Adobe Systems Clinical anatomy of head and neck vessels. Lymphatic drainage Adobe Systems Zápatí prezentace 2 COMMON CAROTID ARTERY •main artery of head •supplies most of the head and neck •most often branch of brachiocephalic trunk (right) and aortic arch (left) •without branches usually Adobe Systems Zápatí prezentace 3 The carotid bifurcation → side predilection of an atherosclerosis - hypertension and small injuries of the vessel wall lead to plaque formation - plaque is made of fat, cholesterol, calcium, and other fibrous material - plaque deposits inside the inner wall of the artery can form a large mass that narrows the lumen (inside diameter of the artery) - - plaque blocks blood flow to the brain and can lead to brain ischemia Adobe Systems Zápatí prezentace 4 CAROTIC ENDARTERECTOMY Carotid endarterectomy - surgical procedure atherosclerotic plaque is removed from the bifurcation of the common carotid artery - plaque is removed from the artery from a longitudinal arrteriotomy (longitudinal incision of the artery) - - 20-30% of ischemic strokes are caused by carotid stenosis - using endarterectomy we reduce the risk the ischemia Obsah obrázku šipka Popis byl vytvořen automaticky Obsah obrázku text Popis byl vytvořen automaticky Adobe Systems Zápatí prezentace 5 INTERNAL CAROTID ARTERY The internal carotid artery (ICA) is one of the two terminal branches of the common carotid artery which supplies the intracranial structures In most cases, the carotid bifurcation occurs between the levels of the C3 and C5 vertebrae Adobe Systems Zápatí prezentace 6 Segments of the internal carotid artery Several classification systems describing the internal carotid artery segemnts have been described The most commonly used classification was described by Bouthillier Obsah obrázku vektorová grafika Popis byl vytvořen automaticky Adobe Systems Zápatí prezentace 7 Bouthillier classification There are seven segments in the Bouthillier classification: C7 (communicating segment) •Anterior choroidal artery •Posterior communicating artery C6 (ophthalmic segment) •Ophthalmic artery •Superior hypophyseal artery C5 (clinoid segment) •without branches C4 (cavernous segment) •Meningohypophyseal trunk (MHT) •Inferolateral trunk (ILT) •Capsular arteries C3 (lacerum segment) •without branches •(or artery of pterygoid canal) C2 (petrosus segment) •Caroticotympanic arteries •Artery of pterygoid canal C1 (cervical segment) •without branches • intradural extradural ICA branches terminally to…. Adobe Systems Zápatí prezentace 8 Central Retinal Artery Obsah obrázku text, bezobratlí, ostnokožci Popis byl vytvořen automaticky - branches off the ophthalmic artery runs in the center of the optic nerve with the central vein of the retina - enters the globe and divides into four branches to supply each quadrant of the globe Adobe Systems Zápatí prezentace 9 RETINAL ARTERY OCCLUSION Occlusion of the central retinal artery – leads to retinal ischemia - an acute condition that often leads to severe visual impairment or blindness and can predict further cerebrovascular events Adobe Systems Zápatí prezentace 10 VERTEBRAL ARTERY Cervical branches Spinal branches Muscular branches Meningeal branches Cranial branches Basilar artery Posterior cerebral arteries - arises from the subclavian artery - ascends in the transverse foramina of the cervical vertebrae - enters the transverse foramen of the sixth cervical vertebra - the two vertebral arteries join to form the basilar artery at the base of the pons Adobe Systems Zápatí prezentace 11 - posterior inferior cerebellar artery (PICA) originates from the vertebral artery - supplies to the cerebellum - AICA and SCA - brachnes from the basilar artery Adobe Systems Zápatí prezentace 12 CIRCULUS ARTERIOSUS CEREBRI WILLISI (Circle of Willis) The circle of Willis consists of an arterial network located at the skull base allowing arterial blood flow exchange between the anterior and the posterior circulation and between the right and left hemispheres Adobe Systems Zápatí prezentace 13 CIRCULUS ARTERIOSUS CEREBRI WILLISI (Circle of Willis) The circle of Willis is composed of the following arteries: Anterior cerebral artery (left and right) Anterior communicating artery Internal carotid artery (left and right) Middle cerebral arteries Posterior communicating artery (left and right) Adobe Systems Zápatí prezentace 14 ARTERIAL SUPPLY OF THE BRAIN Anterior 2/3 → internal carotid artery Posterior 1/3 → vertebral artery Obsah obrázku mapa Popis byl vytvořen automaticky Adobe Systems Zápatí prezentace 15 CT of the brain from a patient with internal carotid artery ischemia Adobe Systems Zápatí prezentace 16 ANEURYSMS IN THE CIRCLE OF WILLIS Intracranial aneurysms are weak pouches in the walls of brain arteries - most often located on the arteries of the circle of Wilis - - rupture of intracranial aneurysms causes subarachnoid haemorrhage, a type of stroke with a high mortality raty (around 50% of patients die) the most common localization of aneurysms is the branching of the arteries - in these places there is the greatest stress on the vessel wall Adobe Systems Zápatí prezentace 17 Subclavian steal syndrome Subclavian steal syndrome result from severe proximal subclavian artery stenosis or occlusion resulting in retrograde flow in the ipsilateral vertebral artery stenosis of the subclavian artery, proximal to the origin of the vertebral artery altered flow on the side of the stenosis - leads to lower blood supply to the brainstem and cerebellum - -dizziness/vertigo/syncope -ataxia -visual changes -dysarthria (difficulty speaking because the muscles you use for speech are weak) Adobe Systems Zápatí prezentace 18 EXTERNAL CAROTID ARTERY External carotid aretry is one of the two terminal branches of the common carotid artery that has many branches that supplies the structures of the neck, face and head Ventral branches Superior thyroid artery Lingual artery Facial artery Medial branches Ascending pharyngeal artery Dorsal branches Occipital artery Posterior auricular artery Terminal branches Maxillary artery Superficial temporal artery Adobe Systems Zápatí prezentace 19 SUPERIOR THYROID ARTERY •Superior laryngeal artery •Cricothyroid artery •Infrahyoid branch •Sternocleidomastoid branch •Glandular branches (anterior, lateral and posterior) - the first of the branches of the external carotid artery - leaves immediately after dividing of the common carotid artery to internal and external carotid arteries - supplies the thyroid gland along with the muscles and mucous membrane of the larynx Adobe Systems Zápatí prezentace 20 LINGUAL ARTERY •Suprahyoid branch •Sublingual artery •Dorsal lingual branches •Deep lingual artery - arises cranially from the large corners of the hyoid bone (where it can be found in the so- called Beclard's angle or Pirogow's triangle) - participates in the supply of the tongue and the lower part of the oral cavity Adobe Systems Zápatí prezentace 21 Deep lingual artery Deep lingual vein Lingual nerve Adobe Systems Zápatí prezentace 22 The lingual artery ligation The lingual artery may be ligated extraorally in two of the large triangles of the anterior neck 1.The Béclard´s angle •caudal: the greater horne of the hyoid bone •cranial: the posterior belly of the digastric muscle 2. The Pirogov triangle •the posterior border of the mylohyoid muscle •the intermediate tendon of the digastric muscle •hypoglossal nerve • Adobe Systems Zápatí prezentace 23 FACIAL ARTERY - branching from external carotid artery - - runs over the edge of the mandible in a winding course through the face around the corner of the mouth, nose to the corner of the eye - - facial artery is palpable against the bony surface of the mandible - can be compressed at this point Adobe Systems Zápatí prezentace 24 FACIAL ARTERY •Ascending palatine artery •Submental artery •Tonsillar branch •Glandular branches •Superior and inferior labial artery •Lateral nasal branch •Angular artery - ascending palatine artery supplies the palate with palatine tonsil and part of the pharynx, upper and lower lips Adobe Systems Zápatí prezentace 25 FACIAL ARTERY Due to the abundant vascular supply of the face, injuries in the face usually bleed profusely even though the injury is not serious rich network of blood vessels compression of the facial artery against the bony surface of the mandible Adobe Systems Zápatí prezentace 26 POSTERIOR AURICULAR ARTERY dorsal branch of the external carotid artery - travels to the region posterior to the ear. - supplies the auricle, the adjacent part of the soft skull, cellulae mastoideae and part of the parotid gland •Muscular branches •Glandular branches •Auricular branch •Stylomastoid artery -Posterior tympanic artery -Mastoid branches -Stapedial branch •Occipital branch Adobe Systems Zápatí prezentace 27 OCCIPITAL ARTERY •Sternocleidomastoid branch •Auricular branch •Mastoid (meningeal) branch •Occipital branches - runs behind the posterior belly of the digastric muscle - supplies the sternocleidomastoid, digastric and cervical muscles, skull in the occipital region, the auricle and the dura mater in the posterior cranial fossa. Adobe Systems Zápatí prezentace 28 ASCENDING PHARYNGEAL ARTERY •Pharyngeal branches •Posterior meningeal artery •Inferior tympanic artery - the only medial branch of the external carotid artery - the smallest branch of the external carotid artery - runs cranially along the pharynx to the base of the skull - supplies the dura mater in the posterior fossa of the skull and inner ear Adobe Systems Zápatí prezentace 29 ASCENDING PHARYNGEAL ARTERY - theoretically, it is possible to injure the internal carotid artery and the ascending pharyngeal artery during tonsilectomy (removal of the palatine tonsils) Adobe Systems Zápatí prezentace 30 SUPERFICIAL TEMPORAL ARTERY •Parotid branches •Transverse facial artery •Anterior auricular branches •Zygomatico-orbital artery •Middle temporal artery •Frontal branch •Parietal branch - represents the final branch of the external carotid artery - rises in the cranial direction, covered by the parotid gland - passes over the the zygomatic arch in front of the auricle - branches in the temporal area and supplies the parotid gland, the anterior part of the auricle and temporalis muscle Adobe Systems Zápatí prezentace 31 MAXILLARY ARTERY 1.MANDIBULAR PORTION (the area behind the neck of the mandible) 2.PTERYGOID PORTION (between the medial and lateral pterygoid muscles in the infratemporal fossa) 3.PTERYGOPALATINE PORTION (in the pterygopalatine fossa) The largest branch of the external carotid artery Adobe Systems Zápatí prezentace 32 MAXILLARY ARTERY MANDIBULAR PORTION The most important branches of this portion are: middle meningeal artery - passing through the foramen spinosum, runs in the epidural space and supplies the dura mater of the middle cranial fossa inferior alveolar artery - runs in the canalis mandibulae and gives off branches for the teeth of the lower jaw, skin and muscles in the chin area Adobe Systems Zápatí prezentace 33 MAXILLARY ARTERY MANDIBULAR PORTION Inferior alveolar artery - enters through the mandibular foramen into the mandibular canal of the lower jaw, which leaves through the mental foramen - supplies the teeth, bone and gum of the lower jaw Adobe Systems Zápatí prezentace 34 MAXILLARY ARTERY PTERYGOID PORTION - gives off branches for the masticatory muscles – masseteric artery and buccal/buccinator artery (buccinator muscle), a branch for the temporomandibular joint and temporalis muscle – deep temporal arteries Adobe Systems Zápatí prezentace 35 MAXILLARY ARTERY PTERYGOPALATINE PORTION - gives off posterior superior alveolar artery and infraorbital artery to supply the upper jaw, descending palatine artery with final branches of greater palatine artery, lesser palatine arteries, artery of the pterygoid canal (or Vidian artery) and sphenopalatine artery, supplying the mucous membrane of the nasal cavity Adobe Systems Zápatí prezentace 36 descending palatine artery - the main artery of the hard and soft palate, branch from the maxillary aretry its branches: greater palatine artery (greater palatine foramen), lesser palatine arteries (lesser palatine foramina) - branches from the pharyngeal ascending artery (external carotid artery) and from the ascending palatine artery (facial artery) also reach the edge of the soft palate sphenopalatine artery - incisive foramen Adobe Systems Zápatí prezentace 37 Bleeding from blood vessels in the area of ​​the nasal mucosa (epistaxis) -most often, bleeding from the Kiesselbachi locus – vascular plexus on the septum - damage to these vessels occurs during strong blowing - Treatment: insertion of tampons into the nose and pressing on the wings of the nose - the bleeding then slowly stops do not tilt the head - the blood should not flow into the neck Obsah obrázku text Popis byl vytvořen automaticky Adobe Systems Zápatí prezentace 38 VENOUS DRAINAGE OF THE HEAD AND NECK 1.Cerebral veins 2.Meningeal veins 3.Dural venous sinuses 4.Diploic veins 5.Veins of labyrinth 6.Emissary veins 7.Retromandibular vein •Superficial temporal vein •Middle temporal vein •Transvers facial vein •Maxillary veins 8. Ophthalmic veins 9. Pharyngeal veins 10. Facial vein 11. Lingual vein •Sublingual vein •Vena comitans nervi hypoglossi 12. Superior thyroid vein 13. Middle thyroid vein 14. External jugular vein venous drainage is abundant Adobe Systems Zápatí prezentace 39 - superior ophthalmic vein flows into the cavernous sinus – drains venous blood from the brain - through the eye vein, it also has a connection with the blood flowing from the facial area some purulent infections in the face (e.g. cheilitis - inflammatory changes in the lips area, furuncle - skin abscess) can spread through this connection to thee cavernous sines and cause serious intracranial infections Adobe Systems Zápatí prezentace 40 Cavernous sinus thrombosis -usually a late complication of an infection of the face or paranasal sinuses. - thrombosis of the cavernous sinus — severe pain behind the eye and in the eye - bleeding (hemorrhage) into the conjunctiva which may protrude the eye - hemorrhage on the fundus of the eye - blindness - loss of consciousness, intracranial hypertension, bleeding... Adobe Systems Zápatí prezentace 41 - connections between the intracranial venous system and the veins in the face - bacterial infection in the area of ​​the face or oral cavity can spread to the brain Adobe Systems Zápatí prezentace 42 PTERYGOID PLEXUS Venous plexus in the nfratemporal fossa - between pterygoid mscles and temporalis muscle - collects blood from the deep areas of the face, masticatory muscles, alveoli of both jaws from the area supplied by the maxillary artery and the orbit - blood flows into retromandibular vein – facial vein – internal jugular vein Adobe Systems Zápatí prezentace 43 INTERNAL JUGULAR VEIN - the main vein of the neck - has an 8-16 mm wide trunk in the cervical neurovascular bundle - runs under the sternocleidomastoid muscle laterally from the internal carotid artery and the common carotid artery - opens into the brachiocephalic vein - collects blood from a large part of the head and neck, including the brain and meninges Adobe Systems Zápatí prezentace 44 LYMFATIC SYSTEM - OVERVIEW - the lymphatic system is a one-way system of the human body, leading from the intercellular spaces to the blood through lymphatic vessels - the lymphatic system consists of lymphatic vessels and highly specialized lymphoid organs and tissues, primarily the thymus, spleen, and tonsils Adobe Systems Zápatí prezentace 45 Lymphatic vessels Lymphatic capillaries form anastomosing networks - the walls of the lymphatic capillaries are very thin and highly permeable - large molecules and particles including bacteria that cannot enter the blood capillaries are carried away by the lymph Adobe Systems Zápatí prezentace 46 Lymph node A lymph node is a spherical or oval-shaped organ - it is found in the circulation of lymphatic vessels and serves as a biological filter of lymph - they play an essential role in the body's defense against microbes and tumor cells (sentinel node - the first lymph node to which cancer spreads) Adobe Systems Zápatí prezentace 47 Lymph nodes of the head and neck The lymphatic system of the head and neck is very rich, therefore the spread of inflammation or tumor occurs very quickly - the lymphatic system of the head and neck is divided into superficial and deep Adobe Systems Zápatí prezentace 48 The lymphatic system of the head and neck - drains lymph from the skin and subcutaneous tissue of the head and neck Includes: occipital nodes - in the occipital region, when enlarged, they can become very painful, as they are close to the occipital nerve mastoid nodes - behind the auricle, posterior side of the auricle superficial and deep parotide nodes - lymph flows from the upper molar, parotid gland nodi lymfatici submentales - lymph flows from the lower lip, tip of the tongue, stored under the chin, lymph travels to the submandibular nodes and deep neck nodes submandibular nodes - lymph flows from the upper lip, lower lip, cheek, teeth, side of the tongue, palate, glandula submandibularis, external nose superficial cervical nodes - lymph flows from the skin and subcutaneous tissue of the neck deep cervical nodes - lymph flows from the teeth, tip of the tongue, root of the tongue, palatine tonsils, glandula sublingualis, glandula thyroidea, sinus maxillaris, larynx (between the muscles, blood vessels, esophagus, trachea and larynx in the neck Adobe Systems Zápatí prezentace 49 Enlargement of lymph nodes Enlarged lymph nodes can occur as a response to inflammation in the mouth and throat in young children they can also become enlarged during teething or in adults when wisdom teeth grow - If a foreign substance enters the body, white blood cells begin to multiply in the nearest lymph nodes, - the lymph nodes swell, cannot squeeze into their tight shell and become painful Common sources of cervical lymphadenitis (enlargement of neck nodes) are odontogenic processes (dental caries, gingivitis - nflammation of the gums, pulpitis-inflammation of the dental pulp) and infections of the soft tissues of the head and face (herpes labialis, insect bites, piercings, acne), angina - acute tonsillitis, nasopharyngitis etc… Adobe Systems Zápatí prezentace 50 Locally, we find swollen nodes, sensitive to palpation, the skin above the nodes is sometimes inflamed and looks red Adobe Systems Zápatí prezentace 51 References: HOMBACH-KLONISCH, S., T. 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