Blood Supply to the Head and Neck

• Most arteries in the anterior cervical triangle arise from the common carotid artery or one of the branches of the external carotid artery.
• Most veins in the anterior cervical triangle are tributaries of the large internal jugular vein.

The Common Carotid Arteries

• The right common carotid artery begins at the bifurcation of the brachiocephalic trunk, posterior to the right sternoclavicular joint.
• The left common carotid artery begins arises from the arch of the aorta and ascends into the neck, posterior to the left sternoclavicular joint.

• Each common carotid artery ascends into the neck within the carotid sheath to the level of the superior border of the thyroid cartilage.
• Here it terminates by dividing into the internal and external carotid arteries. 

The Internal Carotid Artery

• This is the direct continuation of the common carotid artery and it has no branches in the neck.
• It supplies structures inside the skull.
• The internal carotid arteries are two of the four main arteries that supply blood to the brain.

• Each artery arises from the common carotid at the level of the superior border of the thyroid cartilage.
• It then passes superiorly, almost in a vertical plane, to enter the carotid canal in the petrous part of the temporal bone.

• A plexus of sympathetic fibres accompany it.

• During its course through the neck, the internal carotid artery lies on the longus capitis muscle and the sympathetic trunk.
• The vagus nerve (CN X) lies posterolateral to it.

• The internal carotid artery enters the middle cranial fossa beside the dorsum sellae of the sphenoid bone.
• Within the cranial cavity, the internal carotid artery and its branches supply the hypophysis cerebri (pituitary gland), the orbit, and most of the supratentorial part of the brain. 

The External Carotid Arteries 

• This vessel begins at the bifurcation of the common carotid, at the level of the superior border of the thyroid cartilage.
• It supplies structures external to the skull.

• The external carotid artery runs posterosuperiorly to the region between the neck of the mandible and the lobule of the auricle.
• It terminates by dividing into two branches, the maxillary and superficial temporal arteries.
• The stems of most of the six branches of the external carotid artery are in the carotid triangle. 

The Superior Thyroid Artery

• This is the most inferior of the 3 anterior branches of the external carotid.
• It arises close to the origin of the vessel, just inferior to the greater horn of the hyoid.
• The superior thyroid artery runs anteroinferiorly, deep to the infrahyoid muscles and gives off the superior laryngeal artery. This artery pierces the thyrohyoid membrane in company with the internal laryngeal nerve and supplies the larynx.

The Lingual Artery

• This arises from the external carotid artery as it lies on the middle constrictor muscle of the pharynx.
• It arches superoanteriorly, about 5 mm superior to the tip of the greater horn of the hyoid bone, and then passes deep to the hypoglossal nerve, the stylohyoid muscle, and the posterior belly of digastric muscle.

• It disappears deep to the hyoglossus muscle.
• At the anterior border of this muscle, it turns superiorly and ends by becoming the deep lingual artery.

The Facial Artery

• This arises from the carotid artery either, in common with the lingual artery, or immediately superior to it.
• In the neck the facial artery gives off its important tonsillar branch and branches to the palate and submandibular gland.
• The facial artery then passes superiorly under the cover of the digastric and stylohyoid muscles and the angle of the mandible.

• It loops anteriorly and enters a deep groove in the submandibular gland.

• The facial artery hooks around the inferior border of the mandible and enters the face. Here the pulsation of this artery can be felt (anterior to the masseter muscle).

The Ascending Pharyngeal Artery

• This is the 1^st or 2^nd branch of the external carotid artery.
• This small vessel ascends on the pharynx, deep to the internal carotid artery.
• It sends branches to the pharynx, prevertebral muscles, middle ear and meninges.

The Occipital Artery

• This arises from the posterior surface of the external carotid near the level of the facial artery.
• It passes posteriorly along the inferior border of the posterior belly of digastric.
• It ends in the posterior part of the scalp.
• During its course, it is superficial to the internal carotid artery and three cranial nerves (CN IX, CN X and CN XI).

The Posterior Auricular Artery

• This is a small posterior branch of the external carotid artery.
• It arises from it at the superior border of the posterior belly of the digastric muscle.
• It ascends posteriorly to the external acoustic meatus and supplies adjacent muscles, the parotid gland, the facial nerve, structures in the temporal bone, the auricle, and the scalp. 

The Internal Jugular Vein

• This is usually the largest vein in the neck.
• The internal jugular vein drains blood from the brain and superficial parts of the face and neck.
• Its course corresponds to a line drawn from a point immediately inferior to the external acoustic meatus to the medial end of the clavicle.

• This large vein commences at the jugular foramen in the posterior cranial fossa, as the direct continuation of the sigmoid sinus.

• The dilation at its origin is called the superior bulb of the internal jugular vein.
• From here it runs inferiorly through the neck in the carotid sheath.

• The internal jugular vein leaves the anterior triangle of the neck by passing deep to the SCM muscle.
• Posterior to the sternal end of the clavicle, it unites with the subclavian vein to form the brachiocephalic vein.
• Near its termination is the inferior bulb of the jugular vein contains a bicuspid valve similar to that of the subclavian vein.

• The deep cervical lymph nodes lie along the course of the internal jugular vein, mostly lateral and posterior.

Tributaries of the Internal Jugular Vein

• This large vein is joined at its origin by the: inferior petrosal sinus, the facial, lingual, pharyngeal, superior and middle thyroid veins, and often the occipital vein.

The Layers of the Pharyngeal Wall

• The pharyngeal wall is composed of 5 layers. From internal to external, they are as follows.

• Mucous membrane: this lines the pharynx and is continuous with all chambers with which it communicates.

• Submucosa

• Pharyngobasilar fascia: this is a fibrous layer that is attached to the skull.

• Muscular layer: this is composed of inner longitudinal and outer circular parts.

• Buccopharyngeal fascia: this is a loose connective tissue layer.
• This fascia is continuous with the fascia covering the buccinator and pharyngeal muscle.
• It contains the pharyngeal plexus of nerves and veins.

The Temporomandibular Joint

• This articulation is a modified hinge type of synovial joint.
• The articular surfaces are: (1) the head or condyle of the mandible inferiorly and (2) the articular tubercle and the mandibular fossa of the squamous part of the temporal bone.

• An oval fibrocartilaginous articular disc divides the joint cavity into superior and inferior compartments. The disc is fused to the articular capsule surrounding the joint.

• The articular disc is more firmly bound to the mandible than to the temporal bone.

• Thus, when the head of the mandible slides anterior on the articular tubercle as the mouth is opened, the articular disc slides anteriorly against the posterior surface of the articular tubercle

The Submandibular Glands

• Each of these U-shaped salivary glands is about the size of a thumb and lies along the body of the mandible.
• It is partly superior and partly inferior to the posterior 1/2 of the base of the mandible.
• It is partly superficial and partly deep to the mylohyoid muscle.

• The submandibular duct arises from the portion of the gland that lies between the mylohyoid and hyoglossus muscle.

• The duct passes deep and then superficial to the lingual nerve.
• It opens by one to three orifices on a small sublingual papilla beside the lingual frenulum.

• The submandibular gland is supplied by parasympathetic, secretomotor fibres from the submandibular ganglion (preganglionic fibres from the chorda tympani via the lingual nerve).

Intrinsic muscles

    all innervated by recurrent laryngeal nerve except cricothyroid: external laryngeal nerve
    adductors of vocal folds: bring folds together at midline

    Transverse and oblique arytenoids: pull arytenoids together
    Lateral cricoartenoids: spin and slide arytenoids up
    only one abductor of vocal folds
    
    Posterior cricoarytenoids—down and up
    adjustors of shape and tension of vocal folds

    Cricothyroid muscle
    
o    superficial to lateral cricoarytenoid
o    tenses vocal folds by tilting thyroid cartilage forward and sliding forward

    Thyroartenoid and vocalis muscles
    
o    vocalis: sometimes treated as medial most fibers of thyroartenoid muscle
o    different fiber directions
    
    lateral: adduct
    medial: change shape of folds
    control voice by bring bringing together different parts of folds

o    as move from epithelium to vocalis muscle, fold becomes stiffer
o    near connections, vocal folds are stiffer
o    vocal fold: complex, multilayered vibrator

The Laryngopharynx

• The laryngeal part of the pharynx lies posterior to the larynx.
• It extends from the superior border of the epiglottis to the inferior border of the cricoid cartilage, where it narrows to become continuous with the oesophagus.

• Posteriorly, the laryngopharynx is related to the bodies of C4 to C6 vertebrae.

• Its posterior and lateral walls are formed by the middle and inferior constrictor muscles, with the palatopharyngeus and stylopharyngeus internally.

• The laryngopharynx communicates with the larynx through the aditus or inlet of the larynx.
• The piriform recess is a small, pear-shaped depression of the laryngopharyngeal cavity on each side of the inlet of the larynx.