Surgical anatomy of Veins of Head and Neck

Surgical anatomy of Veins of Head and Neck

1. RAHUL RAGHAVENDER 1 st YEAR POST GRADUATE ORAL & MAXILLOFACIAL SURGERY SURGICAL ANATOMY OF VENOUS DRAINAGE OF THE HEAD AND NECK

2. CONTENTS Introduction Veins of Head Diploic veins D ural venous sinuses Veins of scalp Veins of the Neck Applied anatomy

3. INTRODUCTION :

4. Veins of the Head Anatomically, Venous drainage of the  brain and  meninges : Supplied by the dural venous sinuses . Venous drainage of the  scalp and face : Drained by veins synonymous with the arteries of the face and scalp. These drain into the internal and external jugular veins. Venous drainage of the  neck : Carried out by the anterior jugular veins . 

5. DIPLOIC VEINS

6. DURAL VENOUS SINUSES

7. CAVERNOUS SINUS

8. SUPERFICIAL VEINS OF THE FACE & SCALP

9. VEINS DRAINING THE EXTERIOR OF HEAD & FACE Supratrochlear Supraorbital Superficial Temporal Angular Internal Maxillary Retromandibular Anterior Facial Posterior Auricular Occipital

10. THE SUPRATROCHLEAR VEIN Origin: It begins on the forehead in a venous plexus which communicates with the frontal branches of the superficial temporal vein. Course: The veins converge to form a single trunk, which runs downward near the midline of the forehead, parallel with the vein of the opposite side. The two veins are joined, at the root of the nose, by a transverse branch, called the nasal arch, which receives some small veins from the dorsum of the nose. At the medial angle of the orbit the frontal ( supratrochlear ) vein joins the  supraorbital vein, to form the angular vein.

11. THE SUPRAORBITAL VEIN Origin: It begins on the forehead near the zygomatic process of the frontal bone, where it communicates with the frontal branch of the superficial temporal vein. Course: It runs superficial to the Frontalis muscle, and joins the frontal vein at the medial angle of the orbit to form the angular vein. A branch passes through the supraorbital notch, where it receives veins from the frontal sinus and frontal diploë , and subsequently connects with the superior ophthalmic vein.

12. THE ANGULAR VEIN Formation: It is formed by the junction of the frontal and supraorbital veins. Course: Runs obliquely downward, on the side of the root of the nose, till the lower margin of the orbit, where it becomes the anterior facial vein. It receives the veins of the ala nasi , and communicates with the superior ophthalmic vein through the nasofrontal vein, thus establishing an important anastomosis between the anterior facial vein and the cavernous sinus.

13. THE SUPERFICIAL TEMPORAL VEIN 

14. Origin and Course: It begins on the side and vertex of the skull in a plexus which communicates with the supratrochlear and supraorbital veins, with the corresponding vein of the opposite side, and with the posterior auricular and occipital veins. It crosses the zygomatic arch, enters the parotid gland, and unites with the internal maxillary vein to form the posterior facial vein.

15. Tributaries : The superficial temporal vein receives in its course, Parotid veins Articular veins from the temporomandibular joint Anterior auricular veins from the auricles Transverse facial  from the side of the face Middle temporal vein

16. THE FACIAL VEIN

17. Origin: The  anterior facial vein  commences at the side of the root of the nose, and is a direct continuation of the angular vein. Course : It lies behind facial artery; follows a less tortuous course . It runs obliquely downward and backward, crosses over the body of the mandible, and passes obliquely backward, beneath the Platysma and cervical fascia, superficial to the submandibular gland.

18. Facial Vein Tributaries

19. Just anteroinferior to the mandibular angle it is joined by the anterior division of the retromandibular vein to form the common facial vein . It then descends superficial to the loop of the lingual artery, the hypoglossal nerve and external and internal carotid arteries, to enter the internal jugular vein

20. Tributaries: Near its origin, The superior ophthalmic vein, both directly and via the supraorbital vein (connects to cavernous sinus) Receives tributaries from the side of the nose The deep facial vein connecting it to the pterygoid venous plexus Inferior palpebral vein Superior and Inferior Labial vein Buccinator vein Parotid vein Masseteric vein Below the mandible, Submental vein Palatine vein Para tonsillar vein Submandibular vein Superior and Inferior thyroid veins Vena comitans of the hypoglossal nerve

21. Clinical Significance The facial vein has no valves. any infection of the mouth or face can spread via the angular veins to the cavernous sinuses resulting in thrombosis.   During dissection of the facial artery near the margin of the mandible, dissecting too close to the artery can damage the facial vein. This is of importance when the facial vein is being harvested for venous drainage in facial transplantation. The facial vein lies superficial to the submandibular gland, and is ligated and cut when dissecting out the gland.

22. Buccal , Mental and Infraorbital Veins These veins drain the cheek and chin regions and pass into the pterygoid venous plexus.

23. THE PTERYGOID PLEXUS  It is of considerable size, and is situated between the Temporalis and Lateral Pterygoid . This plexus communicates freely with the anterior facial vein; it also communicates with the cavernous sinus, by branches through the sphenoidal emissary foramen. Tributaries: It receives tributaries corresponding with the branches of the internal maxillary artery. Sphenopalatine Middle meningeal Deep temporal Pterygoid Masseteric Buccinator Alveolar Some palatine veins A branch which communicates with the ophthalmic vein through the inferior orbital fissure

24. Clinical Significance : The pterygoid plexus acts as a conduit for the transmission of infection from the superficial veins of the face to the cavernous sinus, which may cause its thrombosis.

25. THE INTERNAL MAXILLARY VEIN  Origin and Course: It is a short trunk which accompanies the first part of the internal maxillary artery. It is formed by a confluence of the veins of the pterygoid plexus , and unites with the superficial temporal vein to form the posterior facial vein.

26. THE RETROMANDIBULAR VEIN Origin and Course : It is formed by the union of the superficial temporal and internal maxillary veins Descends in the substance of the parotid gland, superficial to the external carotid artery but beneath the facial nerve, between the ramus of the mandible and the Sternocleidomastoid muscle. It divides into two branches; an  anterior,  which passes forward and unites with the anterior facial vein to form the common facial vein; a  posterior,  which is joined by the posterior auricular vein and becomes the external jugular vein.

27. LINGUAL VEIN The lingual veins follow two routes. The dorsal lingual veins drain the dorsum and sides of the tongue, join the lingual veins accompanying the lingual artery and enter the internal jugular near the greater cornua of the hyoid bone. The deep lingual vein begins near the tip of the tongue and runs back, lying near the mucous membrane on the ventral surface of the tongue.

28. Clinical Significance: The deep lingual vein may get injured during lingual frenectomy for ankyloglossia treatment, leading to hematoma formation. The lingual veins and their relations

29. THE POSTERIOR AURICULAR VEIN Origin and Course: It begins upon the side of the head, in a plexus which communicates with the tributaries of the occipital and superficial temporal veins. It descends behind the auricle, and joins the posterior division of the retromandibular vein to form the external jugular. Tributaries: Stylomastoid vein Some tributaries from the cranial surface of the auricle.

30. THE OCCIPITAL VEIN Origin & Course: It begins in a plexus at the posterior part of the vertex of the skull. Occasionally it follows the course of the occipital artery and ends in the internal jugular; or may join the posterior auricular and through it drain into the external jugular.

31. VEINS OF THE NECK Veins in the neck show considerable variation. They are superficial or deep to the deep fascia but are not entirely separate systems. Superficial veins are tributaries of the anterior, external and posterior jugular veins. They drain a much smaller volume of tissue than the deep veins. They drain all but the subcutaneous structures, mostly into the internal jugular vein and also into the subclavian vein.

32. EXTERNAL JUGULAR VEIN The external jugular vein drains the scalp and face and some deeper structures. Formation, Course and Relations: The vein is formed by the union of the posterior division of the retromandibular vein with the posterior auricular vein and begins near the mandibular angle just below or in the parotid gland. It descends from the angle, running obliquely, superficial to the sternocleidomastoid , to the root of the neck. Here it crosses the deep fascia and ends in the subclavian vein, behind the clavicle.

33. Between the entrance into the subclavian vein and a point approximately 4 cm above the clavicle, the vein is often dilated, producing a so-called sinus.

34. Tributaries: In addition to formative tributaries, the external jugular receives, And near its end, Transverse cervical Suprascapular Anterior jugular veins In the parotid gland, a branch from the internal jugular the occipital vein (occasionally)

35. Major tributaries of the external jugular vein, draining the external face and scalp.

36. Clinical Relevance: Severance of the External Jugular Vein: The external jugular vein has a relatively superficial course down the neck, leaving it vulnerable to damage. If it is severed, in an injury such as a knife slash, its lumen is held open – this is due to the thick layer of investing fascia. Air will be drawn into the vein and can stop blood flow through the right atrium. This is a medical emergency, managed by the application of pressure to the wound – stopping the bleeding, and the entry of air. Radical Neck Dissection: The external jugular vein is divided near the upper border of the clavicle when dissection is extended from the trapezius muscle to the suprasternal notch. The external jugular vein is the most commonly used venous pedicle in facial transplant for both, the donor and recipient sites.

37. ANTERIOR JUGULAR VEIN Formation & Course: The anterior jugular veins arise as a pair near the hyoid bone from the confluence of the superficial submandibular veins. They descend between the midline and the anterior border of sternocleidomastoid . In the lower part of the neck, deep to sternocleidomastoid but superficial to the infrahyoid strap muscles, each vein joins either the end of the external jugular or may enter the subclavian vein directly.

38. Image showing the External jugular and Anterior Jugular veins. The latter join near the space of Burns to form the jugular venous arch.

39. It communicates with the internal jugular vein, and receives the laryngeal veins. There are usually two anterior jugular veins, united just above the manubrium , anterior to the trachea, by a large transverse jugular arch (called the jugular venous arch ), receiving the inferior thyroid tributaries. They have no valves and may be replaced by a midline trunk.

40. INTERNAL JUGULAR VEIN The internal jugular vein collects blood from the skull, brain, superficial parts of face and much of the neck. Formation: It begins at the cranial base in the posterior compartment of the jugular foramen, where it is continuous with the sigmoid sinus. It has a superior bulb and an inferior bulb. The superior bulb lies at its origin, below the posterior part of the tympanic floor. The inferior bulb lies near its termination.

41. Course: The internal jugular vein descends in the carotid sheath, and unites with the subclavian vein, posterior to the sternal end of the clavicle, to form the brachiocephalic vein. At the inferior bulb, is a pair of valves.

42. Tributaries: Inferior petrosal sinus, Facial vein Lingual vein Pharyngeal vein Superior and Middle thyroid veins Occipital vein, occasionally The internal jugular vein may communicate with the external jugular vein The thoracic duct opens near the union of the left subclavian and internal jugular veins, and the right lymphatic duct opens at the same site on the right.

43. Clinical Relevance of IJV 1. Jugular Venous Pressure is measured from the Right IJV.   2. Radical Neck Dissection: This involves the removal of lymph nodes level I-V and three non-lymphatic structures- the accessory nerve, the IJV and the sternocleidomastoid muscle.

44. RND The IJV is ligated and cut first at its lower and then at its upper end. This prevents transport of tumour emboli into the bloodstream during manipulation . The IJV is exposed by dividing the fibers of the SCM just above the clavicle . Next, the carotid sheath is opened and the IJV is ligated . In case the vein is damaged during dissection, bleeding is controlled by finger pressure and arterial clamps.

45. The upper end of the SCM is divided near the mastoid process & the upper ends of the accessory nerve and internal jugular vein are divided as high as possible.

46. PHARYNGEAL VEINS The pharyngeal veins begin in a pharyngeal plexus external to the pharynx. Usually end in the internal jugular vein Tributaries : Meningeal veins and a vein from the pterygoid canal.

47. THE THYROID VEINS Superior Thyroid Vein It is formed by tributaries in the upper part of the gland. It accompanies the superior thyroid artery, receives the superior laryngeal and cricothyroid veins, and ends in the internal jugular or facial vein. Middle & Inferior Thyroid Vein The middle thyroid vein drains the lower part of the gland and also receives veins from the larynx and trachea. It crosses anterior to the common carotid artery to join the internal jugular vein.

48. The Veins of the Thyroid

49. Clinical Relevance: While performing surgery on the thyroid gland, it is important to identify the short middle thyroid vein before mobilising the thyroid gland. If the vein is damaged or is divided bluntly, it will result in : The vein will retract into the IJV causing a gaping hole in it.

50. SUBCLAVIAN VEIN It is a continuation of the axillary vein. Extends from the outer border of the first rib to the medial border of scalenus anterior, where it joins the IJV to form the brachiocephalic vein. Tributaries: External jugular Dorsal scapular Anterior jugular vein, occasionally The left subclavian vein receives the thoracic duct & the right vein receives the right lymphatic duct .

51. The Subclavian Vein

52. VERTEBRAL VEIN Numerous small tributaries from internal vertebral plexuses leave the vertebral canal above the posterior arch of the atlas and join small veins from local deep muscles in the suboccipital triangle. Their union produces a vessel which enters the foramen in the transverse process of the atlas and forms a plexus around the vertebral artery. It descends through successive transverse foramina and ends as the vertebral vein.

53. The vein emerges from the sixth cervical transverse foramen, descends along with the vertebral artery and opens into the brachiocephalic vein: the opening has a paired valve. As it descends it passes behind the internal jugular vein and in front of the first part of the subclavian artery.

54. TheVertebral Vein

55. Tributaries: Sigmoid sinus by a vessel in the posterior condylar canal . It also receives branches from the Occipital vein Prevertebral muscles Internal and external vertebral plexuses Anterior vertebral vein Deep cervical vein First intercostal vein, sometimes

56. APPLIED ANATOMY

57. CAVERNOUS SINUS THROMBOSIS

58. VALVULAR INCOMPETENCE AND VARICOSE VEINS Varicose veins are characterized by large, bulbous protrusions of the veins beneath the skin of legs. Pathophysiology : Venous valve incompetence occurs when the veins have been overstretched by excess venous pressure lasting weeks or months, for example, in pregnancy or when a person stands continuously for a long time. Stretching the veins increases their diameter but the leaflets of the valves do not increase in size . Therefore, the leaflets no longer close completely and blood regurgitates due to gravitational pull.

59. Internal jugular vein thrombosis: It is a serious event with a potentially fatal outcome. Thrombus may be associated with a malignant tumour , deep neck infection or intravenous drug abuse. Patients may be asymptomatic or may present with a painful swelling of the neck. 

60. Imaging procedures for diagnosis- USG, CT, MRI and MRI Venography .  Therapy - IV antibiotics, systemic anticoagulation. Ligation of IJV is done as a last resort. Complications- pulmonary embolism, sepsis with septic emboli, intracranial propagation of the thrombus with cerebral edema. Contrast-enhanced computerized tomographic scan of the neck showing thrombosis of the left internal jugular vein (white arrow) and inflammation of the soft tissue surrounding the thrombosed vessel

61. JUGULAR VENOUS PULSE AND PRESSURE (the natural manometer) In clinical practice, the internal jugular vein can be observed for pulsations – the nature of which, provide an estimation of right atrial  pressure. When the heart contracts a pressure wave passes upwards into the jugular veins. There are no valves in the brachiocephalic or subclavian veins – so the pulsations are a fairly accurate indication of right atrial pressure.

62. Alternatively, manual pressure over the upper abdomen may be used to produce a transient increase in venous return to the heart which elevates the jugular venous pulse. The jugular venous pulse is usually assessed by observing the right side of the patient's neck, with the patient reclined at 45˚.

63. The normal mean jugular venous pressure, determined at a vertical distance of 4 cm above the sternal angle (or 9 cm above the right atrium), is 6 to 8 mm Hg. Deviation from this normal range reflects either hypovolemia (i.e., mean venous pressure less than 5 mm Hg) or impaired cardiac filling

64. PERIPHERAL VENOUS ACCESS IV access is essential to manage problems in all critically ill patients. Needed for, High volume fluid resuscitation IV access in anticipation of future potential problems, when fluid and/or medication resuscitation may be necessary

65. Contraindications Extremities that have massive edema, burns or injury; in these cases other IV sites need to be accessed. For the patient with severe abdominal trauma, it is preferable to start the IV in an upper extremity because of the potential for injury to vessels between the lower extremities and the heart. In case of cellulitis of an extremity, the area of infection should be avoided because of the risk of inoculating the circulation with bacteria. An area with an indwelling fistula due to inadequate vascular flow.

66. Complications : The main complications of an IV catheter are Infection at the site Development of superficial thrombophlebitis in the vein that is catheterized

67. Peripheral IV sites Preferred site is the veins of the forearm , followed by the median cubital vein- it can accommodate a large bore IV and it is generally easy to catheterize. When the veins of the upper extremities are inaccessible, the veins of the dorsum of the foot or the saphenous vein of the lower leg can be used . If a proximal vein is punctured first, and then an attempt is made to start an IV distal to that site, fluid may leak from the injured proximal vessel.

68. CENTRAL VENOUS ACCESS Central venous cannulation permits Monitoring of the central venous pressure Administration of drugs directly into the central circulation

69. Internal Jugular Vein Cannulation The patient is placed in the supine position with the head turned slightly towards the contralateral side. Landmarks: Two heads of sternocleidomastoid , which form two sides of a triangle with the clavicle as its base. The internal jugular vein lies between the two heads of the muscle, slightly lateral and anterior to the common carotid artery.

70. LA is injected around the apex of the triangle. A needle is inserted at the apex of the triangle and the tip is directed to the midpoint of the triangle, with a downward angulation of 30°. The left internal jugular vein is often smaller in diameter than the right. When the left internal jugular vein is cannulated , additional care must be taken to avoid the thoracic duct and the cupola of the pleura, which is higher than on this side, an arrangement which increases the risk of accidental pneumothorax .

71. References Gray’s Anatomy 40 th edition Oral Anatomy by Lloyd and Dubrul Head and Neck Surgery and Oncology by Stell and Maran Facial Reconstruction by Maria Seimenov Textbook of Pathology by Harsh Mohan Hutchinson’s Clinical Methods Textbook of General Medicine by Kumar and Clark Textbook of Physiology by Guyton and Hall