VENOUS DRAINAGE OF

HEAD AND NECK

PRESENTER: Dr. Ashish Soni

CONTENTS1. Veins2. Structure of veins 3. Role of veins4. Classification of venous system 5. Description of veins

A. Internal jugular vein1. Introduction

2. Tributaries3. Applied anatomy4. JVP

B. External jugular vein1. Tributaries2. Applied aspect

C. Anterior jugular veinD. Variations in veins of head & neck

6. Venous sinuses7. Communication between venous sinuses &

extracranial veins8. CVP9. Diseases of veins10. Conclusion

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

Structure of VeinVeins are thin walled than arteries.Large lumen.Valves, maintain unidirection blood flow.

3 concentric layers ( tunicae)1) Tunica intima - innermost layer(endothilial

cells & internal elastic lamina)2) Tunica media –Middle layer ( contains muscle

tissue, elastic fibres, collagen , external elastic lamina)

3) Tunica adventitia – outer coat (elastic and collegen tissue, muscle fibres)

Differences between arteries and veins

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,

Role of veins

1) Return of deoxygenated blood to heart2) Cushion associated arteries from jaw

movements(periarterial plexus)3) Protect against extensive intracranial pressure.

Veins

Systemic veins Pulmonary Veins-Right Pulmonary vein-Left Pulmonary vein

Head & Neck

Abdomen & Thorax Upper limb Lower limb

Classification of veins

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

Head & neck

External group

a) Internal jugularb)External jugularc) Anterior jugulard)Oblique jugulare)Posterior external

jugular

Internal group

a)Venous sinusesb)Emissary veinsc) Diploic veins

Superficial

External jugular FacialSuperficial temporal

Deep

Pterygoid plexusInternal jugular

Internal jugular veins

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

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

Relations:

a) 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• 9th, 10th,11th & 12th nerve

b) Posteriorlly

• Rectus capitis lateralis

• Transverse process of atlas

• Levator scapulae• Scaleneus medius• Cervical plaxus• Scalenus anterior• Phrenic nerve• Thyrocervical trunk• Inferior thyroid artery

c) Medially

• Internal carotid artery

• Common carotid artery

• Vagus nerve

Tributaries

1. Inferior petrosal sinus2. Pharyngeal veins3. Common facial vein4. Lingual vein5. Superior thyroid vein6. Kocher vein7. Occipital vein8. Thoracic duct (left)9. lymphatic duct (right)

Communications1. With external jugular by oblique jugular2. With cavernous sinus by inferior petrosal

sinus

Superficial cereb

ral veins

Superior sagittal

sinus

Right transverse sinus

Right sigmoid

sinus

Right IJV

Special characteristics of the blood flowDeep

cerebral vein

Great

cerebral vein

Straight sinu

s

Left transvers

e sinus

Left sigmoid sinu

s

Left

IJV

1

2

APPLIED ANATOMY:

1. Infection from middle ear spreads to IJV2. Surgical removal of deep cervical nodes can

puncture IJV3. Easy accessibility between two heads of

sternocleidomastoid muscle for introduction of cannula

4. Thrombophlebitis can occur by spread of infection in caverous sinus

5. Systolic thrill felt over the vein in mitral stenosis6. During CCF dilatation of vein occur7. Queckenstedt’s test – to find out block in CSF

cerculation the test is perform during lumbar puncture

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

a) Facial (anterior facial vein)• Origin – junction of veins of forehead and

nose• Upper part – angular vein

book

Angular vein receives:

1. Frontal vein (anterior parts of scalp)

2. Supraorbital vein (eyebrows)

3. Superior ophthalmic vein (opens into cavernous sinus)

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

Applied anatomy:

A. Facial vein is common source of bleeding following surgery involving posterior vestibule lateral to mandible

B. 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.

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

a) Dorsal lingual veins b) Deep lingual veinsc) Sublingual vein

Variations:

1. Mostly drains into common facial vein

2. In others – open into IJV and some into common facial vein

3. Veins from pharynx often join lingual vein

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

• 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

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.

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

f) Maxillary vein

• It begins in the infratemporal fossa

•It collects blood from the pterygoidPlexus

•Through the pterygoid plexus Itreceives the middle meningeal,posterior superior alveolar, inferioralveolar and other veins from thenose and palate (areas served by The maxillary artery)

•After that it merges with thesuperficial temporal vein to form the retromandibular vein

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.

h) Occipital veinThe 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.

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

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

Tributaries: Formative Occipital vein Oblique jugular Posterior external jugular

Terminal Transverse

cervical anterior jugular Suprascapular

vein

Applied anatomy

a) Injury to the vein cause air embolism

b) Vein becomes dilated above compression level during Valselva’s manoevre

c) Vene puncture performed on this vein

d) Surgical division of sternocleidomastoid muscle requires special care of the vein

e) Increased venous pressure indicates congestive cardiac failure

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

Tributaries: 1. Skin2. Superficial tissues of neck

Applied anatomy:3. Special care required to

preserve the vein during surgical treatment of wry neck

Intracranial Venous sinusFormation:• Venous spaces between the osteal and meningeal

layers of duramater• Formed by reduplication of meningeal layer

Features:• Lined by endothelium • Receive blood from

a) Brain b) Orbitc) Internal eard) CSF

• Valveless• Bidirectional flow

Classification

Posterosuperior group Anteroinferior group

Unpaireda) Superior sagittalb) Inferior sagittalc) Straight d) Occipital

Paireda) Transverseb) Sigmoidc) Petrosquamous

Unpaireda) Anterior intercavernousb) Posterior intercavernousc) Basilar

Paireda) Cavernousb) Superior petrosalc) Inferior petrosal d) Sphenoparietale) Middle meningeal

Superior sagittal sinusCourse:•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 sinusCross section: Triangular

Tributaries:1. Veins from nose 2. Superior cerebral vein3. Parital emissary vein4. Venous lacunae5. Communication with

cavernous sinus

Applied anatomy: Infection from nose, scalp and diploe cause thrombosis of this sinus

Inferior sagittal sinus1. Situated in posterior 2/3 of falx cerebri2. Ends by forming straight sinus 3. It receives

1. Veins of falx cerebri2. Veins from cerebrum

Straight sinusSituated at junction of falx cerebri and tentorium cerebelliContinuation of inferior sagittal sinus

Tributaries:1. Inferior sagittal sinus2. Great cerebral vein 3. Superior cerebellar veins

Transverse sinus1. Large paired sinus , right

sinus larger than left

2. Situated in posterior part of attached margin of tentorium cerebelli

3. Begins as continuation of superior sagittal sinus (right) and straight sinus (left)

Triangular cross section

Ends at mastoid angle

Tributaries:

1. Superior petrosal sinus2. Inferior cerebral vein3. Posterior temporal deploic vein4. Inferior cerebellar vein5. Inferior anastomotic vein6. Petrosquamous sinus

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

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

Tributaries:

1. Communication with pericranium veins2. Communication with sub occipital venus

plexus3. Labyrinthine veins4. 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

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.

Cavernous sinus1. Paired sinus, large venous space situated in

MCF2. Extent: petrous part of temporal bone to SOF

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

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

Tributaries

From orbit

a) Superior ophthalmic vein

b) Inferior ophthalmic vein

c) Central vein of retina

From brain

a) Middle cerebral vein

b) Inferior cerebral vein

Meningeal

a) Middle meningeal vein

b) Sphenoparietal sinus

Communication with:a) Transverse sinus b) IJVc) Pterygoid venous plexus

d) Facial vein e) Superior sagittal sinusf) Opposite cavernous

sinus

Applied anatomy:1. Arterio – venous aneurysm occurs due to

rupture of internal cardiac artery Symptoms: a) Loud systolic thrillb) Exophthalmosc) Conjunctivitis

2. Thrombosis of the sinus resulting in meningitis due to infections in dengerous area of face , nasal cavity and PNSSymptoms: a) pain in eyeb) Oedema of eye lids , cornea and root of nosec) Exophthalmos

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

Superior petrosal sinus1. 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

2. Connection between transverse and cavernous sinus

3. Tributaries:1. Cerebellar vein2. Inferior cerebral vein3. Veins from tympanic cavity

Inferior petrosal sinusShorter 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 9th,10th & 11th nerve and empties into superior bulb of internal jugular veinTributaries:1. labyrinthine vein2. veins from aqueduct of cochlea3. vein from medulla pons and

cerebellum

Middle meningal sinusCommunicate cavernous sinus with superior sagital sinusUnite to form

- parietal- frontal

Liable to be torn during skull fracture

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

Ophthalmic veinsSuperior 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.

• 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

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

Diploic veins:• situated in diploe of cranial veins

Characteristics 1. Valve less2. Non-collespable3. Pouch like elevation at

irregular interval4. On x-ray of skull appear as

transparent bands5. Communicate with meningal,

sinuses and veins of pericranium

Types:• Frontal• Anterior temporal• Posterior temporal• Occipital

EMISSARY

Characteristics:1. Valve-less2. Some veins are constant other inconstant or may be absent3. Thin valves tightly attached to surrounding bones

Types:4. parietal 5. occipital6. mastoid7. condylar8. Spheniod9. Zuckerkandl’s

Veins connecting cavernous sinus with pterygoid venous plexus pass through different foramina1. Foramen lacerum2. Foramen ovale3. Foramen vesali4. Foramen spinosum

Applied anatomy:• Inflammatory process due to infection pass

through these veins and give rise to thrombosis of the sinus

Venous plexusa) PTERYGOID

Location: Between lateral and medial pterygoid or between temporal and lateral pterygoid

Boundaries: 1. Anterior-maxillary

tuberosity2. Superior-base of

skull

Termination:• Posteriorly these

veins unite to form deep facial or maxillary vein

Tributaries:1. Sphenopalatine2. Deep temporal 3. Pterygoid4. Masseteric5. Buccal6. Dental7. Greater palatine8. Middle meningeal9. Inferior opthalmic

Applied anatomy: PSA block

-haematoma-black eye

Serves as media for spread of external infection to the cavernous sinus

b) SUBOCCIPITAL:

1. Located in suboccipital triangle 2. Receives blood from

1. Muscular veins 2. Transverse sinus3. Occipital veins4. Internal vertebral venous plexus5. Condylar emmissary veins

3. Drains into vertebral veins

c). PHARYNGEAL VENOUS PLEXUS:

1. Located on postero lateral region of pharynx

2. Receives blood from1. Pharynx2. Soft palate3. Pre vertebral region

3. Drains into internal jugular and facial veins

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 H2O

SiteNormal

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

 Factors that decrease CVP include:

HypovolemiaDeep inhalationDistributive shock

Factors that increase CVP include:

Hypervolemiaforced exhalationTension pneumothoraxHeart failurePleural effusionDecreased cardiac outputCardiac tamponadeMechanical ventilation

Diseases of veins

Deep vein thrombosis

Varicose veins

Thrombophlebitis

Thread veins

Venous insufficiency

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 cartilage20 cases: the cricoid cartilage46cases: the supraclavicular area (p value <0.05).

In 93% of cases the IJV was found to be larger than the carotid artery.

ConclusionThe 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.

References

1. Textbook of oral anatomy-sicher & dubrul2. Human Anatomy – B.D. Chaurasia3. Wikipidia

Thank you