anastomosing vein the jugular arch angle laterally to pass deep to sternocleidomastoid and open in the external jugular vein

External jugular vein: Begins behind the angle of the mandible by the union of the posterior auricular and posterior division of the retromandibular veins. It descend obliquely, deep to the platysma, receive the posterior external jugular vein pierce the deep fascia just above the clavicle and drain into the subclavian vein

Veins of the Head and neck Tributaries: Posterior auricular vein posterior division of retro mandibular vein Posterior exernal jugular vein transverse cervical vein suprascapular vein anterior jugular vein

External Jugular Vein The external jugular vein is formed behind the angle of the jaw by the union of the posterior auricular vein with the posterior division of the retromandibular vein It descends across the sternocleidomastoid muscle and beneath the platysma muscle It drains into the subclavian vein behind the middle of the clavicle

Anterior Jugular Vein The anterior jugular vein descends in the front of the neck close to the midline Just above the sternum, it is joined to the opposite vein by the jugular arch It joins the external jugular vein deep to the sternocleidomastoid muscle

Internal Jugular Vein The internal jugular vein is a large vein that receives blood from the brain, face, and neck It starts as a continuation of the sigmoid sinus and leaves the skull through the jugular foramen

Internal Jugular Vein It then descends through the neck in the carotid sheath lateral to the vagus nerve and the internal and common carotid arteries It ends by joining the subclavian vein behind the medial end of the clavicle to form the brachiocephalic vein

Internal Jugular Vein Throughout its course, it is closely related to the deep cervical lymph nodes The vein has a dilatation at its upper end called the superior bulb and another near its termination called the inferior bulb Directly above the inferior bulb is a bicuspid valve

Tributaries of Internal Jugular Vein Inferior petrosal sinus Facial vein Pharyngeal veins Lingual vein Superior thyroid vein Middle thyroid vein