venous supply of head & neck
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Transcript of venous supply of head & neck
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
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