Venous drainage of head , neck and face

veins of head and neck(concise)

1. Dr.Bhavesh D hoke Dept.of oral and maxillofacial surgery

2. vein Structure Function of vein Description of veins 1) internal jugular vein 2) external jugular vein 3) anterior jugular vein 4) facial vein 5) pterygoid plexus of vein venous sinuses communication between venous sinuses and extracranial veins Venous drainage of head and neck Diseases of vein

3. Veins ( vena ) are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart except the pulmonary and umbilical veins Usually travel with arteries

4. Structure of Vein  Veins are thin walled than arteries.  Large lumen.  Valves, maintain unidirection blood flow.  3 concentric layers ( tunicae) Tunica intima - innermost layer(endothilial cells & internal elastic lamina) Tunica media – Middle layer Tunica adventitia – outer coat

5. Differences between arteries and veins

6. Return of deoxygenated blood to heart Cushion associated arteries from jaw movements(periarterial plexus) Protect against extensive intracranial pressure.

7. 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 Two brachiocephalic veins unite to form superior vena cava

8. External group Internal jugular External jugular Anterior jugular Oblique jugular Posterior external jugular Internal group Venous sinuses Emissary veins Diploic veins

9. Supe r f ici al External jugular , Facial , Superficial temporal vein Deep Pterygoid plexus Internal jugular

10. VEINS OF THE NECK Veins of the neck are superficial and deep to the deep fascia. Superficial veins are anterior jugular, external jugular and posterior jugular veins; They drain a smaller part of tissue than deep veins. Deep veins drain all subcutaneous structures mostly internal jugular veins and into the subclavian vein

11. The venous blood of head &neck is drained almost entirely by the internal jugular vein , which joins the subclavian vein , behind the sternoclavicular articulation to form the brachiocephalic vein . The two brachiocephalic vein unites to form the superior vena cava. Along the neck two superficial veins are added to the deep internal jugular vein namely the external & anterior jugular vein

12. INTERNAL JUGULAR VEIN: The internal jugular vein receives blood from the brain, face, &neck. It commences at the jugular foramen in the skull as the continuation of the sigmoid sinus it descends through the neck in the carotid sheath &unites with the subclavian vein behind the medial end of the clavicle To form the brachiocephalic vein , immediately below the jugular foramen the vein is widened to form the superior bulb of the internal jugular vein which is contained in the jugular fossa on the inferior surface of the temporal bone.

13. Tributaries- Into the superior bulb opens the inferior petrosal sinus, Veins of the pharynx, tongue &sublingual area drain upper part of the internal jugular vein, Anastomosis between internal &external jugular vein is seen near the upper corner of the carotid triangle.,

14. Facial vein along with anterior division of the Retromandibular vein joins the internal jugular vein. Veins of the larynx & thyroid glands are main tributaries at the lower part of the neck.

15. APPLIED ANATOMY: Infection from middle ear spreads to IJV Surgical removal of deep cervical nodes can puncture IJV Thrombophlebitis of IJV can occure with cannulation Systolic thrill felt over the vein in mitral stenosis During CCF dilatation of vein occur

16. EXTERNAL JUGULAR VEIN It drains mainly scalp and face. .it is formed by the union of posterior division of the retromandibular vein with the posterior auricular vein and begins near the angle of the mandible just below or in the parotid gland. From here it descends obliquely superficial to the sternocleidomastoid to the root of the neck and then it crosses the deep fascia And ends in the subclavian vein. Although valves are present in the external jugular vein but it doesn’t prevent regurgitation. It is covered by the platysma , superficial fascia and the skin

17. Tributaries It receives the posterior external jugular vein and transverse,cervical , suprascapular and anterior jugular vein near it’ s end. It is also joined by the branch from the internal jugular vein near the parotid gland.

18. POSTERIOR EXTERNAL JUGULAR VEIN It begins in the occipital scalp and drains into the skin and the superficial muscles in the postero superior region of the neck. It joins the middle part of the external jugular vein.

19. ANTERIOR JUGULAR VEIN It arises near the hyoid bone and descends between the midline and the anterior border of the sternocleidomastoid . Deep to the sternocleidomastoid it joins the external jugular vein or may enter subclavian vein directly. There are usually two anterior jugular veins which are united just above the manubrium by large transverse jugular arch which receives the inferior thyroid tributaries.

20. FACIAL VEIN It is the main vein of the face. It travels obliquely downwards by the side of the nose &descends to the anterior border & then passes over the surface of the masseter . It crosses body of the mandible &runs in the neck to drain into the internal jugular vein. The common facial vein originates below the angle of the mandible from the junction of the facial & retromandibular vein, Above its junction with the superior labial vein it is termed as angular vein. The angular vein receives the frontal vein, supraorbital vein, veins from the lower lid &from the bridge of the nose.

21. Supraorbital vein begins near the zygomatic process of the frontal bone, passes medially piercing the orbicularis oculi & unites with the supratrochlear vein ,frontal &supra orbital veins anastomoses through wide venous nets with the other veins of the scalp. Superficial temporal, posterior auricular &occipital veins. The angular vein is constantly in communication with the superior ophthalmic vein just above the medial palpebral ligament, & as superior ophthalmic vein opens into the cavernous sinus a link between facial vein & intracranial sinuses of the duramater is seen Facial vein lacks valves & because of its connection with the cavernous sinus it has the clinical significance in the spread of infection.

22. Cavernous sinus thrombosis It is a serious complication of infections of the upper & lower face & neck region .it is more likely to be involved in the potentially fatal spread of infection. Each cavernous sinus communicates with each other, with pterygoid plexus of veins,& superior ophthalmic vein which anastomoses with the facial vein. These major veins drain teeth through the posterior superior &inferior vein & lips through the superior & inferior labial veins. none of the veins that communicate with the cavernous sinus have valves to prevent the retrograde blood flow back into the cavernous sinus

23. therefore dental infection that drain through this major veins initiate theinflammatory respone resulting in blood stasis ,thrombus formation,&increasing extra vascular fluid pressure. Increased pressure can change the direction of blood flow,enabling the transport of this thrombus into the venous sinuses causing cavernous sinus thrombosis. Needle track contamination can also result in spread of infection through pterygoid plexus of veins while administrating posterior superior alveolar block incorrectly.non odontogenic infections originating from the danger triangle of face i.e orbit , nasal region & para nasal sinus.

24. superficial temporal vein: It begins from the wide spread plexus of veins on side of the scalp & along zygomatic arch,frontal & parietal tributaries unite anterior to the auricle, crosses temporal root of zygomatic arch to pass from the temporal region & enter the substance of the parotid gland. It joins maxillary vein posterior to the neck of the mandible to form the retromandibular vein.

25. Retromandibular vein: It is formed by the union of the superficial temporal & maxillary vein in the substance of the parotid gland behind the neck of the mandible . The vein emerges at the lower pole of the gland to unite with the facial vein, It continues downwards on the outer surface of the stylohyoid & digastric muscles In some cases however the a deep branch of retromandibular vein follows the external carotid artery in its deep course &empties into the internal jugular vein.

26. Middle temporal vein Above the root of zygomatic arch ,a middle temporal vein opens into the superficial temporal vein. This middle temporal vein drains into the venous plexus situated underneath the temporal fascia The two maxillary veins are the outlet of the large &dense pterygoid venous plexus which surrouds the maxillary artery in the infra temporal fossa .

27. Pterygoid plexus of veins Veins of the deep structures of the face open here. It is situated between the temporal &lateral pterygoid or between the lateral &medial pterygoid muscles depending on the course of the maxillary artery.. anteriorly it reaches the tuberosity of the maxilla ,superiorly to the base of the skull.

28. VEINS OF THE SCALP & FACE: The superficial part of scalp is drained by supra orbital &supra trochlear veins. Supratrochlear vein- it starts from the venous network connected to the frontal tributaries of the superficial temporal vein, it descends near the midline to the bridge of the nose. where it unites with the supraorbital vein to form the facial vein near the medial canthus of the eye. Supraorbital vein begins near the zygomatic process of the frontal bone passes medially piercing the orbicularis oculi & unites with the supratrochlear vein . frontal &supra orbital veins anastomose through wide venous nets with the other veins of the scalp.superficial temporal,posterior auricular &occipital veins .

29. SINUSES OF THE DURAMATER The blood of the brain and the eye is collected by system of specialized vein in the duramater called sinuses. These sinuses are non collapsible and are formed by the dense rigid and inelastic tissue of the duramater . They drain eventually into the internal jugular vein but there are numerous communications between the sinuses and the extracranial vein.

30. SUPERIOR SAGITTAL SINUS This sinus commences in the region of crista gali of the ethmoid bone and curves posteriorly in the midline over the frontal, parietal and occipital bones. On its way it receives numerous veins from the convexity of the brain. Arachnoid granulations are small cauliflower like extension that protrude into the lateral aspects of the superior saggital sinus . csf leaks back across the arachnoid membrane through these archnoid granulations to enter the venous blood of the superior sagittal sinus.

31. SUPERIOR PETROSAL SINUS small and narrow, connects the cavernous with the transverse sinus. It runs lateralward and backward, from the posterior end of the cavernous sinus, over the trigeminal nerve, and lies in the attached margin of the tentorium cerebelli and in the superior petrosal sulcus of the temporal bone; it joins the transverse sinus where the latter curves downward on the inner surface of the mastoid part of the temporal. It receives some cerebellar and inferior cerebral veins, and veins from the tympanic cavity.

32. INFERIOR SAGITTAL SINUS A narrow sinus, enclosed in the lower free border of a sickle shape median fold of the dura The falx cerebri separates the two hemispheres of the cerebrum.

33. INFERIOR PETROSAL SINUS Situated in the inferior petrosal sulcus formed by the junction of the petrous part of the temporal bone with the basilar part of the occipital bone. It begins in the postero -inferior part of the cavernous sinus, and, passing through the anterior part of the jugular foramen, ends in the superior bulb of the internal jugular vein. The inferior petrosal sinus receives the internal auditory veins and also veins from the medulla oblongata, Pons, and under surface of the cerebellum.

34. OCCIPITAL SINUS This small vein begins on either side of the great occipital foramen & ascends in the midline. It ends at the inner occipital eminence.

35. TRANSVERSE SINUS; The point where the superior saggital sinus ,straight sinus ,&occipital sinus unite is called the confluence of the sinuses .From here the blood is drained by the paired transverse sinus.,Sometimes the straight &superior saggital sinus do not join but continue each into one transverse sinus, Even if they join also a greater amount of blood usually enters into the right transverse sinus than the left,as a consequence the right internal jugular vein is often much larger than the left.

36. The transverse sinus runs almost horizontally across the occipital bone & then over the temporal bone to the point where the superior crest of the temporal pyramid commences. From this point the transverse sinus continues in an S shaped curve as the sigmoid sinus, descending towards the cranial base, the sigmoid sinus continues through the jugular foramen into the internal jugular vein .

37. CAVERNOUS SINUS It is a large venous space situated in the middle cranial fossa on either side of the sphenoid bone. The floor of the sinus is formed by the endosteal duramater .the lateral wall, roof, &medial wall is formed by meningeal duramater . Anteriorly the sinus extends up to the medial end of the superior orbital fissure & posteriorly up to the apex of petrous temporal bone.

38. SIGMOID SINUS It continues medially from the transverse sinus & ends at the mouth of the jugular foramen. Thus all venous blood ultimately collected by the sigmoid sinus drains through the jugular foramina to the internal jugular vein below.

39. There are 4 ways by which extracranial veins communicate with the intracranial veins. 1. Emissary veins 2. Diploic veins 3. Venous plexus surrounding internal carotid artery & cranial nerves 4. Through superior ophthalmic vein or facial vein and retromandibular vein.

40. But the most important of our concern is the connection between pterygoid plexus & cavernous sinus through foramina ovale ,foramina lacerum , & sphenoidal foramina. Pterygoid plexus of veins is drained by posterior superior alveolar vein which drains the posterior part of the maxilla,so infection from this region can directly enter into cavernous sinus through the pterygoid plexus Facial vein through the deep facial vein communicates with the pterygoid plexus.

41. Emissary Veins The emissary veins pass through apertures in the cranial wall and establish communication between the sinuses inside the skull and the veins external to it. Some are always present, others only occasionally so.

42. Diploic veins: Four diploic veins are present Frontal diploic vein- connects to superior sagittal sinus & to the frontal vein Anterior temporal vein- connects to sphenoparietal sinus & deep temporal vein. Posterior temporal vein – connects to sigmoid sinus &to the occipital vein Occipital diploic vein- connects to transverse sinus & to the occipital veins The veins that connect the sinuses & the extracranial veins along the internal carotid artery & many of the cranial nerves are loosely connected with the surrounding tissue & therefore collapsible. This acts as compressible cushioning allowing for the changes in the volume of the artery during its pulsation .

43. Spread of infection through the facial vein The facial vein makes clinically important connections with the cavernous sinus through the superior ophthalmic vein, the pterygoid plexus ,a network of small veins within the infratemporal fossa through the inferior ophthalmic & deep facial veins. Because of these connections, an infection of the face may spread to the cavernous sinus & pterygoid venous plexus. Blood from the medial angle of the eye, nose, &lips usually drains inferiorly through the facial vein, especially when a person is erect, & as facial vein

44. has no valves blood may pass through it in the opposite direction. Consequently, venous blood from the face may enter the cavernous sinus. In individuals with thrombophlebitis of the facial vein, pieces of infected clot may extend into the intracranial venous system & produces thrombophlebitis of the cavernous sinus. Infection of the facial vein spreading to dural venous sinuses may result from the lacerations of the nose or be initiated by pimples on the side of the nose &upper lip, consequently the triangular area from the upper lip to the bridge of the nose is considered the danger area of the face.

45. Venous drainage of scalp Supratrochlear vein Supraorbital vein Superficial temporal vein Posterior auricular vein Occipital vein

46. Applied anatomy The 4 th layer of scalp is loose areolar tissue And infection in that layer readily spread to intracranial sinuses through emissary vein( valveless )

47. Venous drainage of face supratrochlear+supraorbital =angular vein Superficial temporal and maxillary vein Retromandibular vein Posterior auricular vein External jugular vein Internal jugular vein

48. Applied anatomy Facial vein have no valve and it connect cavernous sinus by two way 1) opthalmic vein or supraorbital vein. 2)via deep facial vein to pterygoid plexus and hence to cavernous sinus Thus infective thrombosis of facial vein may extend to intracranial venous sinuses lead to cavernous sinus thrombosis

49. Venous drainage of tongue Dorsal lingual vein- drain the dorsum and side of tongue Deep lingual vein -drain the tip of the tongue and join sublingual vein All these vein terminate in internal jugular vein

50. VEINOUS DRAINAGE OF SALIVARY GLANDS: 1.Parotid gland: Drains into external and internal jugular veins. 2.Submandibular gland: Drains into common facial or lingual vein and ultimately into internal jugular vein. 3.Sublingual gland: Drains into lingual vein and ultimately into internal jugular vein.

51. VEINOUS DRAINAGE OF THE THYROID GLANuuD *The thyroid is drained by superior,middle and inferior thyroid veins. *The superior thyroid vein emerges at upper pole and accompanies the superior thyroid artery ending in Internal Jugular Vein. *The middle thyroid vein also ends in I.J.V *The inferior thyroid veins emerging at the lower border of isthmus,form a plexus in front of trachea and drain into the left brachiocephalic vein . NOTE: A fourth thyroid vein (Kocher’s vein) may emerge between the middle and inferior veins and drain into the internal jugular vein.

52. VEINOUS DRAINAGE OF: 1) HARD PALATE: Drains into the Pterygoid plexus of veins 2)SOFT PALATE: Drains into pterygoid and tonsillar plexus of veins 3)PHARYNX: The veins form a plexus on posterolateral aspect of pharynx which receives blood from pharynx, Soft palate and prevertebral region.It then drains into internal jugular and facial veins. 4)AUDITORY TUBE: Into pharyngeal plexus and pterygoid plexus of veins.

53. 5)NASAL SEPTUM: *The veins form a plexus which is more marked in the Lower part of septum ot Little’s area. *The plexus drains anteriorly into facial vein,posteriorly through the sphenopalatine vein to pterygoid venous plexus. 6)LATERAL WALL OF NOSE: *The veins form a plexus which drains anteriorly into the facial vein ; posteriorly into ,into the pharyngeal plexus of veins and from the middle part,to the pterygoid plexus of veins.

54. VEINOUS DRAINAGE OF THE PARANASAL SINUSES: MAXILLARY SINUS: Into the facial vein and pterygoid plexus of veins SPHENOIDAL SINUS: Into pterygoid venous plexus and cavernous sinus 3) ETHMOIDAL SINUS: Into pterygoid plexus and cavernous sinus FRONTAL SINUS: Into supraorbital and superior ophthalmic veins.

55. VEINOUS DRAINAGE OF LARYNX: A)UPTO THE VOCAL FOLDS: By the superior laryngeal vein which drains into superior thyroid vein. B)BELOW THE VOCAL FOLDS: By the inferior laryngeal vein which drains into inferior thyroid vein.

56. VENOUS DRAINAGE OF EAR: A)EXTERNAL EAR: Veins from outer surface drains into external jugular vein and those from inner surface drain into transverse sinus and venous plexus around auditory tube. B)MIDDLE EAR: Veins from middle ear drain into superior petrosal sinus and the pterygoid plexus of veins. C)TYMPANIC OR MASTOID ANTRUM: The veins drain into mastoid emissary vein,posterior auricular vein and sigmoid sinus.

57. D)INTERNAL EAR: The labyrinthine vein drains into superior petrosal sinus the transverse sinus.Other inconstant veins emerge at different points and open seperately into superior and inferior petrosal sinuses and the internal jugular vein.