Blood supply of head and neck

-Two arterial tracts supply blood to the head and neck: (1) the carotid system and (2) the subclavian system. The
carotid system delivers blood to the upper neck and the head. The subclavian system provides blood to the lower
neck, deep neck, inside of the cranium, shoulder, upper limb, and thorax.

-The veins of the head and neck are organized in two groups: intracranial veins inside the cranium and extracranial
veins outside the skull.

Carotid System
The carotid system begins with the paired common carotid arteries, each of which has a different origin in the root
of the neck or the chest.

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 the aorta in the superior mediastinum. The common carotid artery runs upward
through the neck within the carotid sheath (closely related to the internal jugular vein and vagus nerve), under cover
of the anterior border of the sternocleidomastoid muscle, from the SC joint to the upper border of the thyroid
cartilage. Here (in the carotid triangle of the neck), it divides into the external and internal carotid arteries. The
common carotid has no branches, except its two terminal branches.

Common Carotid Artery Relations

Anterolaterally: Skin, fascia, the SCM muscle, sternohyoid,

sternothyroid, superior belly of the omohyoid

Posteriorly: Transverse processes of the lower 4 cervical

vertebrae, the prevertebral muscles, and the sympathetic
trunk vertebral vessels in the lower part of the neck

Medially: The larynx and pharynx and, below these, the

trachea and esophagus, lobe of the thyroid gland also lies
medially

Laterally: Internal jugular vein and, posterolaterally, the

vagus nerve
Carotid Sinus At its point of division, the terminal part of the common carotid artery (or the beginning of the
internal carotid artery or the terminal common carotid plus the origin of the internal carotid) shows a localized
dilation, called the carotid sinus. The wall of the sinus is relatively thin because its tunica media is thinner than
elsewhere. However, the adventitia is relatively thick and contains numerous nerve endings derived from the
glossopharyngeal nerve. The carotid sinus serves as a reflex pressoreceptor (baroreceptor) mechanism: a rise in
blood pressure causes a slowing of the heart rate and vasodilation of the arterioles.
Carotid Body
The carotid body is a small structure that lies posterior to the point of bifurcation of the common carotid artery or in
the angle of the bifurcation. It is innervated by the glossopharyngeal nerve (and possibly supplemented by the vagus
nerve). The carotid body is a chemoreceptor, being sensitive to excess carbon dioxide and reduced oxygen tension in
the blood. Such a stimulus reflexly produces a rise in blood pressure and heart rate and an increase in respiratory
movements. Carotid Sinus Hypersensitivity In cases of carotid sinus HRS, external pressure on one or both carotid sinuses
can cause excessive slowing of the HR, a fall in blood pressure, and cerebral ischemia with fainting (syncope).

Taking the Carotid Pulse The bifurcation of the common carotid artery into the internal and external carotid
arteries can be easily palpated just beneath the anterior border of the sternocleidomastoid muscle at the level of
the superior border of the thyroid cartilage. This is a convenient site to take the carotid pulse (neck pulse).

1-External Carotid Artery

is one of the terminal branches of the common carotid artery It supplies structures in the neck, face, and scalp; it
also supplies the tongue and the maxilla. The artery begins at the level of the upper border of the thyroid cartilage
and terminates in the substance of the parotid gland posterior to the neck of the mandible by dividing into the
superficial temporal and maxillary arteries. Close to its origin, the artery emerges from undercover of the SCM
muscle, where its pulsations can be felt. At first, it lies medial to the internal carotid artery, but as it ascends in the
neck, it passes backward and lateral to it. External Carotid Artery Branches
2-Internal Carotid Artery
begins at the bifurcation of the common carotid artery at the level of the upper border of the thyroid cartilage. It
supplies the brain, the eye, the forehead, and part of the nose. The artery ascends in the neck embedded in the
carotid sheath with the internal jugular vein and vagus nerve. At first, it lies superficially; it then passes deep to the
parotid salivary gland, The internal carotid artery leaves the neck by passing into the cranial cavity through the
carotid canal in the petrous part of the temporal bone. It then passes upward and forward in the cavernous venous
sinus (without communicating with it). The artery then leaves the sinus and passes upward again medial to the
anterior clinoid process of the sphenoid bone. The internal carotid artery then inclines backward, lateral to the optic
chiasma, and terminates by dividing into the anterior and the middle cerebral arteries.

Internal Carotid Artery Arteriosclerosis Internal Carotid Artery Neck Relations

Extensive arteriosclerosis of the internal carotid artery in Anterolaterally:
the neck can cause visual impairment or blindness in the
eye on the side of the lesion because of insufficient blood Posteriorly:
flow through the retinal artery. Motor paralysis and
Medially:
sensory loss may also occur on the opposite side of the
body because of insufficient blood flow through the middle Laterally:
cerebral artery.

Internal Carotid Artery Branches

Although branches do not exist in the neck, many important branches are given off in the cranial cavity.
circle of Willis
 Subclavian System
The subclavian system consists of the paired subclavian arteries and their branches. As with the common carotid
arteries, the subclavian arteries have different origins on the right and left sides
Subclavian Artery
The right subclavian artery arises from the brachiocephalic artery, behind the right sternoclavicular joint It arches
upward and laterally over the pleura and through the interscalene triangle between the scalenus anterior and
medius muscles. At the outer border of the first rib, it becomes the axillary artery. The left subclavian artery arises
from the arch of the aorta in the thorax. It ascends to the root of the neck and then arches laterally in a manner
similar to that of the right subclavian artery. The scalenus anterior muscle passes anterior to the artery on each side
and divides it into three parts.

First Part of the Subclavian Artery

extends from the origin of the subclavian artery to the medial border of the scalenus anterior muscle This part gives
off the vertebral artery, the thyrocervical trunk, and the internal thoracic artery.

Palpation and Compression of the Subclavian Artery in Patients with Upper Limb Hemorrhage In
severe traumatic accidents to the upper limb involving laceration of the brachial or axillary
arteries, it is imp to remember that exerting strong pressure downward and backward on the 3rd
part of the subclavian artery can stop the hemorrhage. The use of a blunt object to exert the
pressure is of great help, and the artery is compressed against the upper surface of the 1st rib.
HEAD AND NECK VEINS
The veins of the head and neck are organized in two groups: intracranial veins inside the cranium and extracranial
veins outside the skull.

1-Intracranial Veins These are the veins of the brain, dural venous sinuses, diploic veins, and emissary veins.

Brain Veins

Dural Venous Sinuses

Diploic Veins

Emissary Veins

2-Extracranial Veins
These are the veins of the scalp, face, and neck.

Facial Vein

Superficial Temporal Vein

Maxillary Vein

Retromandibular 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 deep to the
platysma muscle and drains into the subclavian vein behind the middle of the clavicle. Tributaries
Posterior external jugular vein
Transverse cervical vein
Suprascapular vein
Anterior jugular vein

---Internal Jugular Vein

is a large vein that receives blood from the brain, scalp, face, and neck. It starts as a continuation of the sigmoid
sinus and leaves the skull through the jugular foramen. 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. Throughout its course, it is closely related to
the deep cervical lymph nodes. The vein has a dilation at its upper end called the superior bulb and another near its
termination called the inferior bulb. A bicuspid valve is situated directly above the inferior bulb. Relations:

Tributaries:
Inferior petrosal sinus
Facial vein
Pharyngeal veins
Lingual vein
Superior thyroid vein
Middle thyroid vein
Subclavian Vein
The subclavian vein is a continuation of the axillary vein at the outer border of the first rib (see Fig. 12.54). It joins
the internal jugular vein to form the brachiocephalic vein, and it receives the external jugular vein. In addition, it
often receives the thoracic duct on the left side and the right lymphatic duct on the right. Relations:
Anteriorly: Clavicle
Posteriorly: Scalenus anterior muscle and the phrenic nerve
Inferiorly: Upper surface of the first rib
Clinical Notes
Internal Jugular Vein Penetrating Wounds
The hemorrhage of low-pressure venous blood into the loose connective tissue beneath the investing layer of deep
cervical fascia may present as a large, slowly expanding hematoma. Air embolism is a serious complication of a
lacerated wall of the internal jugular vein. Because the wall of this large vein contains little smooth muscle, its injury
is not followed by contraction and retraction (as occurs with arterial injuries). Moreover, the adventitia of the vein
wall is attached to the deep fascia of the carotid sheath, which hinders the collapse of the vein. Blind clamping of the
vein is prohibited because the vagus and hypoglossal nerves are in the vicinity.

1-Internal Jugular Vein Catheterization

The internal jugular vein is remarkably constant in position. It descends through the neck from a point halfway
between the tip of the mastoid process and the angle of the jaw to the sternoclavicular joint. Above, the anterior
border of the sternocleidomastoid muscle overlaps it, and below, this muscle covers it laterally. Just above the
sternoclavicular joint, the vein lies beneath a skin depression (the lesser supraclavicular fossa) between the sternal
and clavicular heads of the sternocleidomastoid muscle and the clavicle. In the posterior approach, the tip of the
needle and the catheter are introduced into the vein about two fingerbreadths above the clavicle at the posterior
border of the sternocleidomastoid muscle (Fig. 12.58). In the anterior approach, with the patient’s head turned to
the opposite side, the lesser supraclavicular fossa is identified. A shallow skin depression usually overlies the triangle.
The needle and catheter are inserted into the vein at the apex of the triangle in a caudal direction.
Subclavian Vein Thrombosis
Spontaneous thrombosis of the subclavian and/or axillary veins occasionally occurs after excessive and
unaccustomed use of the arm at the shoulder joint. The close relationship of these veins to the first rib and the
clavicle and the possibility of repeated minor trauma from these structures are probably factors in its development.
Secondary thrombosis of subclavian and/or axillary veins is a common complication of an indwelling venous
catheter. Rarely, the condition may follow a radical mastectomy with a block dissection of the lymph nodes of the
axilla. Persistent pain, heaviness, or edema of the upper limb, especially after exercise, is a complication of this
condition.
Anatomy of Subclavian Vein Catheterization
The subclavian vein is located in the lower anterior corner of the posterior triangle of the neck, where it lies
immediately posterior to the medial third of the clavicle.
Anatomy of Problems
--Hitting the clavicle: The needle may be “walked” along the lower surface of the clavicle until its posterior edge is
reached.
--Hitting the first rib: The needle may hit the first rib, if the needle is pointed downward and not upward.
--Hitting the subclavian artery: A pulsatile resistance and bright red blood flow indicate that the needle has passed
posterior to the scalenus anterior muscle and perforated the subclavian artery.
Anatomy of Complications
Pneumothorax
Hemothorax
Subclavian artery puncture
Internal thoracic artery injury
Diaphragmatic paralysis

2-Supraclavicular Approach
Many prefer this approach for the following anatomic reasons:
The site of penetration of the vein wall is larger, because it lies at the junction of the internal jugular vein and the
subclavian vein, which makes the procedure easier. The needle is pointed downward and medially toward the
mediastinum, away from the pleura, avoiding the complication of pneumothorax. The catheter is inserted along a
more direct course into the brachiocephalic vein and superior vena cava.
Anatomic Complications
occur as the result of damage to neighboring anatomic structures:
--Diaphragm paralysis: --Pneumothorax or hemothorax: --Brachial plexus injury: