venous supply of head & neck

1. VENOUS DRAINAGE OF HEAD AND NECK PRESENTER: Dr. Ashish Soni

2. CONTENTS Veins Structure of veins Role of veins Classification of venous system Description of veins Internal jugular vein Introduction Tributaries Applied anatomy JVP External jugular vein Tributaries Applied aspect Anterior jugular vein Variations in veins of head & neck

3. Venous sinuses Communication between venous sinuses & extracranial veins CVP Diseases of veins Conclusion

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

5. 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 ( contains muscle tissue, elastic fibres , collagen , external elastic lamina) Tunica adventitia – outer coat (elastic and collegen tissue, muscle fibres )

6. Differences between arteries and veins

7. Arteries Veins Oxygen Concentration: Arteries carry oxygenated blood (with the exception of the pulmonary artery and umbilical artery). Veins carry deoxygenated blood (with the exception of pulmonary veins and umbilical vein). Types: Pulmonary and systemic arteries. Superficial veins, deep veins, pulmonary veins and systemic veins Direction of Blood Flow: From the heart to various parts of the body. From various parts of the body to the heart. Anatomy: Thick, elastic muscle layer that can handle high pressure of the blood flowing through the arteries. Thin, elastic muscle layer with semilunar valves that prevent the blood from flowing in the opposite direction. Overview: Arteries are red blood vessels that carry blood away from the heart. resistance vessels Veins are blue blood vessels that carry blood towards the heart. capacitance vessels Rigid walls: more rigid collapsible Thickest layer: Tunica media Tunica adventitia Location: Deeper in the body Closer to the skin Valves: Aren't present (except for semi-lunar valves) Are present,

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

9. Veins Systemic veins Pulmonary Veins -Right Pulmonary vein -Left Pulmonary vein Head & Neck Abdomen & Thorax Upper limb Lower limb Classification of veins

10. 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

11. Head & neck External group Internal jugular External jugular Anterior jugular Oblique jugular Posterior external jugular Internal group Venous sinuses Emissary veins Diploic veins

12. Superficial External jugular Facial Superficial temporal Deep Pterygoid plexus Internal jugular

13. Internal jugular veins

14. Veins of the Head and neck Internal jugular vein: It receive blood from the brain, face and the neck. It emerges through the jugular foramen,as a continuation of the sigmoid sinus descend down in the neck, first behind then lateral to the internal carotid artery inside the carotid sheath Terminate beneath the triangular interval between the sternal and the clavicular head of the sternocleidomastoid muscle joining the subclavian vein to form the brachiocephalic vein

15. Bulbs of vein: a) Superior bulb: located in jugular fossa on inferior surface of temporal bone beneath the floor of middle ear cavity. b) Inferior bulb: located at the termination of the vein, lies beneath the lesser supraclavicular fossa

16. Relations: Superficially Sternocleidomastoid Posterior belly of digastric Superior belly of omohyoid Parotid gland Styloid process Accessory vein Posterior auricular artery Occipital artery Sternocleidomastoid artery Lower root of ansa cervicalis Infrahyoid muscle Anterior jugular vein Deep cervical lymph nodes Internal carotid artery 9 th , 10 th ,11 th & 12 th nerve

17. Posteriorlly Rectus capitis lateralis Transverse process of atlas Levator scapulae Scaleneus medius Cervical plaxus Scalenus anterior Phrenic nerve Thyrocervical trunk Inferior thyroid artery

18. Medially Internal carotid artery Common carotid artery Vagus nerve

19. Tributaries Inferior petrosal sinus Pharyngeal veins Common facial vein Lingual vein Superior thyroid vein Kocher vein Occipital vein Thoracic duct (left) lymphatic duct (right)

20. Communications With external jugular by oblique jugular With cavernous sinus by inferior petrosal sinus

21. Special characteristics of the blood flow 1 2

22. APPLIED ANATOMY: Infection from middle ear spreads to IJV Surgical removal of deep cervical nodes can puncture IJV Easy accessibility between two heads of sternocleidomastoid muscle for introduction of cannula Thrombophlebitis can occur by spread of infection in caverous sinus Systolic thrill felt over the vein in mitral stenosis During CCF dilatation of vein occur Queckenstedt’s test – to find out block in CSF cerculation the test is perform during lumbar puncture

23. Jugular venous pulse (JVP) Determine activity of atrium Seen better then felt Preferable over EJV Elevation of JVP indicative of cardiac failure Hepato Jugular reflex Elicited by deep compression of right lobe of liver

24. a) Facial (anterior facial vein) Origin – junction of veins of forehead and nose Upper part – angular vein book

25. Angular vein receives: Frontal vein (anterior parts of scalp) Supraorbital vein (eyebrows) Superior ophthalmic vein (opens into cavernous sinus)

26. Facial vein anastomose with infraorbital vein and mental vein. Joins the: Pterygoid plexus through deep facial vein Cavernous sinus through superior ophthalmic vein Anastomosis of facial vein

27. Applied anatomy: Facial vein is common source of bleeding following surgery involving posterior vestibule lateral to mandible Infection from face can spread in a retrograde direction and cause thrombosis of the cavernous sinus. This is specially occur in presence of infection in upper lip and lower part of nose. Called dangerous area of the face. Dangerous area of the face .

28. c) Lingual vein The  lingual veins  begin on the dorsum, sides, and under surface of the  tongue , and, passing backward along the course of the  lingual artery , end in the  internal jugular vein . Drains tongue and sublingual region Three branches Dorsal lingual veins Deep lingual veins Sublingual vein

29. Variations: Mostly drains into common facial vein In others – open into IJV and some into common facial vein Veins from pharynx often join lingual vein

30. d) Retromandibular Vein Retromandibular vein: formed by the union of superficial temporal and maxillary vein from the pterygoid plexus passes downwards in the substance of the parotid gland emerging from its lower border & divide into two divisions

31. Anterior division: joins the facial vein Posterior division: pierces the deep fascia and join the posterior auricular to form the external jugular . It empty into the subclavian vein

32. e) Superficial temporal vein It begins on the side and vertex of the skull in a plexus which communicates with the frontal vein and  supraorbital vein, with the corresponding vein of the opposite side, and with the posterior auricular vein and occipital vein. From this network frontal and parietal branches arise, and unite above the  zygomatic arch to form the trunk of the vein, which is joined by the middle temporal vein emerging from the  temporalis muscle.

33. It then crosses the posterior root of the  zygomatic arch, enters the substance of the parotid gland, and unites with the internal maxillary vein to form the posterior facial vein. It drains the lateral scalp It drain into and form the retromandibular vein with the maxillary vein

34. Maxillary vein • It begins in the infratemporal fossa •It collects blood from the pterygoid Plexus •Through the pterygoid plexus It receives the middle meningeal , posterior superior alveolar, inferior alveolar and other veins from the nose and palate (areas served by The maxillary artery) •After that it merges with the superficial temporal vein to form the retromandibular vein

35. g) Posterior auricular vein The  posterior auricular vein  begins upon the side of the head, in a plexus which communicates with the tributaries of the occipital vein and superficial temporal veins. It descends behind the  auricula , and joins the posterior division of the posterior facial vein to form the external jugular .

36. h) Occipital vein The  occipital vein  begins as a plexus at the posterior aspect of the scalp from the external occipital protuberance and superior nuchal line to the back part of the vertex of the skull. From the plexus emerges a single vessel, which pierces the cranial attachment of the  Trapezius  and, dipping into the venous plexus of thesuboccipital triangle, joins the deep cervical and vertebral veins.

37. Occasionally it follows the course of the occipital artery and ends in the internal jugular; in other instances, it joins the posterior auricular vein and through it opens into the external jugular. The parietal emissary vein connects it with the superior sagittal sinus; and as it passes across the mastoid portion of the temporal bone, it receives the mastoid emissary vein which connects it with the transverse sinus. The occipital  diploic vein sometimes joins it

38. External jugular vein Drains major part of face & scalp Begins behind the angle of the mandible by the union of the posterior auricular and posterior division of the retromandibular veins . It descend obliquely, deep to the platysma , receive the posterior external jugular vein pierce the deep fascia just above the clavicle and drain into the subclavian vein

39. Tributaries: Formative Occipital vein Oblique jugular Posterior external jugular Terminal Transverse cervical anterior jugular Suprascapular vein

40. Applied anatomy Injury to the vein cause air embolism Vein becomes dilated above compression level during Valselva’s manoevre Vene puncture performed on this vein Surgical division of sternocleidomastoid muscle requires special care of the vein Increased venous pressure indicates congestive cardiac failure

41. Anterior jugular vein start below the chin, pass beneath the platysma to the suprasternal notch. Pierce the deep fascia and is connected to the other side by an anastomosing vein the jugular arch angle laterally to pass deep to sternocleidomastoid and open in the external

42. Tributaries: Skin Superficial tissues of neck Applied anatomy: Special care required to preserve the vein during surgical treatment of wry neck

43. Intracranial Venous sinus Formation: Venous spaces between the osteal and meningeal layers of duramater Formed by reduplication of meningeal layer Features: Lined by endothelium Receive blood from Brain Orbit Internal ear CSF Valveless Bidirectional flow

44. Classification Posterosuperior group Anteroinferior group Unpaired a) Superior sagittal b) Inferior sagittal c) Straight d) Occipital Paired a) Transverse b) Sigmoid c) Petrosquamous Unpaired a) Anterior intercavernous b) Posterior intercavernous c) Basilar Paired a) Cavernous b) Superior petrosal c) Inferior petrosal d) Sphenoparietal e) Middle meningeal

45. Superior sagittal sinus Course: Begins antriorly at crista galli by union of tiny meningeal veins. Communicate with veins of frontal sinus , occasionally with the veins of nose through foramen caecum Runs upwards and backwards, and large in size Ends near internal occipital protuberance by turning to one side , usually right , continuous with right transervers sinus Cross section: Triangular

46. Tributaries: Veins from nose Superior cerebral vein Parital emissary vein Venous lacunae Communication with cavernous sinus Applied anatomy: Infection from nose, scalp and diploe cause thrombosis of this sinus

47. Inferior sagittal sinus Situated in posterior 2/3 of falx cerebri Ends by forming straight sinus It receives Veins of falx cerebri Veins from cerebrum

48. Straight sinus Situated at junction of falx cerebri and tentorium cerebelli Continuation of inferior sagittal sinus Tributaries: Inferior sagittal sinus Great cerebral vein Superior cerebellar veins

49. Transverse sinus Large paired sinus , right sinus larger than left Situated in posterior part of attached margin of tentorium cerebelli Begins as continuation of superior sagittal sinus (right) and straight sinus (left)

50. Triangular cross section Ends at mastoid angle Tributaries: Superior petrosal sinus Inferior cerebral vein Posterior temporal deploic vein Inferior cerebellar vein Inferior anastomotic vein Petrosquamous sinus

51. Confluence of sinus: The point where the superior sagittal sinus, straight sinus and occipital sinus unite called Confluence of sinus Located on the right side of the internal occipital protuberance

52. Sigmoid sinus Each sinus right & left is direct communication of traservers sinus S- shaped Extends from posteroinferior angle of parietal bone to posterior part of jugular foramen , becomes the superior bulb of jugular vein. Grooves the mastoid part of temporal bone

53. Tributaries: Communication with pericranium veins Communication with sub occipital venus plexus Labyrinthine veins Cerebellar veins Applied anatomy Thromboisis of the sinus occur from the infection of the in the middle ear & otitis media or in mastoid process called mastoiditis During operation on mastoid process should be careful about the sigmoid sinus, so that it not exposed. Otitic hydrocephalus

54. Occipital sinus The  occipital sinus  is the smallest of the cranial sinuses. It is situated in the attached margin of the  falx cerebelli , and is generally single, but occasionally there are two. It commences around the margin of the foramen magnum by several small venous channels, one of which joins the terminal part of the transverse sinus; it communicates with the posterior internal vertebral venous plexuses and ends in the confluence of the sinuses.

55. Cavernous sinus Paired sinus, large venous space situated in MCF Extent: petrous part of temporal bone to SOF

56. Relation: Medially Pituitary gland Sphenoidal sinus Laterally Temporal lobe with uncus Superiorly Optic tract, optic chiasma , Olfactory tract,ICA Inferiorly Foramen lacerum , junction of body & greater wing of sphenoid bone Anteriorly Superior orbital fissure & apex of orbit Posteriorly Petrous part of temporal bone

57. Structure passing through sinus Structures in lateral wall of sinus ICA VI cranial nerve III cranial nerve IV cranial nerve V 1 and V2 division of V cranial nerve

58. Tributaries From orbit Superior ophthalmic vein Inferior ophthalmic vein Central vein of retina From brain Middle cerebral vein Inferior cerebral vein Meningeal Middle meningeal vein Sphenoparietal sinus

59. Communication with: Transverse sinus IJV Pterygoid venous plexus d) Facial vein e) Superior sagittal sinus f) Opposite cavernous sinus

60. Applied anatomy: Arterio – venous aneurysm occurs due to rupture of internal cardiac artery Symptoms: Loud systolic thrill Exophthalmos Conjunctivitis Thrombosis of the sinus resulting in meningitis due to infections in dengerous area of face , nasal cavity and PNS Symptoms: pain in eye Oedema of eye lids , cornea and root of nose Exophthalmos

61. Inter Cavernous sinus Usually two in number Connects two cavernous sinus Form venous circle Situated at anterior and posterior margins of diaphragma sellae

62. Superior petrosal sinus Its originate from posterosuperior corner of cavernous sinus , courses posteriorly and laterally along the superior crest of temporal pyramid, reaches transvers sinus, bends to continue into sigmoid sinus Connection between transverse and cavernous sinus Tributaries: Cerebellar vein Inferior cerebral vein Veins from tympanic cavity

63. Inferior petrosal sinus Shorter and wider Arises from the inferoposterior corner of the cavernous sinus follow petro-occipital fissure backward to the anterior border of jugular foramen Crosse the 9 th ,10 th & 11 th nerve and empties into superior bulb of internal jugular vein Tributaries: labyrinthine vein veins from aqueduct of cochlea vein from medulla pons and cerebellum

64. Middle meningal sinus Communicate cavernous sinus with superior sagital sinus Unite to form - parietal - frontal Liable to be torn during skull fracture

65. Communication between intracranial veins & extracranial veins Emissary Mastoid Parietal Condylar Occipital Sphenoid Zuckerkandl’s Ophthalmic Superior opthalmic Inferior opthalmic Venous plexus Pterygoid Suboccipital Pharyngeal Diploic Frontal Anterior temporal Posterior temporal Occipital

66. Ophthalmic veins Superior opthalmic vein The  superior ophthalmic vein  begins at the inner angle of the orbit in a vein named the  nasofrontal  which communicates anteriorly with the angular vein; it pursues the same course as the ophthalmic artery, and receives tributaries corresponding to the branches of that vessel.

67. Forming a short single trunk, it passes between the two heads of the Rectus lateralis  and through the medial part of the superior orbital fissure, and ends in the cavernous sinus. The  ethmoidal veins drain into the superior ophthalmic vein

68. Inferior opthalmic vein Formed in floor and medial wall of orbit Ends by joining superior opthalmic vein Tributaries: Veins from rectus inferior, obliqus inferior, lacrimal sac Communication with pterygoid plexus Applied anatomy: Blood borne infections of nose or teeth spread into cavernous sinus

69. Diploic veins: situated in diploe of cranial veins Characteristics Valve less Non- collespable Pouch like elevation at irregular interval 4. On x-ray of skull appear as transparent bands 5. Communicate with meningal , sinuses and veins of pericranium Types: Frontal Anterior temporal Posterior temporal Occipital

70. EMISSARY Characteristics: Valve-less Some veins are constant other inconstant or may be absent Thin valves tightly attached to surrounding bones Types: parietal occipital mastoid condylar Spheniod Zuckerkandl’s

71. Veins connecting cavernous sinus with pterygoid venous plexus pass through different foramina Foramen lacerum Foramen ovale Foramen vesali Foramen spi nosum Applied anatomy: Inflammatory process due to infection pass through these veins and give rise to thrombosis of the sinus

72. Venous plexus PTERYGOID Location: Between lateral and medial pterygoid or between temporal and lateral pterygoid

73. Boundaries: Anterior-maxillary tuberosity Superior-base of skull Termination: Posteriorly these veins unite to form deep facial or maxillary vein

74. Tributaries: Sphenopalatine Deep temporal Pterygoid Masseteric Buccal Dental Greater palatine Middle meningeal Inferior opthalmic

75. Applied anatomy: PSA block - haematoma -black eye Serves as media for spread of external infection to the cavernous sinus

76. b) SUBOCCIPITAL: Located in suboccipital triangle Receives blood from Muscular veins Transverse sinus Occipital veins Internal vertebral venous plexus Condylar emmissary veins Drains into vertebral veins

77. c). PHARYNGEAL VENOUS PLEXUS : Located on postero lateral region of pharynx Receives blood from Pharynx Soft palate Pre vertebral region Drains into internal jugular and facial veins

78. Central venous pressure pressure of blood in the thoracic vena cava, near the right atrium  Normal CVP can be measured from two points of reference: Sternum: 0–5  cm H2O Midaxillary line: 8-15 cm H 2 O Site Normal pressure range (in  mmHg ) Central venous pressure 3–8 Right ventricular pressure systolic 15–30 diastolic 3–8 Pulmonary artery pressure systolic 15–30 diastolic 4–12 Pulmonary vein/ Pulmonary capillary wedge pressure 2–15 Left ventricular pressure systolic 100–140 diastolic 3-12

79.   Factors that decrease CVP include: Hypovolemia Deep inhalation Distributive shock Factors that increase CVP include: Hypervolemia forced exhalation Tension pneumothorax Heart failure Pleural effusion Decreased cardiac output Cardiac tamponade Mechanical ventilation

80. Diseases of veins

81. Deep vein thrombosis

82. Varicose veins

83. Thrombophlebitis

84. Thread veins

85. Venous insufficiency

86. Anatomical Variations of Internal Jugular Vein as seen by “Site Rite II” Ultrasound Machine - an initial experience in Pakistani Population Hameedullah,M . A. Rauf,F . H. Khan   (  Department of Anaesthesia. The Aga Khan University Hospital, Karachi.  )   49 cases :the angle of the mandible (p value <0.05), 22 cases: the thyroid cartilage 20 cases: the cricoid cartilage 46cases: the supraclavicular area (p value <0.05). In 93% of cases the IJV was found to be larger than the carotid artery.

87. Conclusion The jugular veins and its tributaries form the primary venous drainage of head & neck. As these are surrounded by many important anatomic structures so care should be taken to preserve these veins during any surgical manipulation of surrounding structures.

88. References Textbook of oral anatomy- sicher & dubrul Human Anatomy – B.D. Chaurasia Wikipidia

89. Thank you