venous supply of head & neck


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venous supply of head & neck

  1. 1. PRESENTER: Dr. Ashish Soni
  2. 2. 1. Veins 2. Structure of veins 3. Role of veins 4. Classification of venous system 5. Description of veins A. Internal jugular vein 1. Introduction 2. Tributaries 3. Applied anatomy 4. JVP B. External jugular vein 1. Tributaries 2. Applied aspect C. Anterior jugular vein D. Variations in veins of head & neck
  3. 3. 6. Venous sinuses 7. Communication between venous sinuses & extracranial veins 8. CVP 9. Diseases of veins 10. Conclusion
  4. 4. 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. 5. Structure of Vein  Veins 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)
  6. 6. Differences between arteries and veins
  7. 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. 8. 1) Return of deoxygenated blood to heart 2) Cushion associated arteries from jaw movements(periarterial plexus) 3) Protect against extensive intracranial pressure.
  9. 9. Veins Systemic veins Pulmonary Veins -Right Pulmonary vein -Left Pulmonary vein Head & Neck Abdomen & Thorax Upper limb Lower limb
  10. 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. 11. External group a) Internal jugular b) External jugular c) Anterior jugular d) Oblique jugular e) Posterior external jugular Internal group a) Venous sinuses b) Emissary veins c) Diploic veins
  12. 12. Superficial External jugular Facial Superficial temporal Deep Pterygoid plexus Internal jugular
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. b) Posteriorlly • Rectus capitis lateralis • Transverse process of atlas • Levator scapulae • Scaleneus medius • Cervical plaxus • Scalenus anterior • Phrenic nerve • Thyrocervical trunk • Inferior thyroid artery
  17. 17. c) Medially • Internal carotid artery • Common carotid artery • Vagus nerve
  18. 18. Tributaries 1. Inferior petrosal sinus 2. Pharyngeal veins 3. Common facial vein 4. Lingual vein 5. Superior thyroid vein 6. Kocher vein 7. Occipital vein 8. Thoracic duct (left) 9. lymphatic duct (right)
  19. 19. Communications 1. With external jugular by oblique jugular 2. With cavernous sinus by inferior petrosal sinus
  20. 20. Superficial cerebral veins Superior sagittal sinus Right transverse sinus Right sigmoid sinus Right IJV Special characteristics of the blood flow Deep cerebral vein Great cerebral vein Straight sinus Left transverse sinus Left sigmoid sinus Left IJV 1 2
  21. 21. APPLIED ANATOMY: 1. Infection from middle ear spreads to IJV 2. Surgical removal of deep cervical nodes can puncture IJV 3. 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 stenosis 6. During CCF dilatation of vein occur 7. Queckenstedt’s test – to find out block in CSF cerculation the test is perform during lumbar puncture
  22. 22. 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
  23. 23. a) Facial (anterior facial vein) • Origin – junction of veins of forehead and nose • Upper part – angular vein book
  24. 24. Angular vein receives: 1. Frontal vein (anterior parts of scalp) 2. Supraorbital vein (eyebrows) 3. Superior ophthalmic vein (opens into cavernous sinus)
  25. 25. Anastomosis of facial vein
  26. 26. 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.
  27. 27. 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 veins c) Sublingual vein
  28. 28.  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
  29. 29. 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
  30. 30. • 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
  31. 31. 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.
  32. 32.  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
  33. 33. f) 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
  34. 34. 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.
  35. 35. 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.
  36. 36.  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
  37. 37. 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
  38. 38. Tributaries:  Formative  Occipital vein  Oblique jugular  Posterior external jugular  Terminal  Transverse cervical  anterior jugular  Suprascapular vein
  39. 39. 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
  40. 40. •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
  41. 41. Tributaries: 1. Skin 2. Superficial tissues of neck Applied anatomy: 1. Special care required to preserve the vein during surgical treatment of wry neck
  42. 42. Formation: • 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) Orbit c) Internal ear d) CSF • Valveless • Bidirectional flow
  43. 43. 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
  44. 44. 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
  45. 45. Tributaries: 1. Veins from nose 2. Superior cerebral vein 3. Parital emissary vein 4. Venous lacunae 5. Communication with cavernous sinus Applied anatomy: Infection from nose, scalp and diploe cause thrombosis of this sinus
  46. 46. 1. Situated in posterior 2/3 of falx cerebri 2. Ends by forming straight sinus 3. It receives 1. Veins of falx cerebri 2. Veins from cerebrum
  47. 47. Situated at junction of falx cerebri and tentorium cerebelli Continuation of inferior sagittal sinus Tributaries: 1. Inferior sagittal sinus 2. Great cerebral vein 3. Superior cerebellar veins
  48. 48. 1. 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)
  49. 49.  Triangular cross section  Ends at mastoid angle  Tributaries: 1. Superior petrosal sinus 2. Inferior cerebral vein 3. Posterior temporal deploic vein 4. Inferior cerebellar vein 5. Inferior anastomotic vein 6. Petrosquamous sinus
  50. 50. 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
  51. 51. • 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
  52. 52. Tributaries: 1. Communication with pericranium veins 2. Communication with sub occipital venus plexus 3. Labyrinthine veins 4. 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
  53. 53. •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.
  54. 54. 1. Paired sinus, large venous space situated in MCF 2. Extent: petrous part of temporal bone to SOF
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Communication with: a) Transverse sinus b) IJV c) Pterygoid venous plexus d) Facial vein e) Superior sagittal sinus f) Opposite cavernous sinus
  59. 59. Applied anatomy: 1. Arterio – venous aneurysm occurs due to rupture of internal cardiac artery Symptoms: a) Loud systolic thrill b) Exophthalmos c) Conjunctivitis 2. Thrombosis of the sinus resulting in meningitis due to infections in dengerous area of face , nasal cavity and PNS Symptoms: a) pain in eye b) Oedema of eye lids , cornea and root of nose c) Exophthalmos
  60. 60. • Usually two in number • Connects two cavernous sinus • Form venous circle • Situated at anterior and posterior margins of diaphragma sellae
  61. 61. 1. 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 vein 2. Inferior cerebral vein 3. Veins from tympanic cavity
  62. 62. 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 9th,10th & 11th nerve and empties into superior bulb of internal jugular vein Tributaries: 1. labyrinthine vein 2. veins from aqueduct of cochlea 3. vein from medulla pons and cerebellum
  63. 63. Communicate cavernous sinus with superior sagital sinus Unite to form - parietal - frontal Liable to be torn during skull fracture
  64. 64. 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
  65. 65. 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.
  66. 66. • 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
  67. 67. 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
  68. 68. Diploic veins: • situated in diploe of cranial veins Characteristics 1. Valve less 2. Non-collespable 3. 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
  69. 69. EMISSARY Characteristics: 1. Valve-less 2. Some veins are constant other inconstant or may be absent 3. Thin valves tightly attached to surrounding bones Types: 1. parietal 2. occipital 3. mastoid 4. condylar 5. Spheniod 6. Zuckerkandl’s
  70. 70. Veins connecting cavernous sinus with pterygoid venous plexus pass through different foramina 1. Foramen lacerum 2. Foramen ovale 3. Foramen vesali 4. Foramen spinosum Applied anatomy: • Inflammatory process due to infection pass through these veins and give rise to thrombosis of the sinus
  71. 71. a) PTERYGOID Location: Between lateral and medial pterygoid or between temporal and lateral pterygoid
  72. 72. Boundaries: 1. Anterior-maxillary tuberosity 2. Superior-base of skull Termination: • Posteriorly these veins unite to form deep facial or maxillary vein
  73. 73. Tributaries: 1. Sphenopalatine 2. Deep temporal 3. Pterygoid 4. Masseteric 5. Buccal 6. Dental 7. Greater palatine 8. Middle meningeal 9. Inferior opthalmic
  74. 74. Applied anatomy:  PSA block -haematoma -black eye  Serves as media for spread of external infection to the cavernous sinus
  75. 75. b) SUBOCCIPITAL: 1. Located in suboccipital triangle 2. Receives blood from 1. Muscular veins 2. Transverse sinus 3. Occipital veins 4. Internal vertebral venous plexus 5. Condylar emmissary veins 3. Drains into vertebral veins
  76. 76. c). PHARYNGEAL VENOUS PLEXUS: 1. Located on postero lateral region of pharynx 2. Receives blood from 1. Pharynx 2. Soft palate 3. Pre vertebral region 3. Drains into internal jugular and facial veins
  77. 77. 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 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
  78. 78. 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
  79. 79. 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.
  80. 80. 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.
  81. 81. 1. Textbook of oral anatomy-sicher & dubrul 2. Human Anatomy – B.D. Chaurasia 3. Wikipidia