VENOUS DRAINAGE OF HEAD AND

NECK REGION

PRESENTER: MODERATOR:
DENIS JACOB KURIAN DR.VENKATESH ANEHOSUR
 CONTENTS
INTRODUCTION

VENOUS STRUCTURE v/s ARTERIAL STRUCTURE

CLASSIFICATION OF VEINS AND VENOUS SYSTEM

VENOUS DRAINAGE OF HEAD, FACE, NECK

CLINICAL APPLICATIONS

CONCLUSION

REFERENCES
INTODUCTION

Veins are the blood vessels which carry the

deoxygenated blood from entire body to the
right atrium.

Except Pulmonary veins and Umbilical veins.

Veins are major reservoirs of blood .

Valves are present to
prevent backflow of blood.

Of the 70% of systemic

CAPI
circulation, 54% of blood is

AR 11%

LLAR
5%
TE

I
RI

ES
present in the veins.

ES
HEART
VEINS
12%
5 54%

A RY
MON
L
PU 18%
 ARTERIES VEINS

Oxygen Concentration: Arteries carry oxygenated blood Veins carry deoxygenated blood

Thickest layer: Tunica media Tunica adventitia

Structure: Thick, elastic muscle layer Thin, elastic muscle layer

Rigid walls: More rigid Collapsible

Location: Deeper in the body Closer to the skin

Arteries are red blood vessels Veins are blue blood vessels that

Overview: that carry blood away from the carry blood towards the heart.
heart. resistance vessels capacitance vessels
★ Classification of veins and venous system

Pulmonary

Systemic

Portal

Venous system
 SUPERFICIAL
VEINS

VEINS

SINUSES DEEP
VEINS
 ★VENOUS SYSTEM OF HEAD AND NECK REGION

◉ This venous system can be divided into :-

A] VEINS OF THE BRAIN B] VEINS OF THE SCALP

✓ Dural venous sinuses

✓ Diploic veins
✓ Emissary veins

C] VEINS OF THE FACE

D] VEINS OF THE NECK

✓ Veins of the eyelids

✓ Veins of Pharynx
✓ Veins of Lacrimal Apparatus
✓ Veins of Larynx
✓ Veins of Orbit
✓ Superficial veins
✓ Veins of Eyeball
✓ Deep Veins
✓ Veins of Oral cavity
✓ Veins of Nasal cavity
✓ Veins of Infratemporal region
DEVOID OF VALVES & MUSCLES
 VENOUS
SINUSES
RIGHT SIDE OF BRAIN LEFT SIDE OF BRAIN

LEFT SIDE OF SCALP, FACE,

RIGHT SIDE OF SCALP, FACE, NECK
NECK

RIGHT EXTERNAL RIGHT INTERNAL LEFT INTERNAL LEFT EXTERNAL

JUGULAR VEIN JUGULAR VEIN JUGULAR VEIN JUGULAR VEIN

LEFT
RIGHT SUBCLAVIAN RIGHT BRACHIOCEPHALIC BRACHIOCEPHALIC LEFT
VEIN VEIN SUBCLAVIAN
VEIN
VEIN

SUPERIOR VENA CAVA

RIGHT ATRIUM OF
HEART
 INTRA-CRANIAL
VENOUS DRAINAGE
 GENERAL CHARACTERISTICS
Valve less

Non- collapsible

Pouch like elevation at irregular

interval

On x-ray of skull appear as

transparent bands

Communicate with meningal sinuses

and veins of pericranium
 

DIPLOIC VEINS


• Occupy channels within the

bones of the vault of the skull

1. Frontal diploic vein

2. Anterior temporal diploic vein

3. Posterior temporal diploic vein

4. Occipital diploic vein

 EMISSARY VEINS
Types:

1. Mastoid Emissary Vein

2. Posterior Condyloid Vein
3. Occipital Emissary Vein
4. Parietal Emissary Vein
5. Sphenoidal Emissary Vein (Vesalius)
6. Emissary Veins of the
Foramen Caecum
Foramen Ovale
Foramen Lacerum
 VEINS OF THE BRAIN

Cerebral veins

Cerebellar veins

Veins of the Brainstem

 CLINICAL RELEVANCE

SUBDURAL HEMATOMA

Commonly results due to tearing

of a cerebral vein as it enters the
superior sagittal sinus
INTRA-CRANIAL VENOUS SINUS

Spaces between endosteal

and meningeal layers of
duramater.

Lined by epithelium

Absence of muscular coat

No valves
Receive :
1) Venous blood from brain,
meninges and bone
2) CSF

Drains to internal jugular veins.

Communicates extracranially
through emissary veins.
 VENOUS SINUSES
CRANIAL
VENOUS SINUSES

PAIRED UNPAIRED

1. Cavernous sinus 1. Superior Sagittal sinus

2. Inferior Sagittal sinus
2. Superior Petrosal sinus
3. Straight sinus
3. Inferior Petrosal sinus
4. Occipital sinus
4. Transverse sinus
5. Anterior Intercavernous
5. Sigmoid sinus sinus
6. Sphenoparietal sinus 6. Posterior Intercavernous
7. Petrosquamous sinus sinus
8. Middle meningeal sinus 7. Basilar plexus of veins
CAVERNOUS SINUS
STRUCTURE STRUCTURES
PASSING IN LATERAL
THROUGH WALL OF
SINUS SINUS

OCCULOMOTOR
CRANIAL NERVE
INTERNAL
CAROTID TROCHEALR
ARTERY CRANIAL NERVE

ABDUCENT OPTHALMIC AND

CRANIAL NERVE MAXILLARY
DIVISION OF
TRIGEMINAL
CRANIAL NERVE
VENOUS DRAINAGE
OF HEAD
SUPRATROCHLEAR VEIN
• Venous network which
connects to the frontal
tributaries of superficial
temporal vein.

• Over forehead.

• Forms facial vein near

medial canthus.
 SUPRAORBITAL VEIN

A branch passes through supraorbital

notch to join superior ophthalmic vein .

In notch it receives veins from frontal

sinus & frontal diploe.
FACIAL VEIN

• Union of supraorbital
and supratrochlear veins
at medial canthus

• Lies behind facial artery and is

less tortuous
Facial veins have no valves and it
connects to CAVERNOUS SINUS
by 2 routes.

1.) via ophthalmic vein or

supraorbital vein.

2) via deep facial vein to pterygoid

plexus.

Thus infective thrombosis of facial

vein may extend to intracranial
venous sinuses.
PTERYGOID VENOUS PLEXUS

1. Located between temporalis and two pterygoid muscles on postero-lateral

region of pharynx

2. Receives blood from

• Pharynx
• Soft palate
• Pre vertebral region

3. Drains into internal jugular and facial veins

Tributaries from :

Sphenopalatine,

Deep temporal,
Pterygoid,

Masseteric,
Buccal,

Alveolar,
Greater palatine

Middle meningeal
veins
Connects with facial vein
via deep facial vein
With cavernous sinus through
emissary veins of sphenoidal,
foramen ovale and
foramen lacerum.

With the middle

meningeal veins through
anterior diploe veins.
SUPERFICIAL TEMPORAL VEIN

• Widespread network across

scalp.
• Enters parotid gland to unite
with maxillary vein

• Forms retromandibular vein.

 MAXILLARY VEIN

Passes between sphenomandibular

ligament and neck of mandible, to
enter parotid gland

Collects blood from

pterygoid plexus
RETROMANDIBULAR VEIN

• Emerges from lower border of

parotid substance & divide into
two divisions :

• ANTERIOR DIVISION

• POSTERIOR DIVISION
RETROMANDIBULAR VEIN

• Anterior division:
joins the facial vein

• Posterior division:
pierces deep fascia and
join posterior auricular
to form external
jugular.
 POSTERIOR AURICULAR VEIN

Arises in a parieto-occipital
network.

Drains the region of the

scalp behind the ear.

Joins posterior division of

retromandibular vein to form
external jugular vein.
OCCIPITAL VEIN

Begins in a posterior
network in the scalp.

In suboccipital triangle,
joins the deep cervical
and vertebral veins.

Joined by diploë in the

occipital bone
 LINGUAL VEINS

Veins follow three

routes:

1.Dorsal Lingual Veins:

Dorsum & sides of tongue

2.Deep Lingual Vein:

Tip of the tongue

3.Sublingual Vein
VENOUS DRAINAGE
OF NECK
EXTERNAL JUGULAR VEIN

• Position of the EXTERNAL
JUGULAR VEIN is marked
out by a line from the angle of
the mandible to the middle of
the clavicle.

• A point on this line about 4

cm. above the clavicle indicates
the spot where the vein pierces
the deep fascia.
Largely drains scalp and
face.

Union of posterior division

of retromandibular vein
and post auricular
vein.
 INTERNAL JUGULAR VEIN

Drains brain.

Deep vein of the neck

Posterior compartment of
jugular foramen at the base
of skull.

Combines with subclavian

vein to form
BRACHIOCEPHALIC VEIN
• SUPERIOR BULB :
• Below the jugular
foramen, it is widened
to form superior bulb.

• INFERIOR BULB :
• At junction with
subclavian vein , it is
again widened to form
inferior bulb
TRIBUTARIES OF INTERNAL JUGULAR VEIN

◇ INFERIOR PETROSAL
SINUS

◇ COMMON FACIAL VEIN

◇ LINGUAL VEIN

◇ PHARYNGEAL VEIN

◇ SUPERIOR THYROID
VEIN

◇ MIDDLE THYROID
VEIN

◇ OCCIPITAL VEIN
 CLINICAL
APPLICATIONS
 DANGEROUS AREA OF FACE

◇ It lies between the angular & facial veins

◇ Communications exist between the facial veins and venous
sinuses through the ophthalmic veins
◇ Infections can be introduced by this route causing
meningitis
 HEMATOMA

Hematoma following
POSTERIOR SUPERIOR
ALVEOLAR block.

Needle is inserted too far

posteriorly.
PULSATING EXOPHTHALMOS

Communication between
Internal Carotid artery and
Cavernous sinus due to
head injury
Results in exophthalmos
and chemosis

Protruding eye pulsates in

synchrony with the radial
pulse, a phenomenon
known as Pulsating
exophthalmos
 PHLEBECTASIA OF INTERNAL JUGULAR
VEIN

Congenital fusiform dilatation

Soft, compressible mass in the neck

during straining or is triggered by
the Valsalva maneuver

Doppler imaging confirms the

diagnosis and is the gold standard
CAVERNOUS SINUS
THROMBOSIS

• Serious, life threatening

infection.

• Superior spread of
odontogenic infection via
haematogenous route.
 CAVERNOUS SINUS
MANAGEMENT

Surgery
Antibiotics
Steroids
Anticoagulants
 LIGATION OF FACIAL VEIN

◇ The Common facial, (anterior) Facial and Ranine veins are encountered during
Submandibular gland excision.

◇ The facial vein is ligated and divided where it crosses the Submandibular gland.

◇ Incision is made at least 1/2 inch

below the lower border of mandible

TRANSCERVICAL APPROACH

◇ Platysma muscles, cutaneous tissue

and skin cut.

◇ Soft tissue bluntly ressected , facial

vein isolated, tied and cut.
KUSSMAUL'S SIGN

Paradoxical rise in Jugular

Venous Pressure (JVP) on
inspiration.

Indicative of right heart

failure
SUBLINGUAL ABSORPTION OF DRUGS

◇ Sublingual drugs are

placed beneath the
tongue for rapid
absorption.

◇ The drug dissolves

and enters the deep
lingual veins in less
than a minute
 CENTRAL VEIN CATHETERIZATION

INDICATIONS
• Measurement of central venous
pressure

• Infusion of irritant/long term

drugs and total parenteral nutrition

• Difficult peripheral access

• Monitoring of mixed venous or

jugular bulb oxygen saturations

• Replacement of circulating volume

ANTERIOR APPROACH
POSTERIOR APPROACH
 LIGATION OF INTERNAL JUGULAR
VEIN

Forms of Internal Jugular vein ligation

❖ Lower end ligation

❖ Upper end ligation

❖ Bilateral Ligation
❖ Lower end ligation

Identify the Sternocleidomastoid muscle

The carotid sheath is opened

A length of at least 2 cms is identified to facilitate ligation

Ligatures of either silk or vicryl are placed around the vein,

making sure that the Vagus is not included

3 ligatures are used; 2 at lower end & 1 at upper end and

both ends are transfixed.

The transfixation stitch on the lower end is known as the ‘

Houseman’s suture
❖ Upper end ligation

The upper end should be ligated first as it prevents distention of blood in

the vein.

Upper end of IJV ligation is identified by the division of

sternocleidomastoid muscles.

Its position may be located by palpating the transverse process of C2 over

which it lies.

Before tying any ligatures, the vagus and hypoglossal nerve should be
identified and preserved.

The vein is mobilized using right angled Lahey forceps, non absorbable
sutures are placed to facilitate ligation.

2 suture above and 1 below the point of division

❖ Bilateral ligation

Patients who need bilateral ligation of the internal jugular veins should
be investigated preoperatively with digital subtraction angiography.

The ligation should be carried out in two stages

Internal jugular vein on the most involved site is ligated in the first stage.

The Internal jugular vein on the less involved side should be isolated as a
structure within the carotid complex, ligate its various branches and
carry out the neck dissection

After a gap of two weeks the other Internal jugular vein is ligated.
Venous drainage post Internal jugular vein ligation

Following ligation of IJV during radical neck dissection invisible

channels open up .
These channels are situated around the epidural space of the foramen
magnum and in the neck muscles.
This vertebral venous plexus drains into right and left subclavian veins
at the cervicothoracic junction via single vessel

These cervical draining vessels do not resemble any of the jugular

veins, but the vertebral vein with tributaries from the internal
vertebral plexus, anterior vertebral vein and deep cervical veins
 ANASTOMOSIS OF INTERNAL
JUGULAR VEIN

END-TO-END ANASTOMOSIS: After

revascularisation, the decreased venous
flow may accelerate venous thrombosis.
END-TO-SIDE ANASTOMOSIS:
Preserves blood flow by avoiding
ligation and decreases the likelihood of
thrombosis.
MONITORING FLAP VITALITY POST ANASTOMOSIS

◇A healthy flap appears well perfused- bleeds on fine prick- PRICK TEST

◇Signs of flap failure- occurs due to inadequate venous drainage and insufficient arterial supply

◇The flap edges and margins start appearing dark, pale, dusky
MANAGEMENT OF BLEEDING

• Air embolism and not

bleeding
• Identify and occlude
temporarily with
pressure or arterial
clamps.
• Repair with 6-0 Ethilon
 VENOUS MALFORMATIONS

3rd most common vascular

anomaly in the head and
neck

Present as soft, compressible,

non-pulsatile masses with
blue discolouration
VENOUS ANEURYSM

• Venous dilatation in the neck may

involve the internal or external
jugular vein, an anterior jugular
vein or a superficial
communicating vein
• Severe retching and
vomiting could lead to
presentation of
congenital aneurysmal
dilatation by herniation
through weakened local
fascia
 PHLEBECTASIA ANEURSYMS
• Saccular
• Fusiform

• Secondary to trauma,
• Congenital in origin
or diseases involving
veins.

• Variable in both their • Vary in size from 5 to

diameter and length 20 cm in diameter

• Spindle-shaped • Spherical shape

Computed tomographic cerebral venography

Magnetic resonance cerebral venography

 ARTERIOVENOUS FISTULAS

It is an abnormal connection between an artery and a vein

Types :

Acquired arteriovenous fistulas

Arteriovenous fistulas in the face & neck
Dural arteriovenous fistulas
Peripheral arteriovenous fistulas
Cerebral arteriovenous fistulas
Spinal arteriovenous fistulas
Vein of Galen arteriovenous fistulas

Treatment :
Endovascular Embolization
Microsurgery
Stereotactic radiosurgery
VEIN GRAFTING
 CONCLUSION
Venous supply is responsible for the drainage of the blood into the right atrium of
the heart which maintains the venous pressure of the head and neck region.

The absence of valves and muscles in the veins of head and neck causes infections
to spread in the retrograde direction leading to complications like thrombosis.

Catheterization of the Jugular veins is helpful in administering medications and

fluids in patients where it is difficult to palpate peripheral veins

The Jugular veins and its tributaries form the primary venous drainage of head
and 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
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THANK

YOU